HIPERTENSI DAN

KOMPLIKASI
KARDIOVASKULAR

Dr Mustika Mahbubi SpJP FIHA

Introduction
 Definition of
hypertension

Office BP ≥ 140/90 mmHg

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Criteria of Hypertension
 Organ Damage by Hypertension

 Whatever the cause o BP elevation, the ultimate

consequences are similar. High BP itself is
generally asymptomatic but can result in
devastating effects on many organs

 Target organ complications of hypertension reflect

the degree of BP elevation

 3 mechanism : (1) the increased workload fo the

heart and (2) arterial
damage resulting rom the combined effects to the
elevated pressure itsel (weakened vessel walls)
and accelerated atherosclerosis
 The renin
angiotensin–
aldosterone
system
Pathogenesis of the major consequences of arterial
hypertension

(Lilly, 2011)
Target Organ damage in
Hypertension

(Lilly, 2011)
 LVH and Diastolic Dysfunction
 The high arterial pressure (heightened afterload) wall tension of
LV increases  hypertrophy

 LVH  elevation of LV filling  diastolic dysfunction  HF

preserved ejection fraction ->pulmonary congestion

 LVH is one of strongest predictors of cardiac morbidity in

hypertensive patients.

 The degree of heart hypertropohy correlates with the development

of congestive heart failure, angina, arrhythmias, myocardial
infarction and sudden cardiac death
 Systolic Dysfunction

 LVH and increases LV mass may be insufficient to balanced the

high wall tension caused by elevated pressure - LV vontractile
capacity deteriorates  systolic dysfunction  reduced CO and
pulmonary congestion

 Systolic dysfunction is also provoked by the accelerated

development of coronary artery disease with resultant periods of
myocardial ischemia
 Coronary Artery Disease

 Chronic hypertension is major contributor to development

of Myocardial Ischemia dan infarction

 Reflect combination of accelerated coronary

atherosclerosis (decreased myocardial oxygen supply) and
the high systolic workload (increase oxygen demand)

 Hypertensives have higher incident of postmyocardial

infarction complication such as rupture of the ventricular
wall, LV aneurysm formation dan CHF
 Aorta and peripheral vasculature

 The accelerated atherosclerosis associated with hypertension

may result in plaque formation and narrowing throughout the
arterial vasculature

 Chronic hypertension may lead to the development of

aneurysms particularly of the abdominal aorta. An abdominal
aortic aneurysm (AAA)

 Elevated blood pressure  accelerates degenerative changes

in the media of the aorta. When the weakened wall is further
exposed to high pressure  allowing blood to dissect into the
aortic media and propagate in either direction within the
vessel wall
Cardiovascular Risk Of
Hypertension??
 Cardiovascular Risk is influenced by
Severity of Hypertension, other Risk
Factors, Hypertension-mediated Organ
Damage and Disease

Williams B, Mancia G et al. Eur Heart J (2018); doi:10.1093/eurheartj/ehy339

Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/HJH0000000000001940
2018 ESC/ESH Guidelines for the management of arterial hypertension
European Heart Journal (2018) doi:10.1093/eurheartj/ehy339
European Journal of Hypertension (2018) doi:10.1097/HJH.0000000000001940
 COMPELLING INDICATIONS
IN HYPERTENSION

 Heart failure

 Post-myocardial infarction

 High coronary disease risk/angina pectoris

 Diabetes

 Chronic kidney disease

 Recurrent stroke prevention

Chobanian AV, et al. Hypertension. 2003;42:1206–1252

Mancia G, Fagard R, et al. J Hypertens 2013, 31:1281–1357
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 Hypertension mediated organ
Damage (HMOD)

Organ Organ damage

Heart Left ventricular hypertrophy

Carotid wall thickening (IMT >0.9 mm) or

Brain
plaque

Kidney Albuminuria

Vascular Pulse wave velocity

Mancia G, Fagard R, et al. J Hypertens 2013, 31:1281–1357

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 Preferred drugs for patients
WITH cardiac Conditions

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 Most hypertensive patients should initiate treatment
with a single pill combination comprising two
antihypertensive drugs

EXCEPT

Monotherapy is indicated for:

• Low-risk patients with grade 1 hypertension whose
SBP is <150 mm Hg
• Very high risk patients with high normal BP
• Frail older patients

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339

Initiation of drug treatment

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339

 POSSIBLE COMBINATIONS

Thiazide
Diuretics

-
ARBs
blockers

Other
antihypertensives CCBs

ACE
inhibitors Mancia G, et al. J Hypertens 2013; 31: 1281–1357
 First step combination treatment in
some specific conditions

 Diabetes: RAS blocker+CCB or D (IA)

 CAD: BB or CCB+RAS blocker (IA)
 CKD: RAS blocker+ CCB or D (loop D)
 Cerebrovascular Disease:RAS Blocker+CCB or D(IA)
 AF: BB and/or nondihCCB (IIaB)
 Hf(r/p*EF):RAS blocker+BB,D+Antialdo(IA)(*IIaB)
 COPD: RAS blocker+CCB
 LEAD: RAS blocker+CCB or D (*BB may be considered)
Uncomplicated hypertension

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339

Hypertension and CAD

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339

Hypertension and HFrEF

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339

Hypertension and atrial fibrillation

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339
 HOW ABOUT
HYPERTENSION
EMERGENCIES???
 Hypertensive emergencies Cardiac
Complications???
 1%–2% of patients with hypertension will have a hypertensive
emergency during their lifetime (Deshmukh 2011)
 Hypertensive crises are acute, severe elevations in blood pressure
that may or may not be associated with target-organ dysfunction
 Hypertensive emergencies are characterized by acute, severe
elevations in blood pressure, often greater than 180/110 mm Hg
(typically with systolic blood pressure [SBP] greater than 200 mm Hg
and/or diastolic blood pressure [DBP] greater than 120 mm Hg)
associated with the presence or impendence of target-organ
dysfunction
 Hypertensive urgencies are characterized by a similar acute elevation
in blood pressure but are not associated with target-organ dysfunction
 Hypertensive emergencies  uncontrolled
blood pressures (BPs)  progressive or
impending end-organ dysfunction

 Cardiovascular end-organ damage 

Myocardial ischemia/infarction
Acute left ventricular dysfunction
Acute pulmonary edema
Aortic dissection
Benken, CCSAP 2018
Diagnostic workup and target
BP of Hypertension
emergencies

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339

BP Treatment Goals for Hypertensive
Emergency

Benken, CCSAP 2018

 In Hypertension Urgency whow these patient no clinical

evidence of acute HMOD (Hypertension mediated organ
damage). They do not usually require admission to hospital and
BP reduction, they do not usually require admission to hospital
and BP reduction  oral medication
Drug for Hypertension emergencies

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339

Thank you
Whats new in 2018?
 PREFERRED DRUGS

No Compelling Indications

Guidelines Preferred drugs

“JNC 8” 2014 Thiazide, CCB, ACE-I, ARB

ESH/ESC 2013 Diuretic, CCB, ACE-I, ARB, beta blocker

CHEP 2013 Thiazide, CCB, ACE-I, ARB, beta blocker (age

less than 60 years)
JNC 8, the Eight Joint National Committee; ESH/ESC, European Society of
Hypertension/European Society of Cardiology; CHEP, Canadian Hypertension
Education Program

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