HIPERTENSI

HIPERTENSI : Problem kardiovaskuler : Stroke, GPDO, PJK, Aneurisma, Hipertensi krisis Komplikasi : - Memperpendek usia; - Harapan hidup <<; - Biaya pengobatan >>

INSIDEN : Tahun - tahun >> TGT : - Kesadaran masyarakat kesehatan - Check up rutin : 10 - 20% ( USA : 15 - 20%; JEPANG : 15 - 22% Singapura : 14%; India : 15%; Philiphina : 10,8% Indonesia : 15%) Perlu survei yg luas pada masyarakat - Case finding - Problem kesehatan masyarakat Pengobatan yang rasional : - Komplikasi dihindari - Umur >> - Kualitas hidup

FENOMENA GUNUNG ES
H. + Keluhan + Pengobatan baik H. + Komplikasi H. + Keluhan + Pengobatan tak baik

H. Tanpa keluhan Border line Nomiotensi

DEFINISI
Piekerning : Tek Darah : - Umur - Sex - Lingkungan Hence Kaplan : Tek darah Prognosa Penatalaksanaan : O < 45 th : 130/90 mm Hg O > 45 th : 140/95 mm Hg O- segala umur : 160/95 mm Hg : Tek darah > 140/90 mmHg : Tek darah > 140/90 mmHg : Tek darah > 140/80 mmHg

NYHA WHO (1993) JNC (1997)

Kriteria

: Diastole 96 - 100 Std I 100 - 109 Std II 110 - 119 Std III > 120 Std IV

Hipertensi sistolik : Tek sitole > 160 mmHg

1. Umur : >> umur Tek darah >> Kriteria 160/90 Hipertensi Umur : Hipertensi sistolik 2. Sex : Muda Pria > Wanita > 45 tahun Pria = Wanita

FAKTOR PREDISPOSISI

3. BB

: Gemuk Hipertensi Hipertensi Gemuk Hipertensi gemuk > BB ideal Kenaikan 10 kg dari BB ideal >> tensi, 3 mmHg

4. Hiriditer : OT Anak Anak dengan OT (+) 2 Anat OT (-) 5. Garam : NaCl Na air 6. Stress : Stress Hipotal Catekol >> Sympatis >> Resistensi >> 7. Sosio ekonomis : - Kota > didesa - Tegang, Makanan, Olah Raga 8. Lain-Lain : Rokok, Kopi, Alkohol

PENYEBAB
1. PRIMER (IDIOPATIK) = ESSENSIAL
- 80 -90 % Prevalensi Hipertensi - Faktor : Usia, Sex, BB, Heriditas, Stress, Garam - NaCl : 5 - 15 gr/hr Prevalensi > 15 - 20 % - Simpatis >> Parasimpatis << (Neurogenik) COP >> - Ginjal : Pengaturan air + garam Renin angiotensin sistem - Na >> Tek Darah >> - Simpatis >> Tek Darah >> - Atas dasar renin HE 1. HE Tinggi Renin : - Muda - NOR Adrenalin >> - COP >> 2. HE Normo Renin 3. HE Rendah Renin : - Tua - Resistensi >>

Renin Angistensin I ACE Angistensin II Vasokonstriksi Aldosteron Na Vol Tek Darah

RAAS

Aktivasi RAA
COP Angiotensi I Angiotensi II Afterload

Vasokonstruksi
Aldosteron

Preload

2. Hipertensi Sekunder (H.S.)

10% Prevalensi Hipertensi
A. GINJAL : Parenchym : - GHA / GNC - PHA / PNC - Polikistik ginjal - Kimmel Stiel-Wilson - Peny Kollagen - DM - Tumor - Batu - Stenosis A. Renalis - Nephro Sklerosis - Fistula A - V - Obstruksi : Tumor

Vaskuler :

B. HORMONAL :

- Phaechromacytoma - Cushing S.

C. COARCTATIO AORTA D. KEHAMILAN : Eklampsi E. KEL. SYARAF

KOMPLIKASI
Gejala : Individual : - Pusing, mual, muntah - Kaku Kuduk - Iritable - Keluhan (-) 1. H LVH Gagal Jantung 2. H Atherosklerosis P.J.K

LVH : Tingginya tekanan darah LVH GNA, Eklamspi, Phaechroma LVH LHF
Frohliek : Kel Jantung OK H. I. Besar DBN EKG, X Foto II. LAH, Gallop (BJ 4) III. LVH, EKG X Foto IV. LVF

LV DELAT

Tek Darah
L.V. Wall Tension L.V. O2 Consump Miokard Hypobia Diastolic Compliance LVEDP

LVH

LVF

ATHEROSKLEROSIS
Atherosklerosis >> Atherom Plaque >> Trombus Lumen A. Coroner << (> 50% Lumen) P.J.K

MC Kenna : PJK - H 22% ASPAC Boedi D. Sutanegara Antono E. : 15% : 16% : 22% : 28,6%

D. Sargowo

: 21,6%

AP

MCI

SD

Mortality risk in relation to sex and B.P.

Systolic blood pressure mmHg Standard risk
8797 98127
128-137 138-147 148-157 158-177 178-197 > 198
woman men

Diastolic blood pressure

48-68 69-83 83-88 88-93 93-98 98-108 108-118 > 118 0 100 200 300 400 500 600 700 800
woman men

Mortality ratio in %

Klasifikasi hipertensi untuk umur 18 th ( JNC VII )

Klasifikasi
Normal Prehipertensi Stadium 1 Stadium 2

Sistolik (mmHg) < 120 120 - 139 140-159 160

Diastolik (mmHg) < 80 80 - 89 90-99 100

Severe Hypertension

Patient assessment
Complete cell blood count Complete metabolic panel ECG : ischemic, infarct ? Radiography : cardiomegaly,pulmonary edema,aortic abnormality

PENATALAKSANAAN (WHO)
1. HIPERTENSI : 1. Non Farmakologik - Diet - OR - Stress (-) - Rokok (-) 2. Fakmakologik Stepped care WHO I, II, III, IV. 2. KOMPLIKASI : LVF : Kontraksi : Inotropik Preload : Diuretik Afterload : - Vasodelator - Ace inhobitor : - Suplai O2 : - Vasodelator Nitrat, Acenning - Ca antagonis - Demand O2 : Blocker

PJK

MANAGEMENT HIPERTENSI PADA DIABETES

Vasokonstriksi Direct sel otot polos vaskuler HT, atheroschlerosis

Ang II

Faktor pertumbuhan (bFGFs, PDGF, TGF1, IL-6, PAF, Arachidonat) kardiomiosit: LVH , sel2 mesangial: glomeruloschlerosis, sel otot polos vaskuler: HT, atheroschlerosis

Tonus saraf simpatik sel2 otot polos vaskuler : HT, kardiomiosit : LVH

In patients with proteinuria > 1g and renal insufficiency blood pressure goal < 125/75 mmHg

Dietary and Lifestyle Modifications

Maintain weight loss (5 10%) Exercise 3045 min at least three times per week Reduced sodium intake to 100 mmol (2.4 g) per day Smoking cessation Adequate intake of dietary potassium, calcium, and magnesium Reduced alcohol intake to <1 oz of ethanol (24 oz of beer) per day Diet rich in fruits and vegetables but low in fat

Lifestyle Modification to Lower Blood Pressure

Stults B. Diabetes Spectrum 2006; 19: 25

Pharmacologic Treatment

Advances in the Treatment of Hypertension

Chobanian AV. N Engl J Med 2009;361:878-87, 2009

Pharmacologic Therapy
ACE Inhibitors (SOLVD Trial) Angiotesin II Receptor Blockers (ARB) (RENAAL, IRMA II, IDNT Study) -Blockers (UKPDS Study) Calcium Channel Blockers (CCB) (ABCD Trial) Diuretics (ALLHAT Study)

Effects of Hypertension Treatment on Morbid Events

Comparative Drug Trials in Patients with Hypertension

Chobanian AV. N Engl J Med 2009;361:878-87, 2009

In patients with proteinuria > 1g and renal insufficiency blood pressure goal < 125/75 mmHg

Algorithm for Management of Hypertension

Chobanian AV. N Engl J Med 2009;361:878-87, 2009

Blood pessure > 130/80 mmHg on two visits < month apart Blood pessure > 140/90 mmHg or albuminuria or TOD

Blood pessure 130-139/80-89 mmHg No Albuminuria No other TOD

Lifestyle modification for 3 months

Management of Hypertension in Diabetes

Blood pressure > 130/80 mmHg ACE inhibitors or ARB therapy or thiazzide if no albuminuria or TOD Lifestyle modification Consider two-drugs therapy if blood pressure > 150/90 mmHg Blood pressure > 130/80 mmHg after 1 month Add thiazide (or twice daily loop diuertic if creatinine > 1.8 mg/dlor estimated GFR < ml/min/1.732) add ACE inhibitor or ARB if on thiazide Blood pressure > 130/80 mmHg after 1 month Add nonDHP CCB (veraparmil or diltiazem) Blood pressure > 130/80 mmHg after 1 month

Add DHP CCB

Substitute DHP CCB for monDHP CCB Add -blocker Blood pressure > 130/80 mmHg after 1 month

Recess for causes of resistant hypertension Consider consultation with specialist

Fixed-dose Combinations
Diuretic + Ace ARB -Blockers

Other Combinations

Chobanian AV. N Engl J Med 2009;361:878-87, 2009

The Hypertension Paradox

More Uncontrolled Disease Despite Improved Therapy

INADEQUATE CONTROL OF HYPERTENSION IN DIABETES

only 15%of those with a BP 140/90 mmHg, were started on antihypertensive medication 2836% of diabetic hypertensive patients have their blood pressure controlled to < 130/80 mmHg

Rates of Awareness, Treatment, and Control of High Blood Pressure in the United States (19762004

Chobanian AV. N Engl J Med 2009;361:878-87, 2009

Changes in the Prevalence and Control of Hypertension in the United States (19882004)

The rate of control has increased from 27% to 35% during the same period

CONCLUSIONS
The presence of hypertension in diabetic patients significantly increases their risk of micro- and macrovascular complications. This "deadly duo" increases the cardiovascular event rate two fold Hypertension among diabetic patients has been linked with - nephropathy - retinopathy, - development of cerebrovascular disease, - significant decline in cognitive function Target BP control < 130/80mmHg (<125/75 mmH if microalbuminuria > 1g/day

Principles of Therapy for Hypertensive Emergencies

Patients must be hospitalized for monitoring Dire consequences of lowering BP too quickly Treated with parenteral Lower MAP {1/3(SBP-DBP)+DBP} by 25% within 1-2 hours or diastolic 110 mmHg, then 160/100 mmHg within 2-6 hours. Exception for ischemic stroke IV infusion is prefer than bolus Avoid the urge to turn to sublingual nifedipine

Hypertension,Brian C. Poole and Anitha Vijayan in Nephrology and Subspeciality Consult,Lippincott Williams and Wilkins,2004

Preferred Drugs for Selected Hypertensive Emergencies

Emergency Preferred Drugs Drugs to Avoid

CVA

Nicardipine Labetalol Nitroprusside Diltiazem Nitroprusside Labetalol Diltiazem Nicardipine Nitroprusside Nitroglycerine Enalaprilate Loop Diuretics Nitroglycerine Nicardipine Nitroprusside Diltiazem Nitroprusside Labetalol Esmolol

Diazoxide,hydralazine (increase ICP)

Hypertensive Encephalopathy

Congestive Heart Failure

Labetalol and Esmolol (decreased HR)

Myocardial infarct,Ungina

Diazoxide,hydralazine (increase HR,O2 demand

Aortic Dissection

Diazoxide,hydralazine, nicardipine

Hypertensive emergencies,Roy Colven,in Emergency Medical Therapy,2000. WB saunders Company

PANDUAN DOSIS & PENGGUNAAN NICARDIPINE INJEKSI

INDIKASI
1. HIPERTENSI EMERGENSI Dosis : 0.5 6 Mcg/Kg BB/menit (syeringe pump / infus drip) : 2 10 Mcg/Kg BB/menit (syeringe pump / infus drip) 10 30 Mcg/Kg BB/menit ( bolus I.V. )

2. Krisis hipertensi akut selama tindakan operesi

Dosis

SYRINGE PUMP KRISIS HIPERTENSI AKUT SELAMA OPERASI

INDIKASI Nicardipine injeksi 1 ampul 10 mg Spuit 50 cc (mL/jam) Atau Pediatric Drip (=1 cc = 60 tetes)

HIPERTENSI EMERGENSI BERAT BADAN 40 kg 50 kg 60 kg 70 kg 80 kg 90 kg DOSIS NICARDIPINE INJEKSI (mcg/kg BB/menit)

0.5
6 8 9 11

1.0
12 15 18 21

1.5
18 23 27 32

2.0
24 30 36 42

3.0
36 45 54 63

4.0
48 60 72 84

5.0
60 75 90 105

6.0
72 90 108 126

7.0
84 105 126 147

8.0
96 120 144 168

9.0
108 135 162 189

10.0
120 150 180 210

12
14

24
27

36
41

48
54

72
81

96
108

120
135

144
162

168
189

192
216

216
243

240
270

Pelarut / cairan infus yang dapat digunakan a.l :

Sodium Chlorida / NaCl, Dextrose 5%, Potacol-R, Glucose 5%, Ringer Asetat, KN Solution 1A, KN Solution 1B,
kecuali Sodium bicarbonat & Ringer Laktat

Dosis diltiazem-injeksi pada Hipertensi Krisis

Konsentrasi diltiazem-injeksi 0.1% (1mg/ml/100 mg/100 cc) Laju infus (ml/jam)

Dosis * Berat Badan (kg) (ug/mnt)

5 12 15 18 21

10 24 30 36 42

15 36 45 54 63

40 50 60 70

BAGAN DOSIS NITROGLYCERINE

Dosis :10-200 ug/menit KONSENTRASI 5 x amp 10 ml nitroglycerine dalam 500 ml 10 20 30 40 50 60 70 80 90 100 110 KECEPATAN INFUS DIENCERKAN KONSENTRASI 100 g/ml: 5 x amp 10 ml nitroglycerine dalam 50 ml 10 20 30 40 50 60 70 80 90 100 110 KECEPATAN INFUS

mll/jam drop/menit
6 12 18 24 30 36 42 48 54 60 66

ml/jam drop/menit
0,6 1,2 1,8 2,4 3,0 3,6 4,2 4,8 5,4 6,0 6,6

120
130 140 150

72
78 84 90

120
130 140 150

7,2
7,8 8,4 9,0

HTN Urgencies
No proven benefit of rapid BP reduction in asymptomatic patients Goal BP <160/110 mmHg or fall less than 25% MAP within 6 hours Oral medications preferred,shortacting given in repeated doses Close monitoring for overshoot hypotension

Drugs for hypertensive urgencies

Captopril Enalaprilate Clonidine loading Labetalol Prazosine nitroglycerine minoxidil

Clonidine:8-12 hrs,captopril : 4-6 hrs, labetalol: 4-8 hrs

Cerebral Perfussion Pressure CPP=MAP/CVR. To maintain CPP, changes in MAP must be matched by compensatory changes in CVR. In normal nonhypertensive subjects, CBF is relatively constant with CPPs (or MAPs) : 60 to 150 mm Hg Neuronal death occurs when CBF is reduced below 10 to 15 mL/100 g per minute

Cerebral Perfussion Pressure

CPP = MAP ICP CBF =

CPP ICP CBF r n l

8 CPP r4

nl
: Cerebral Perfusion Pressure : Intracranial Pressure : Cerebral Blood Flow : vessel diameter : viscosity : vessel length

Blood pressure management in ICH

Recommendation in patients with history of chronic hypertension in spontaneous ICH

Recommendation in patients with history of chronic hypertension (for the first few hours) 1. if systolic BP is >180 mmHg, diastolic BP >105 mmHg, or mean arterial BP 130 mmHg on 2 readings 20 minutes apart, institute intravenous medications (level of evidence V, grade C recommendation). 2. if systolic BP is < 180 mmHg and diastolic BP < 105 mmHg, defer antihypertensive therapy. 3. In patients with ICP who have an ICP monitor, CPP (MAP ICP) should be kept > 70 mm Hg (level of evidence V, grade C recommendation).

Recommendation in patients with history of chronic hypertension in spontaneous ICH

3. MAP > 110 mm Hg should be avoided in the immediate postoperative period 4. If systolic BP falls below 90 mm Hg pressure should be given

Recommendation in patients without history of chronic hypertension in spontaneous ICH

Increased risk of hemorrhagic formation when diastolic BP > 100 mmHg.

After ICH as a rule, systolic pressure of approximately 140-160 mmHg and diastolic pressure of 90-100 mmHg suffice for adequate systemic, cerebral and coronary perfusion

1.

In general:
Treatment of BP in patients with spontaneous ICH more aggressive than ischemic stroke Rationally theoretical Lowering BP decrease the risk of ongoing bleeding Over aggressive treatment of BP CPP brain injury >> if ICP

Blood pressure management in Acute Ischemic Stroke

Blood pressure management in Acute Ischemic Stroke

No specific data defining the levels of hypertension that should trigger treatment in these settings. By consensus, recommended that acute treatment be withheld in patients with SBP is >220 mm Hg or the DBP is >120 mm Hg Drugs that can lead to precipitous declines in blood pressure such as sublingual calcium channel antagonists should be avoided Exceptions to the recommendation to avoid treatment of acute hypertension noted in the American Stroke Association scientific statement include patients with hypertensive encephalopathy, aortic dissection, acute renal failure, acute pulmonary edema, acute myocardial infarction, or severe Hypertension. January 12, 2004;43:137.) hypertension

Tragedi Sampit

Telah nampak kerusakan di darat dan di laut disebabkan perbuatan tangan manusia, supaya Allah merasakan kepada mereka sebahagian dari (akibat) perbuatan mereka, agar mereka kembali (ke jalan yang benar) QS. Ar Ruum (30) : 41

 Jikalau Allah menghukum manusia karena kezalimannya, niscaya tidak akan ditinggalkanNya di muka bumi sesuatupun dari makhluk yang melata, tetapi Allah menangguhkan mereka sampai kepada waktu yang ditentukan. Maka apabila telah tiba waktu (yang ditentukan) bagi mereka, tidaklah mereka dapat mengundurkannya barang sesaatpun dan tidak (pula) mendahulukannya Qs. An Nahl (16) : 61

Dan bila dikatakan kepada mereka: Janganlah kamu membuat kerusakan di muka bumi, mereka menjawab: "Sesungguhnya kami orang-orang yang mengadakan perbaikan." Ingatlah, sesungguhnya mereka itulah orang-orang yang membuat kerusakan, tetapi mereka tidak sadar. (Qur'an, 2:11-12)

CASE PRESENTATION

CASE-1: A 39 years old pregnant female in OBGYN department presented with seizure 1 hour before admission, initially with headache. She had a recurrent abortus (2x). She had a history of strumectomy and performing ablation in 1988. History of hypertension was denied. She has been consulted to our ward to manage her high blood pressure. during pre operation procedure. Our examination revealed BP was 180/100 mmHg, PR was 110x/m, RR was 20x/m. slow speech, brittle hair, dry skin, mix edema, Deep tendon reflex was decreased. TFU ~1/2 proc. Xyphoid -umbilicus. Laboratory result revealed low FT4 level and High TSH level. How do you manage this patient?

CASE PRESENTATION

Problem list: 1. GVP1100Ab200, 36-38 weeks, HSVB, BOH, >35 y.o 2. Obs. Seizure 2.1 Emergency HT superimposed preeclampsia 3. Recurrent abortion 3.1 Antiphospholipid syndrome 3.2 Sticky platelet syndrome 4. Eclampsia

CASE PRESENTATION

CASE 2 A 40 y.o female has been consulted from Surgery department. She presented with burn trauma on her face, both arms and legs after she got blast from LPG when she was cooking. She will be performed debridement, but the blood pressure was 210/120 mmHg. No hypertension before. How do you manage the patient?

CASE PRESENTATION

CASE 3 A How do you manage the patient?