HYPERTENSION MANAGEMENT:

WHAT ARE THE GUIDELINES’

RECOMMENDATION?

Antonia Anna Lukito

Webinar PERKI
18 April 2020
 OUTLINES

• Brief Information on Hypertension

• Comparison of International
Guidelines
• Indonesia: Konsensus Penatalaksanaan
Hipertensi 2019
BRIEF INFORMATION ON
HYPERTENSION
 INTRODUCTION

• It affects nearly 1 billion people worldwide – around 25% of

the adult population. (Indonesia 2018 = 34.1%)
• Prevalence of hypertension is similar in both men and women
and increases with age consistently in all world regions.
• As BP tends to increase with age and as the trend for longer
life continues, hypertension is likely to become more
prevalent in the future.
• Although hypertension is frequently asymptomatic, it is one of
the most commonly treated disorders, because it increases
the risk of CVD ie IHD and stroke.
 RISK FACTORS OF
HYPERTENSION - MODIFIABLE
Obesity – There is a strong link between obesity and
high BP. Losing weight has been shown to reduce BP. It
is possible that dietary factors – high salt, high fat and
low K – contribute to high BP
Diet – High Na intake and low K or Ca intake have
been linked to high BP, as has a diet high in animal fats
(saturated fats).
Lack of exercise – Regular, moderate exercise may
help to lower BP.
Hyperlipidemia – increased plasma lipid levels (total
cholesterol, LDL, triglycerides) is a characteristic of
metabolic syndrome and is a risk factor for CVD
Hypertension and high plasma lipids often occur
concomitantly and joint treatment is often
recommended. Losing weight, reducing dietary fat
intake and increasing exercise can help lower
cholesterol and triglyceride levels.
Smoking – There is an acute rise in BP and HR following
smoking even one cigarette, and heavy smoking is associated
with a persistent rise in BP and also with an increase in BPV.
Smoking is also a strong RF for CVD, and the cessation of
smoking is considered to be the single most effective
measure for the prevention of CVDs including stroke and
MI.
Alcohol abuse – There is a close relationship between
alcohol consumption and BP:, the greater the alcohol intake,
the higher the BP. HTN is common among heavy drinkers.
However, moderate drinkers appear to have a reduced risk
of CVD.
Type2-DM– There is an interrelation between DM and
HTN, with 50% of individuals with DM also being HTN. The
coexistence of HTN and DM increases the risk of
developing renal and other organ damage and has a higher
incidence of CVD including stroke, CAD, CHF, PAD and CV
mortality. Strict control of blood glucose can reduce the risk
of high BP and the lowering of BP in DM patients has been
shown to reduce CV risk.
Stress – Despite popular conceptions, a link between stress
and HTN has not been reliably demonstrated
 RISK FACTORS OF HYPERTENSION -
UNMODIFIABLE

Family history – HTN ‘runs in families’, and ‘normotensive’ children of HTN parents tend
to have higher BPs than comparable individuals without HTN parents. The effect is thought
to be due to a combination of genetic predisposition and environmental factors.
Gender – Until the menopause, women are much less prone to develop HTN than men
of the same age. After the menopause, the risk eventually equalizes – it is believed that the
difference is due to a protective effect of the female sex hormones.
Age – SBP tends to rise with age in Westernized societies; DBP rises until about age 60
then tends to fall. However, in rural non-Westernized societies, HTN is rare and BP rises
with age are minimal. This suggests that the rise is a result of diet, lifestyle and
environmental factors rather than the aging process alone.
Ethnicity – Ethnic origin appears to have some effect on the risk of HTN – in
Westernized societies the prevalence of HTN is higher among Afro-Caribbean people than
among white people. However, since HTN is rare among Afro-Caribbean people in rural
Africa, this suggests that some environmental factors may have a greater impact on Afro-
Caribbean individuals. Japanese people who moved from Japan to the USA showed a fall in
the high rates of HTN and stroke seen in Japan, but an increase in IHD. Once again, this
demonstrates some kind of interaction between environment and ethnic origin.
COMPARISON OF
INTERNATIONAL
GUIDELINES
 TALES OF HYPERTENSION
ALTITUDE
GUIDELINESACCOMPLISH
ON TARGET
ACCF/AHA
HYVET
SPRINT
REIN-2 ESH/ESC ACCORD-BPESC/ESH

CAMELOT ACC/AHA NICE ASH-ISH

2003 2005 2007 2009 2011 2014 2017 2018

JNC 7 JNC 8 ACC/AHA ESC/ESH
BLOOD PRESSURE DEFINITION
ESC 2018 ACC/AHA 2017

KATEGORI TDS TDD

Optimal < 120 mmHg dan <80 mmHg INASH 2019

dan/a
Normal 120-129 mmHg 80-84 mmHg
tau
dan/a
Normal-tinggi 130-139 mmHg 85-89 mmHg
tau
dan/a
Hipertensi derajat 1 140-159 mmHg 90-99 mmHg
tau
dan/a 100-109
Hipertensi derajat 2 160-179 mmHg
tau mmHg
INITIAL BP FOR TREATMENT
ACC/AHA 2017

Whelton et al. JACC vol 71;19:e127-248

INITIAL BP FOR TREATMENT
ESC 2018
 CHOICES OF DRUG THERAPY

ESC 2018

ACC/AHA 2017
CHOICES OF DRUG THERAPY

The Resolution ( for Clinical Practice)

➤ Broad agreement that the basis for therapy
is ARB or ACEI,CCB and thiazide /thiazide
like agents (B blocker when indicated)
➤ Startwith combination therapy (single pill
preferred)
BP TARGET FOR TREATMENT:
➤ ACC/AHA 2017 :
ELDERLY
 Elderly age of > 65 yo
 Treat more intensively ( based on NHANES; >65% has
ASCVD risk 88%, >75% has ASCVD risk 100%)
 Target SBP <130/80 mmHg
➤ ESC 2018 :
 Old > 65 yo , Very Old > 80 yo
 > 65 yo treat less intensively
 Target SBP 130 - 139 mmHg
 ACC/AHA 2017 vs ESC 2018
DIFFERENCES SIMILARITIES
Accurate diagnosis for hypertension
BP definition
detection
Out of office BP for white coat and masked
BP classification
HT

Target BP therapy in elderly BP therapy based on CV risk assessment

Drug treatment and non pharmacological

Target BP for treatment
lifestyle for BP lowering
Add antihypertensive to non
CV risk assessment method pharmacological therapy at lower BP
threshold
Combination therapy preferably single pill
combination

Lower BP target for treatment

KONSENSUS PENATALAKSANAAN HIPERTENSI 2019
Perlunya Panduan Hipertensi Indonesia
Konsensus Hipertensi Indonesia 2019
 Diagnosis Hipertensi
Diagnosis hipertensi ditegakkan bila TDS ≥140 mmHg dan/atau
TDD ≥90 mmHg pada pengukuran berulang di klinik

KATEGORI TDS TDD

Optimal < 120 mmHg dan <80 mmHg

Normal 120-129 mmHg dan/atau 80-84 mmHg

Normal-tinggi 130-139 mmHg dan/atau 85-89 mmHg

Hipertensi derajat 1 140-159 mmHg dan/atau 90-99 mmHg
Hipertensi derajat 2 160-179 mmHg dan/atau 100-109 mmHg
Hipertensi derajat 3 ≥ 180 mmHg dan/atau ≥ 110 mmHg
Hipertensi sistolik terisolasi ≥ 140 mmHg dan < 90 mmHg
 Batasan Tekanan Darah di Klinik & luar Klinik
untuk Diagnosis Hipertensi

Kategori TDS TDD (mmHg)

(mmHg)
TD Klinik ≥140 dan/atau ≥90

ABPM

Rerata pagi-siang hari (atau bangun) ≥135 dan/atau ≥85

Rerata malam hari (atau tidur) ≥120 dan/atau ≥70

Rerata 24 jam ≥130 dan/atau ≥80

Rerata HBPM ≥135 dan/atau ≥85

Ambang Batas TD untuk Inisiasi Obat
Alur Panduan Inisiasi Terapi Obat Sesuai
dengan Klasifikasi Hipertensi
 PENILAIAN HMOD
(HYPERTENSION-MEDIATED ORGAN DAMAGE)
Target Tekanan Darah di Klinik
 Obat Hipertensi Oral
Frekuens Frekuensi
Dosis KELAS OBAT Dosis (mg/hari)
per hari
KELAS OBAT i
(mg/hari) OBAT-OBAT LINI KEDUA
per hari
Diuretik loop Furosemid 20 – 80 2
OBAT-OBAT LINI UTAMA
Torsemid 5 – 10 1
Tiazid atau HCT 25 – 50 1 Diuretik hemat Amilorid 5 – 10 1 atau 2
thiazide-type Indapamide 1,25 – 2,5 1 kalium Triamteren 50 – 100 1 atau 2
diuretics Diuretik antagonis Eplerenon 50 – 100 1 atau 2
ACE inhibitor Captopril 12,5 – 150 2 atau 3 aldosteron Spironolakton 25 – 100 1
Enalapril 5 – 40 1 atau 2 Beta bloker - Atenolol 25 – 100 1 atau 2
Lisinopril 10 – 40 1 kardioselektif Bisoprolol 2,5 – 10 1
Perindopril 5 – 10 1 Metoprolol 100 - 400 2
Ramipril 2,5 – 10 1 atau 2 tartrate
ARB Candesartan 8 – 32 1 Beta bloker– Nebivolol 5 – 40 1
kardioselektif
Eprosartan 600 – 800 1 atau 2
vasodilator
Irbesartan 150 – 300 1
Losartan 50 – 100 1 atau 2 Beta bloker – non Propanolol IR 160 – 480 2
kardioselektif Propanolol LA 80 – 320 1
Olmesartan 20 – 40 1
Telmisartan 20 – 80 1 Beta bloker – Carvedilol 12,5 – 50 2
Valsartan 80 – 320 1 kombinasi reseptor
CCB - Amlodipin 2,5 – 10 1 alfa dan beta
dihidropiridin Felodipin 5 – 10 1 Alfa-1 bloker Doxazosin 1–8 1
Nifedipin OROS 30 – 90 1 Prazosin 2 – 20 2 atau 3
Lercanidipin 10 - 20 1 Terazosin 1 – 20 1 atau 2
CCB – Diltiazem SR 180 – 360 2 Sentral alfa-1 agonis Metildopa 250 – 1000 2
nondihidropiri Diltiazem CD 100 – 200 1 dan obat sentral Klonidin 0,1 – 0,8 2
lainnya
din Verapamil SR 120 – 480 1 atau 2
Direct vasodilator Hidralazin 25 - 200 2 atau 3
Minoxidil 5 – 100 1–3
Strategi Penatalaksanaan Hipertensi Tanpa
Komplikasi
Strategi Pengobatan pada Hipertensi dengan
Penyakit Arteri Koroner
Strategi Pengobatan pada Hipertensi dan PGK*

*PGK : Penyakit Ginjal

Kronik
Strategi Pengobatan Hipertensi dan Gagal
Jantung dengan Fraksi Ejeksi Menurun
Strategi Pengobatan Hipertensi dan Fibrilasi Atrial
Pharmacologic treatment recommendations of hypertension
complicated by co-morbidity
 How Low Should We Go?

• There is a linear relationship between SBP and

cardiovascular risk, above SBP of 115 mm Hg
• There remains a concern regarding the potential for a ‘J’
shape curve on treated BP levels
• In November 2015 the results of ‘The SPRINT’ trial were
published in the NEJM
• In March 2016 an updated meta-analysis on target SBP
levels was published in the Lancet
• HOPE 3 was published in April 2016 in NEJM
• These studies have yet to impact on published BP
guidelines but they are likely to have significant impact in
32
the months ahead
 Conclusions
• The decision to embark on drug therapy will not be dictated
solely by the level of BP but by an assessment of overall CV
risk
• Unless the CV risk is low and or SBP < 150 mmHg, treatment
should be started with dual-drug therapy
• ACEi/ARBs, CCB or Thiazides or thiazide like diuretics are the
usual first choices of drugs
• Remember out of office BP to ensure that apparently
resistant hypertension is real and check on concordance
• There remains a concern regarding the potential for a ‘J’
shape curve on treated BP levels
#BersatuKitaBisaMelawanCovid-19
#TELEMEDICINE-KKJI-COVID-19TIMES

TERIMA KASIH