HYPERTENSION

MAIMUN SYUKRI

Batasan Hipertensi
1. Bila tekanan sistolik >= 140 mmHg, dan atau tekanan diastolik >= 90 mmHg, atau sedang mendapat obat antihipertensi. 2. Dilakukan dua kali atau lebih pengukuran pada dua kali atau lebih kunjungan.

Blood Pressure Classification

B !lassi"i#ation Nor al $B mmHg !"#$ and or or or DB mmHg !%$ %$%) )$)) -"$$

Pre&'pertension "#$"() Sta*e " H'pertension Sta*e # H'pertension "+$",) -".$

WHO/ISH 2003.

ESC/ESH 2003 .

Classification of /lood pressure le0els of t&e Britis& H'pertension Societ'

!ategor%

$%stoli# blood pressure 1 H*2 !"#$ !"($ "($4"()

Diastoli# blood pressure 1 H*2 !%$ !%, %,4%) )$4)) "$$4"$) ""$ !)$ !)$
Brit Med J 2004 328:634-40.

Opti al Nor al Hi*&3nor al

H%pertension 5rade " 1 ild2 "+$4",) 5rade # 1 oderate2 ".$4"6) 5rade ( 1se0ere2 "%$ &solated $%stoli# H%pertension 5rade " "+$ 3 ",) 5rade # -".$

AUSTRALIA 2003

BP Measure ent Tec&ni7ues

'ethod In3office Brie" Des#ription T8o readin*s9 , inutes apart9 sittin* in c&air: Confir ele0ated readin* in contralateral ar : Indicated for e0aluation of ;8&ite3 coat< HTN: A/sence of "$4#$= BP decrease durin* sleep a' indicate increased C>? ris@: Pro0ides infor ation on response to t&erap': Ma' &elp i pro0e ad&erence to t&erap' and e0aluate ;8&ite3coat< HTN:

A /ulator' BP onitorin*

Self3 easure ent

JNC 7 2003

Office BP Measure ent

Use auscultatory method with a properly calibrated and validated instrument. Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level. Appropriate-sized cuff should be used to ensure accuracy. At least two measurements should be made. Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals JNC 7 2003

Ho8 to

easure /lood pressure accuratel'

sphygmomanometer Patient should be seated and relaxed, preferably for several minutes prior to the measurement and in a quiet room Appropriate cuff size. Average the readings. If the firsty two readings differ by more than 1 mm!g systolic or " mm!g diastolic or if the initial readings are high# ta$e several readings after five minutes of %uiet rest# until consecutive readings do not vary by greater than these amounts. !deally, patients should not ta"e caffeine#containing beverages or smo"e for at least two hours before blood pressure is measured, $$$$$$$ Australia, 2004

BoA # Procedures for /lood pressure

easure ent

(hen measuring blood pressure, #are should be taken to ))).. to sit "or se*eral minutes in a +uiet room be"ore beginning blood pressure measurements. ,ake at least t-o measurements spa#ed b% 1.2 min, )))). /se a standard bladder )). but ha*e a larger and a smaller bladder a*ailable "or "at and thin arms, respe#ti*el%. Ha*e the #u"" at the heart le*el, -hate*er the position o" the patient. /se phase & and 0 ))))). 'easure blood pressure in both arms at "irst *isit to dete#t possible di""eren#es ))))))))..

'easure blood pressure 1 and 1 min a"ter assumption o" the standing position in elderl% subje#ts, diabeti# patients, ))))).. 'easure heart rate b% pulse palpation 230 s4 a"ter the se#ond measurement in the sitting position.

HIPERTENSI Tekanan Darah :

R t -r t d ri 2 ! "i #e$eri!% & ' (e&)*!*r & # d + !t* , &) -er-ed ' (e&)*!*r & # d + !t* d*d*!

.2

 T? @e@uatan dara& @eti@a ele8ati dindin* arteri Benis Hipertensi Hipertensi Resisten Hipertensi E er*ensi Hipertensi Ur*ensi Berdasar@an Pen'e/a/ Hipertensi Pri er idiopati@ )$3),= Hipertensi S@under Siste i@

re*alensi Hipertensi
/$5 enduduk de-asa4 &ndonesia 10 6uta dari total 2 1 dari 4 orang

Baliem 0,718 $ukabumi 29,78

Etiolo*'
Pri ar' &'pertension ),= of all cases Secondar' &'pertension ,= of all cases C&ronic renal disease 4

ost co

on

C>? Ris@ Cactors

!ypertension& 'igarette smo$ing (besity& )*+I ,- $g.m/0 1hysical inactivity 2yslipidemia& 2iabetes mellitus& +icroalbuminuria or estimated 345 6" ml.min Age )older than 77 for men# "7 for women0 4amily history of premature '82 )men under age 77 or women under age "70

&'omponents of the metabolic syndrome.

Identifia/le Causes of H'pertension

9leep apnea 2rug-induced or related causes 'hronic $idney disease 1rimary aldosteronism 5enovascular disease 'hronic steroid therapy and 'ushing:s syndrome 1heochromocytoma 'oarctation of the aorta ;hyroid or parathyroid disease

Tar*et Or*an ?a a*e

!eart < =eft ventricular hypertrophy < Angina or prior myocardial infarction < 1rior coronary revascularization < !eart failure *rain < 9tro$e or transient ischemic attac$ 'hronic $idney disease 1eripheral arterial disease 5etinopathy

Cate*ories of &'pertensi0e end3or*an da a*e

Origin
Large arteries

Category
Loss of compliance Dissecting! ane"rysm Peripheral occl"si#e arterial $isease Nephrosclerosis

%i$ney

&irkenh'ger an$ $e Lee"( )**+!

Hipertensi , %er"sakan Organ Target

20

Da/orator' Tests
5outine ;ests < >lectrocardiogram < Urinalysis < *lood glucose# and hematocrit < 9erum potassium# creatinine# or the corresponding estimated 345# and calcium < =ipid profile# after ?- to 1/-hour fast# that includes high-density and low-density lipoprotein cholesterol# and triglycerides (ptional tests < +easurement of urinary albumin e@cretion or albumin.creatinine ratio +ore e@tensive testing for identifiable causes is not generally indicated unless *1 control is not achieved

Treat ent O0er0ie8

3oals of therapy =ifestyle modification 1harmacologic treatment < Algorithm for treatment of hypertension 'lassification and management of *1 for adults 4ollowup and monitoring

5oals of T&erap'
5educe '82 and renal morbidity and mortality. ;reat to *1 61A .? mm!g or *1 61- .B mm!g in patients with diabetes or chronic $idney disease. Achieve 9*1 goal especially in persons ,7 years of age.

Si*n and S' pto s

Essential HTN is usuall' 3 as' pto atic 3 undetected for an' 'ears 3 &eadac&e9 BP ele0ated s'stolic /e'ond #$$ H* or BP risin* rapidl' 1can occur in ali*nant HTN2

S' pto atic associated 8it& ali*nant HTN

Headac&e Blurred 0ision C&est pain Breat&lessness Nausea9 0o itin* AnAiet'9 confusion9 co a SeiEures

Conse7uences of Mali*nant HTN

End Or*an Aorta Brain Heart Kidne' 5astrointestinal Placenta Ot&er Co plications Aortic disection Hipertensi0e encepa&lopat&' Cere/ral Infarction or Hae or&ar*e Cardiac failure M'ocardial isc&e ic or infarction Renal failure Hae aturia AnoreAia9nausea90o itin*9a/do inal pain Ecla psia Micro3an*iopat&ic &ae ol'tic ane ia

Conse7uences of &'pertension
Cardiac disease Deft 0entricular failure An*ina M'ocardial infarction Cere/ro0ascular disease Transient isc&e ic attac@s Stro@e Multi3infarct de entia H'pertensi0e encep&alopat&'

Conse7uences of &'pertension
>ascular disease Aortic aneur's Occlusi0e perip&eral 0ascular disease Arterial dissection Ot&ers Pro*ressi0e renal failure H'pertensi0e retinopat&'

Ris@ of H'pertension
Ad0ancin* a*e Positi0e fa il' &istor' of pre ature cardio0ascular disease S o@in* H'perc&olesterole ia

H'pertension is t&ou*&t to account for F 3 One4&alf of all deat&s due to stro@e 3 Up to one 7uarter of coronar' &eart disease deat&s

Isolated S'stolic &'pertension increase t&e ris@ of F stro@e and coronar' &eart disease /' a/out +$= cardio0ascular deat& /' a/out ,$= &eart failure /' a/out ,$=

Aetiolo*' of &'pertension
Essential &'pertension 1pri erGidiopat&ic &'pertension re ain uncertain 1*enetic and en0iron ental factors contri/ute to de0elop ent of &'pertension2 Secondar' &'pertension

Secondar' &'pertension
Renal parenc&' al disease9 causes F 3 t&e *lo erulonep&ritides 3 dia/etic nep&ropat&' 3 anal*esic nep&ropat&' 3 adult pol'c'stic @idne' disease Renal arter' stenosis Pri ar' &'peraldosteronis P&aeoc&ro oc'to a

Secondar' &'pertension
Aortic coarctation Cus&in*Hs s'ndro e ?ru* induced &'pertension
3 t&e oral contraception pill 3 steroids 3 NSAI? 3i unosuppressi0e 3 s' pat&o i etics 3 ana/olic steroids 3 er't&ropoieti n 3 onoa in oAidase in&i/itors T&'rotoAicosis Rare ono*enic s'ndro e

Clinical asses ent of &'pertension

Si*n and s' pto s Pointers to secondar' &'pertension Ceatures of ali*nant &'pertension End or*an da a*e H'pertensi0e nep&ropat&' Deft 0entricular &'pertrop&' H'pertensi0e retinopat&'

5rades of &'pertension retinopat&'

5rade I Ceatures Mild narro8in* or sclerosis of t&e retinal arteriole9 no s' pto s9 5ood *eneral &ealt& >enous co pression at artrio0enous crossin* 1A3> nippin*2 no s' pto s9 *ood *eneral &ealt& Retinal oede a9 cotton 8ool spots9 &e or&a*es9 often s' pto s All a/o0e Papiloede a9S' pto atic Cardiac and renal function often i paired9 reduced sur0i0al

II

III I>

Treat ent
Non P&ar acot&erap' 1lifest'le odification2 P&ar acot&erap'

Pengobatan

Tujuan:
%&'(% ()*%(!+%& (),-*%(%& .,'%& +%,')+ %&'(% ()/%+!%&

Sasaran Pengelolaan
Me&i" i ) , /id*# d & ide&ti0i! %i 0 !t1r ri%i!1 ! rdi12 %!*" r " i& t * ) &))* & , &) $e&,ert i , &) d # t $e$#e&) r*/i #r1)&1%i% 3 #e&)1- t & Me&)et /*i #e&,e- - te! & & d r / , &) ti&))i Me&i" i d &, !er*% ! & 1r) & d & #e&, !it ! rdi12 %!*" r
34

Strategi Penatalaksanaan Hipertensi

6:!; re*enti" Deteksi <*aluasi engobatan
JNC VI, 1997

Pre0entif
Untu@ ence*a& atau Hipertensi e perla /at terIadin'a

Merupa@an solusi Ian*@a panIan* Mence*a& terIadi @o pli@asi ?apat en*&enti@an atau

asala& &ipertensi

en*uran*i /ia'a

pen*o/atan dan @o pli@asi

NHBPEP Working Group Report on Primary Prevention of Hypertension

Preventif
/pa%a pre*enti" primer; ,erhadap indi*idu %ang potensial hipertensi; ,D normal tinggi =i-a%at keluarga hipertensi >besitas ?onsumsi tinggi garam ?urang akti"itas ?onsumsi tinggi alkohol Diharapkan pre*alensi Hipertensi turun

Intervensi Preventif Primer

,erbukti <"ekti" ,urunkan BB ?urangi @aram ?urangi 5lkohol >lah =aga
<"ekti" terbatas 'anajemen $tres ?alium 'in%ak &kan 2Aish oil4 ?alsium 'agnesium $erat !egak makronutrien

Deteksi
Dilakukan di "asilitas kesehatan dengan alat ukur %ang standar dan #ara %ang benar asien diberitahu tentang makna ,Dn%a asien dianjurkan melakukan pemeriksaan periodik sesuai dengan ,D pertama Diharapkan ditemukan kasus tahap a-al

Evaluasi
'en#ari pen%ebab hipertensi 2sekunder4 'emeriksa adan%a kerusakan organ target dan pen%akit lain 'en#ari "aktor risiko 'engetahui respon pengobatan, e"ek samping dan kepatuhan pasien

JHO3ISH 5uidelines for Mana*e ent of H'pertensionF Stratification of Cardio0ascular Ris@

&loo$ Press"re mm Hg! -ra$e ) /il$ hypertension SB( .406.74 1r 8B( 40644 L1+ ri%! Med ri%! Hi)/ ri%! ;er, /i)/ ri%! -ra$e + /o$erate hypertension SB( .606.94 1r 8B( .006.04 Med ri%! Med ri%! Hi)/ ri%! ;er, /i)/ ri%! -ra$e . Se#ere hypertension SB( .80 1r 8B( ..0 Hi)/ ri%! ;er, /i)/ ri%! ;er, /i)/ ri%! ;er, /i)/ ri%!

Ot/er ri%! 0 5t1r% &d di%e %e /i%t1r,

I :1 1t/er ri%! 0 5t1r%

II .62 ri%! 0 5t1r%

III 3 1r $1re ri%! 0 5t1r% 1r TO8 1r di -ete%

I0 ACC

TO8 < T r)et-1r) & d $ )e ACC < A%%15i ted 5"i&i5 " 51&diti1&%

=*ide"i&e% %*-51$$ittee. WHO-ISH =*ide"i&e%. J Hypertens .444>.9:.7.-.83.

BP TARGETS: WITH !T C "P#ICATI N : $%40/&0 ''H( )IABETES C*) PR TEIN!RIA + % (/, : $ %30/&0 ''H( : $ %30/&0 ''H( : $%2-/7- ''H(

Difest'le Modification
'odi"i#ation 5pproBimate $B redu#tion 2range4 ,#$ H*G"$ @* 8ei*&t loss %"+ #% +) #+ H* H* H* H*

Jei*&t reduction Adopt ?ASH eatin* plan ?ietar' sodiu reduction P&'sical acti0it' Moderation of alco&olconsu ption

Difest'le Reco endations for H'pertensionF P&'sical Acti0it'

Sho"l$ 1e prescri1e$ to re$"ce 1loo$ press"re

2 I T T

?reB*e&5, I&te&%it, Ti$e T,#e

- ?1*r 1r 0i2e ti$e% #er +ee! - M1der te - 47-60 $i&*te% 8,& $i5 e@er5i%e - W "!i&) - C,5"i&) - :1&-51$#etiti2e %+i$$i&)

?1r # tie&t% +/1 re #re%5ri-ed #/ r$ 51"1)i5 " t/er #,: E@er5i%e %/1*"d -e #re%5ri-ed % dA*&5ti2e t/er #,

Treat ent of H'pertension

?iuretic ACE3In& ARB Beta /loc@er Alp&a /loc@er ?irect renin in&i/itor

Treat ent Al*orit& for Adults 8it& S'stolic3 ?iastolic H'pertension without anot&er co pellin* indication
T3R-ET 4)567*6 mmHg INITI3L TRE3T/ENT 3ND /ONOTHER3P:
Lifestyle mo$ification therapy

Thia9i$e

3CE8I

3R&

Long8acting DHP8CC&

&eta8 1locker

3lpha81locker as initial monotherapy

Indications for P&ar acot&erap'

$trongl% consider prescription ifF
A0era*e ?BP e7ual or o0er )$ H* andF H'pertensi0e Tar*et3or*an da a*e 1or C>?2 or Independant cardio0ascular ris@ factors
Ele0ated s'stolic BP Ci*arette s o@in* A/nor al lipid profile Stron* fa il' &istor' of pre ature C> disease Truncal o/esit' Sedentar' Difest'le

A2er )e 8B( eB* " 1r 12er 80 $$H) &d di -ete%

Di"retics

81lockers

3T) receptor 1lockers

;81lockers

Ca 3ntagonist

3CE Inhi1itors
+66. -"i$elines for /anagement of Hypertension< = of Hypertension +66. C>I> : 0erapamil ? @&locker ESH.ESC 2003

BNC 6F Mana*e ent of H'pertension /' Blood Pressure Classification

Initial Dr"g Therapy &P Classification
Normal G.20/80 $$ H) Prehypertension )+68).*7B68B* mm Hg Stage ) hypertension .40-.74/40-44 $$ H)

Lifestyle /o$ification
E&51*r )e :es Ie%

Aitho"t Compelling In$ication

Aith Compelling In$ication

No $r"g in$icate$ T/i Cide-t,#e di*reti5% 01r $1%t> $ , 51&%ider ACE-IF ARBF BBF CCBF 1r 51$-i& ti1& 2-dr*) 51$-i& ti1& 01r $1%t D*%* "", t/i Cide-t,#e di*reti5 &d ACE-IF ARBF BBF 1r CCBE

Dr"g s! for the compelling in$ications 8r*)D%E 01r t/e 51$#e""i&) i&di5 ti1&%> 1t/er &ti/,#erte&%i2e dr*)% Ddi*reti5%F ACE-IF ARBF BBF CCBE % &eeded 8r*)D%E 01r t/e 51$#e""i&) i&di5 ti1&%> 1t/er &ti/,#erte&%i2e dr*)% Ddi*reti5%F ACE-IF ARBF BBF CCBE % &eeded

Stage + hypertension H.60/.00 $$ H)

Ie%

ACE-I < &)i1te&%i&-51&2erti&) e&C,$e i&/i-it1r> ARB < &)i1te&%i&-re5e#t1r -"15!er> BB < -et -"15!er> CCB < 5 "5i*$ 5/ &&e" -"15!er. C/1- &i & A; et ". JAMA. 2003>284:2760-2792.

Co pellin* Indications for Indi0idual ?ru* Classes

!ompelling &ndi#ation ?ia/etes &nitial ,herap% >ptions THIAK9 BB9 ACE9 ARB9 CCB ACEI9 ARB !lini#al ,rial Basis
NKC3A?A 5uideline9 UKP?S9 ADDHAT NKC 5uideline9 Captopril Trial9 RENAAD9 I?NT9 REIN9 AASK

C&ronic @idne' disease

Recurrent stro@e THIAK9 ACEI pre0ention

PRO5RESS

JNC 7 2003