DIAGNOSIS &

TATALAKSANA
UMUM HIPERTENSI
Syafrizal nasution

GAWAT !!!!!!!

Sindroma hipertensi: bukan hanya

sekedar TD yang tinggi
Penurunan
Regangan arteri
Obesitas

Disfungsi
endotel

Metabolisme
Lemak abnormal

Metabolisme
Glukosa abnormal

Hypertension
Accelerated
Atherogenesis

Disfungsi
Neurohormonal

Hipertropi & Disfungsi

Ventrikel kiri
Metabolisme
Insulin Abnormal

Gangguan Fungsi
Ginjal
Perubahan
mekanisme
Pembekuan darah

Kannel WB. JAMA. 1996;275:1571-1576. Weber MA et al. J Hum Hypertens. 1991;5:417-423. Dzau VJ et al. J
Cardiovasc Pharmacol. 1993;21(suppl 1):S1-S5.

Impact of high-normal BP on CV risk

16
14
Cumulative 12
10
incidence of 8
CV events
6
(%)
4
2
0
12
Cumulative 10
incidence of 8
CV events 6
4
(%)
2
0

High-normal BP

Men

Normal BP
Optimal BP

Women

High-normal BP
Normal BP

6
Years

10

12

Optimal BP

Optimal BP: <120/80 mmHg; normal BP: 120-129/80-84 mmHg;

high-normal BP: 130-139/85-89 mmHg
BP, blood pressure; CV, cardiovascular

Vasan RS, et al. N Engl J Med 2001;345:1291-1297

Hypertension Risk for

ESRD

Compared with BP < 120/80 mmHg, the

adjusted relative risks for developing ESRD in
subject without baseline renal disease:
RR
CI
BP
1,62

95% CI (1,27 - 2,07)

120-129 / 80- 84

1,98

95% CI (1,55 2,52)

130-139 / 85-89

2,59

95% CI (2,07-3,25)

140-159 / 90-99

3,86

95% CI (3,00 4,96)

160-179 / 100-109

3,88

95% CI (2,82- 5,34)

180-209 / 110-119

4,25

95% CI (2,63-6,86)

210 / 120
Hsu, et al. Arch Intern Med. 2005

MILLIMETRES MATTER
A 2-mmHg reduction in DBP would
result in a 6% reduction in the risk of
CHD and a 15% reduction in the risk of
stroke and TIAs

DBP, diastolic blood pressure; CHD, coronary heart disease;

TIA, transient ischaemic attack

Cook NR, et al. Arch Intern Med 1995;155:701-709

Sumut
(-)

BLOOD PRESSURE MEASUREMENT

PENTINGNYA AKURASI
PENGUKURAN TD

Ketidakakuratan pengukuran TD dapat menimbulkan

masalah perbedaan 5 mmHg membawa akibat yang
besar
Overestimasi orang dengan prehipertensi
hipertensi
Underestimasi orang dengan hipertensi
normotensi/ klasifikasi HTN yang berbeda
Perlu diketahui faktor-faktor yang mempengaruhi
akurasi pengukuran TD

POSITION OF THE
PATIENT

POSITION OF THE PATIENT

Sitting position
Arm and back are supported.
Feet should be resting firmly on
the floor
Feet not dangling.

POSITION OF THE ARM

(FALSE!!)

POSITION OF THE ARM (FALSE!!)

Raise patient arm so that the brachial artery is roughly at the

same height as the heart. If the arm is held too high, the reading
will be artifactually lowered, and vice versa.

POSITION OF THE ARM

Palm is facing up.

The arm should remain somewhat bent and completely
relaxed

BLOOD PRESSURE ASSESSMENT:

PATIENT PREPARATION AND POSTURE
Standardized Preparation:
Patient
1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the
preceding 30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before
measurement
8. Patient should stay silent prior and during the
procedure.

BLOOD PRESSURE ASSESSMENT:

PATIENT PREPARATION AND POSTURE
Standardized technique:
Posture
The patient should be calmly seated
with his or her back well supported and
arm supported at the level of the
heart.
His or her feet should touch the floor
and legs should not be crossed.

Penilaian hasil pengukuran

Adanya variasi TD dari setiap pengukuran yang

berbeda maka diagosis hipertensi harus didasarkan
pd beberapa pengukuran yg dilakukan pd
kesempatan yg berbeda.
Pada setiap kesempatan pengukuran, lakukan
minimal 2 kali pengukuran dgn interval waktu 2
menit. Jika pembacaan berbeda lebih dari 5 mmHg
maka lakukan pengukuran tambahan sampai
didapat 2 hasil pengukuran yg nilainya mendekati.
Untuk diagnosa, diambil 3 kali hasil pengukuran pd
interval waktu minimal 1 M

CRITERIA OF MEASUREMENT IN DIFFERENT METHODS

Systolic BP
mmHg

Diastolic BP
mmHg

Clinic BP

140

Home BP

135

Ambulatory BP
24 hour
Day
Night

130
135
120

90
85
80
85
70

Japan Society of Hypertension 2009

AMBULATORY BLOOD PRESSURE MONITORING - ABPM

1.
2.
3.
4.

24 hour B.P monitoring (every 15 minutes)

Today - 24 hour B.P. control is essential
Identifies dippers and non-dippers
Excludes white coat hypertension

30

BLOOD PRESSURE MAY BE AFFECTED BY MANY DIFFERENT

CONDITIONS

BLOOD PRESSURE MAY BE AFFECTED BY MANY

DIFFERENT CONDITIONS

Cardiovascular disorders
Neurological conditions
Kidney and urological
disorders

BLOOD PRESSURE MAY BE AFFECTED BY MANY

DIFFERENT CONDITIONS

Pre eclampsia in pregnant

women
Psychological factors such as
stress, anger, or fear

Eclampsia

BLOOD PRESSURE MAY BE AFFECTED BY MANY

DIFFERENT CONDITIONS

Various medications
"White coat hypertension" may occur if the medical visit
itself produces extreme anxiety

Blood Pressure Classification

JNC VII Classification 2003

BP (mmHg)
Sistolic

Diastolic

Classification

<80

Normal

130-139 and/or

85-89

Pre Hypertension

140-159 and/or

90-99

Hypertension Stage 1

160

100

Hypertension Stage 2

<130

and

and/or

Klasifikasi Tekanan Darah (WHO/ISH) 2007

Category
Optimal
Normal
High-normal
Grade 1 hypertension (mild)
Subgroup : borderline
Grade 2 hypertension (moderate)
Grade 3 hypertension (severe)
Isolated systolic hypertension
Subgroup : borderline

WHO-ISH
WHO-ISH

Systolic

Diastolic

< 120
< 130
130 - 139
140 - 159
140 - 149
160 - 179
> 180
> 140
140 - 149

< 80
< 85
85 - 89
90 - 99
90 - 94
100 - 109
> 110
<90
< 90

Klasifikasi Tekanan Darah

ESC/ESH (European Society of Cardiology/Hypertension) 2007

Journal of Hypertension 2007, 25:11051187

PENANGANAN HIPERTENSI
Sedini mungkin
Bertahap

Protokol WHO
&
JNC VII

Target
TD < 140/90 mmhg
(tanpa Komplikasi)

TD < 140/90 mmhg

(DM,PGK,PJK,)

Kerusakan
Target organ

UNDER
TREATMENT
VS

OVER
TREATMENT

Protokol

WHO
Tatalaksana Hipertensi &
Diabetes Terintegrasi
Pelayanan kesehatan tingkat
Pertama
Negara Berkembang
Usia > 40 th
Perokok
Obesitas
Hipertensi
Diabetes
Riw penyakit KV Prematur
/DM/Peny Ginjal orang tua/saudara

Langkah
Langkah
Langkah
Langkah
Langkah

Ulangi langkah 2
Ulangi langkah 3
Ulangi langkah 4
% resiko
Tentukan Kunjungan &
managemen selanjutnya

1
2
3
4
5

:
:
:
:
:

Tanyakan
Nilai
Rujuk ?
Resiko KV ?
pemberian obat?

B:Langkah
Kunjungan
II
A:Langkah
Kunjungan
I

WHO
Protokol

A:Langk
ah
Kunjung
an I

Langkah 1 : Tanyakan
Langkah 2 : Nilai
Langkah 3 : Rujuk ?
Langkah 4 : Resiko KV
(bila tdk dirujuk) ?
Langkah 5 : pemberian
obat?

Langkah 1 : Tanyakan
Penyakit jantung,
stroke,TIA,diabetes,Peny Ginjal
Nyeri dada/sesak saat aktifitas, nyeri
tungkai saat berjalan
Komsumsi Obat
Merokok
Alkohol
Pekerjaan (Statis atau mobile)
Olah raga 30 mnt/hari atau 5 hari/mgg

Langkah 2 : Nilai

Berat Badan,Tinggi badan & Lingkar Pinggang

Palpasi Jantung,Nadi perifer & Abdomen
Auskultasi jantung dan paru
Tekanan darah
KGD Puasa dan Sewaktu
Proteinuria
Ketonuria ?
Kolesterol ?
Bila DM : tes sensasi kaki & pulsasi Arteri
dorsalis pedis/tibialis

Langkah 3 : Rujuk ?
TD 140/90 mmhg pada usia<40 th ( Hipertensi
sekunder?)
Ada peny jantung,stroke,TIA,DM,peny ginjal
Angina pektoris,Klaudikasio intermiten
Perburukan gagal jantung
TD>140/90 atau 130/80 mmhg (+DM) & 2-3 obat
hipertensi
Proteinuria
Bila DM ,rujuk bila:
DM Baru dgn keton 2+/kurus ,usia<30 th
KGD>250 mg/dl dgn metformin dosis maks, (-)/
(+) SU
Infeksi berat/luka tungkai

Langkah 4 : Resiko KV (bila

tdk dirujuk)
Gunakan cara resiko WHO/ISH sesuai
ketentuan regional WHO (Searo B)
Gunakan usia, jenis kelamin,status
merokok,TDS,DM (dan kadar kolesterol)
Usia 50-59 pilih kolom usia 50,bila 60-69
th pilih kolom usia 60 dst
Untuk usia < 40 th,pilih kolom usia 40

WHO-ISH Guidelines for Management of

Hypertension: Stratification of Cardiovascular
Risk
Blood Pressure (mm Hg)
Grade 1

Grade 2

Grade 3

Mild
hypertension

Moderate
hypertension

Severe
hypertension

Other risk factors and

disease history

SBP 140159
or DBP 9099

SBP 160179
or DBP 100109

SBP 180
or DBP 110

I No other risk factors

Low risk

Med risk

High risk

II 12 risk factors

Med risk

Med risk

Very high risk

III 3 or more risk factors

or TOD or diabetes

High risk

High risk

Very high risk

Very high risk

Very high risk

Very high risk

IV ACC

TOD = Target-organ damage

ACC = Associated clinical

Guidelines subcommittee. WHOISH Guidelines. J Hypertens

Treatment initiation: WHO/ISH 1999

SBP 140-180 mmHg or DBP 90-110 mmHg on several occasions
(Grades 1 and 2 hypertension)
Assess other risk factors, TOD and ACC
Initiate lifestyle measures
Stratify absolute risk
Very high

High

Medium

Low

Begin drug
treatment

Begin drug
treatment

Monitor BP
and other risk
factors for
3-6 months

Monitor BP
and other risk
factors for
6-12 months

SBP 140 or
DBP 90
Begin drug
treatment
SBP, systolic blood pressure; DBP, diastolic blood pressure;
TOD, target organ damage; ACC, associated clinical conditions,
including cardiovascular disease and renal disease

SBP <140 or
DBP <90
Continue to
monitor

SBP 150 or
DBP 95
Begin drug
treatment

SBP <150 or
DBP <95
(borderline)
Continue to
monitor

1999 WHO/ISH Guidelines for the Management of Hypertension.

J Hypertens 1999;17:151-183

TINGKATAN RESIKO (WHO/ESC/ESH 2007)

Journal of Hypertension 2007, 25:11051187

Rekomendasi Awal terapi Hipertensi ( WHO/ESC/ESH 2007)

Journal of Hypertension 2007, 25:11051187

Jangan asal tuduh ya !!!!!!!

Framingham Risk Score```

Langkah 5 : Gunakan Obat sbb:

TD>160/100 mmhg harus segera beri obat
hipertensi
Semua DM & Peny KV (PJK,TIA, serebro vaskuler &
vaskuler perifer) bila stabil terus kan obat dan
dianggap resiko KV >30%
Semua Kolesterol total >320 mg/dl diberi statin
selain nasihat pola hidup sehat
Bila resiko <20% :
Edukasi diet,aktifitas fisik,stop merokok
Resiko<10% recheck 12 bulan
Resiko 10-20% cek/3 bln hingga target tercapai
selanjutnya tiap 6-9 bln

Langkah 5 : lanjutan
Bila Resiko 20-30%
Edukasi diet,aktifitas fisik & konseling stop
merokok
Bila TD>140/90 atau 130/80 mmhg (+DM)
pertimbangkan satu diantara dosis rendah
Diuretik,B Bloker,ACEI,CCB (pertimbangkan
ketersediaan DPHO PT Askes
Cek teratur/3-6 bln
Bila resiko >30%
Edukasi diet,aktifitas fisik & konseling stop
merokok
Bila TD>140/90 atau 130/80 mmhg (+DM)
pertimbangkan satu diantara dosis rendah
Diuretik,B Bloker,ACEI,CCB (pertimbangkan

B:Langkah
Kunjungan
II

Ulangi langkah 2
Ulangi langkah 3
Ulangi langkah 4
% resiko
Tentukan Kunjungan &
managemen selanjutnya

B:Langkah Kunjungan II
(lanjutan)
Bila Resiko <20% :
Komsumsi Obat Cek ulang /12 bulan untuk
dinilai kembali resiko kardioserebrovaskuler
Konsultasi diet,aktifitas fisik,berhenti
merokok
Bila resiko 20-30% :
Lanjutkan seperti langkah 4 & cek ulang/3 bln
Bila resiko masih tetap >30% setelah 3-6 bln
intervensi obat pada kunjungan I
Rujuk ke Tingkat sekunder

Pil Kontrasepsi & Hipertensi

Walaupun secara statistik pil kontrasepsi
meningkatkan resiko Hipertensi secara
bermakna namun resiko defenitif untuk
terjadinya hipertensi cukup kecil shg wanita tak
perlu takut mengkomsumsinya
Pengguna Pil Kontrasepsi sebaikinya cek TD
secara reguler
Wanita Hipertensi dianjurkan tdk minum pil
kontrasepsi
Pemberian kontrasepsi oral harus
mempertimbangkan manfaat & kerugiannya

Protokol

JNC VII
(The Seventh Report Of The Joint
Comitee On Prevention,
Detection,evaluation
And Treatment Of High Blood Pressure)

JNC VII: Penanganan Hipertensi sesuai

Klasifikasi TD
Initial Drug Therapy
Life Style
Without
BP Classification
Modification Compelling
Normal
<120/80 mm Hg
Prehypertension
120-139/80-89 mm
Hg
Stage 1
hypertension
140-159/90-99 mm
Hg

Encourage

With Compelling
Indication

Indication

Drug(s) for the

compelling
indications
Thiazide-type diuretics
Yes
Drug(s) for the
for most; may consider
compelling indications;
ACE-I, ARB, BB, CCB, or
other antihypertensive
combination
drugs (diuretics, ACE-I,
ARB, BB, CCB) as
needed
Stage 2 hypertension
Yes
2-drug combination for most Drug(s) for the
(usually thiazide-type diuretic compelling indications;
160/100 mm Hg
and ACE-I, ARB, BB, or
other antihypertensive
CCB)
drugs (diuretics, ACE-I,
ARB, BB, CCB) as
needed
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB =
beta blocker; CCB = calcium channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.
Yes

No drug indicated

The Newest
Guideline!!!

Algoritme Managemen Hipertensi JNC

8 2014

Algoritme Managemen Hipertensi JNC 8

2014 (cont)

Jangan sampai
ya !!!

Take Home Message

Hipertensi masih menjadi masalah global
Peningkatan TD sedikit saja akan meningkatkan
resiko morbiditas dan mortalitas KV
Pengurangan TD 2 mmhg saja akan menurunkan
resiko morbiditas dan mortalitas KV
Tatalaksana Hipertensi harus dimulai sedini mungkin
Dokter sebagai motor pelayanan kesehatan Tingkat
Pertama memegang peranan penting dalam usaha
menurunkan angka morbiditas dan mortalitas
hipertensi melalui tatalaksana yang tepat sesuai
tingkat resikonya

Thank you