Farmako Anti Hipertensi

Asupan
garam
berlebih

Jumlah
nefron
berkurang

Retensi
natrium
ginjal

Renin
angiotensin
berlebih

Perubahan
genetis

Obesitas

Perubahan
membran
sel

Hiperinsulinesmia

Konstriksi
vena

CURAH
JANTUNG

Hipertrofi
struktural

Konstriksi
fungsionil

Kontraktilitas

Preload

Hipertensi

Aktivitas
berlebih
saraf
simpatis

Penurunan
permukaan
filtrasi

Volume
cairan

TEKANAN
DARAH

Stress

Bahanbahan yang
berasal dari
endotel

TAHANAN
PERIFER

tahanan perifer

curah jantung
Autoregulasi

Blood pressure goals in hypertensive patients (ESH-ESC)

Recommendations
SBP goal for most
Patients at lowmoderate CV risk
Patients with diabetes
Consider with previous stroke or TIA
Consider with CHD
Consider with diabetic or non-diabetic CKD

<140 mmHg

SBP goal for elderly

Ages <80 years
Initial SBP 160 mmHg

140-150 mmHg

SBP goal for fit elderly

Aged <80 years

<140 mmHg

SBP goal for elderly >80 years with SBP

160 mmHg

140-150 mmHg

DBP goal for most

<90 mmHg

DB goal for patients with diabetes

<85 mmHg

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.

Lifestyle Modifications to Manage HTN

Modification

Recommendations

Approximate Systolic
Blood Pressure
Reduction

Weight Reduction

Maintain normal body

weight (BMI 18.5-24.9)

5-20 mm Hg for each

10 kg weight loss

Adapt eating plan

Consume diets rich in

fruits, vegetables, low
fat dairy and low
saturated fat

8-14 mm Hg

Dietary sodium reduction

Reduce sodium to no
more than 2.4 g/day
sodium or
6 g/day NaCl

2-8 mm Hg

Increase physical activity

Engage in regular
aerobic activity such as
walking
(30 min/day on most
days)

4-9 mm Hg

Moderate alcohol
consumption

Limit alcohol to no more

than 2 drinks/d for men

2-4 mm Hg

Source: The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

2013 ESH/ESC Guidelines for the management of arterial hypertension

Monotherapy vs. drug combination strategies to achieve target BP

Choose between

Mild BP elevation
Low/moderate CV
risk

Single agent

Switch
to different agent

Previous agent
at full dose

Full dose
monotherapy

Two drug
combination
at full doses

Marked BP elevation
High/very high CV risk

Twodrug combination

Previous combination
at full dose

Switch
to different twodrug
combination

Add a third drug

Three drug
combination
at full doses

Moving from a less intensive to a more intensive therapeutic strategy

should be done whenever BP target is not achieved.
BP, blood pressure; CV, cardiovascular.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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2013 ESH/ESC Guidelines for the management of arterial hypertension

Possible combinations of classes of antihypertensive drugs

Thiazide diuretics

-blockers

Angiotensin-receptor
blockers

Other
antihypertensives

Calcium
antagonists

ACE inhibitors
Green continuous lines: preferred combinations; green dashed line: useful combination (with some
limitations); black dashed lines: possible but less well tested combinations; red continuous line: not
recommended combination. Although verapamil and diltiazem are sometimes used with a beta-blocker to
improve ventricular rate control in permanent atrial fibrillation, only dihydropyridine calcium antagonists should
normally be combined with beta-blockers.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over
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Preferred hypertension treatment in specific conditions

Condition

Drug

Asymptomatic organ damage

LVH

LVH ACE inhibitor, calcium antagonist, ARB

Asymptomatic atherosclerosis

Calcium antagonist, ACE inhibitor

Microalbuminuria

ACE inhibitor, ARB

Renal dysfunction

ACE inhibitor, ARB

Clinical CV event
Previous stroke

Any agent effectively lowering BP

Previous myocardial infarction

BB, ACE inhibitor, ARB

Angina pectoris

BB, calcium antagonist

Heart failure

Diuretic, BB, ACE inhibitor, ARB, mineralocorticoid receptor antagonists

Aortic aneurysm

BB

Atrial fibrillation, prevention

Consider ARB, ACE inhibitor, BB or mineralocorticoid receptor antagonist

Atrial fibrillation, ventricular rate control

BB, non-dihydropyridine calcium antagonist

ESRD/proteinuria

ACE inhibitor, ARB

Peripheral artery disease

ACE inhibitor, calcium antagonist

Other
ISH (elderly)

Diuretic, calcium antagonist

Metabolic syndrome

ACE inhibitor, ARB, calcium antagonist

Diabetes mellitus

ACE inhibitor, ARB

Pregnancy

Methyldopa, BB, calcium antagonist

Blacks

Diuretic, calcium antagonist

ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BB, beta-blocker; BP, blood pressure; CV, cardiovascular; ESRD, end-stage renal
disease;
ISH, isolated systolic hypertension; LVH, left ventricular hypertrophy.

Compelling indications for hypertension treatment

Class

Contraindications
Compelling

Possible

Diuretics
(thiazides)

Gout

Metabolic syndrome
Glucose intolerance
Pregnancy
Hypercalcemia
Hypokalaemia

Beta-blockers

Asthma
AV block (grade 2 or 3)

Metabolic syndrome
Glucose intolerance
Athletes and physically active patients
COPD (except for vasodilator beta-blockers)

Calcium antagonists
(dihydropyridines)

Tachyarrhythmia
Heart failure

Calcium antagonists
(verapamil, diltiazem)

AV block (grade 2 or 3, trifascicular block)

Severe LV dysfunction
Heart failure

ACE inhibitors

Pregnancy
Angioneurotic oedema
Hyperkalaemia
Bilateral renal artery stenosis

Women with child bearing potential

Angiotensin receptor blockers

Pregnancy
Hyperkalaemia
Bilateral renal artery stenosis

Women with child bearing potential

Mineralocorticoid
receptor antagonists

Acute or severe renal failure (eGFR <30 mL/min)

Hyperkalaemia

A-V, atrio-ventricular; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; LV, left
ventricular.

Oral antihypertensive drugs*

Oral antihypertensive drugs* (continued)

ACEIs, angiotensin converting enzyme inhibitors; BBs, beta blockers; CCBs, calcium channel blockers
* In some patients treated once daily, the antihypertensive effect may diminish toward the end of the dosing interval
(trough effect).
BP should be measured just prior to dosing to determine if satisfactory BP control is obtained. Accordingly, an increase
in dosage or frequency may need to be considered. These dosages may vary from those listed in the Physicians Desk
Reference (57th ed.).
Available now or becoming available soon in generic preparations.
Source: Physicians Desk Reference. 57th ed. Montvale, NJ: Thompson PDR, 2003.

Tabel No 2 Obat-obat parenteral untuk penanganan hipertensi emergensi pd

edema paru dan sindroma koroner akut
Obat

Golonga
n

Dosis

Onset
kerja

Mas Efek samping

a
kerja

Sodium
nitroprusi
d

Vasodilato 0,25-10
r
Mg/kg/mn
Arteri &
t
vena

Segera
stlh
distop

1-2
mnt

Mual,
hipotensi,keracunan
tiosianat,
methemoglobinemia
dan sianida.

Nitrogliser Vasodilato 5-300

in
r:
mcg/mnt
Arteri &
vena

1-5 mnt

3-5
mnt

Sakit kepala, mual,

takikardia, muntah
toleransi

Isosorbid
dinitrat

1-5 mnt

3-5
mnt

Sakit kepala,mual,
takikardia, muntah,
toleransi

5-15
menit

3040
meni

Hipotensi,takikardi,m
ual muntah, muka
merah

Vasodilato 1- 10
r:
mg/jam
Arteri &
vena

Nikardipin Kalsium
antagonis

5-15
mg/jam

Tabel 1. Klasifikasi Hipertensi menurut kelompok umur

Kelompok umur

Hipertensi
bermakna

Hipertensi
berat

Neonatus 7 hari

Td S > 96

Td S > 106

8 30 hari

Td S > 104

Td S > 110

Bayi < 2 tahun

Td S > 112
Td D > 74

Td S > 118
Td D > 84

Anak 3-5 tahun

Td S > 116
Td D > 76

Td S > 124
Td D > 84

Anak 6-9 tahun

Td S > 126
Td D > 78

Td S > 84
Td D > 130

Anak 10 12

Td S > 126
Td D > 82

Td S > 134
Td D > 90

Remaja 13-15 tahun

Td S > 136
Td D > 86

Td S > 144
Td D > 92

Remaja 16-18 tahun

Td S > 142
Td D > 92

Td S > 150
Td D > 98
17

Tabel 2. Obat Antihipertensi untuk Penanggulangan

Krisis Hipertensi
Obat

Cara
pembelian

Dosis Awal

Respons
Awal

Lamanya
Respon

Efek Samping/
Komen

Diazoksid

IV cepat
(1-2 menit)

2-5 mg/kg, bila

dalam 30
menit respons
(-) ulangi

3-5 menit

4-24 jam

Nausea,
hiperglikemia
rentsni natrium

Natrium

Infus pompa

0,5 sampai 8
mikrogram/kg/
menit

Segera

Selama
infus

Perlu monitor
resiko
ketatiosianat

Hidralazi
n

IV atau IM

0.1 - 0.2
mg/kg

10-30 menit

2-6 jam

Takikardia,
flushing, saku
kepala

Reserpin

IM

0.07 mg/kg,
maksimal 2,5
mg

1,5 3 jam

2-12 jam

Hidung
tersumbat,
respon lambat

Klonidin

IM
IV

0.002
mg/kg/kali.
Ulangi 4-6
jam. Dapat
dinaikan
sampai 3 X
lipat

IV : 5 menit
IM :
beberapa
menit lebih
lama

Beberapa
jam

Mengantuk,
bradikardia,
kering.
Hipertensi
reboun

18

Tabel 3 a. Dosis Obat anti Hipertensi Oral pada Anak

Klasifikasi/Nama Obat

Dosis (oral/hari)

Interval Dosis

Awal

Maksimal

Hidroklorotiazid

1 mg/kg

2 mg/kg

Sekali sehari

Klortalidon

1 mg/kg

2 mg/kg

Sekali sehari

Spironolakson

1 mg/kg

3 mg/kg

Tiap 12 jam

Furosemid

1 mg/kg

10 mg/kg

Tiap 12 jam

Penghambat beta
Propranolol

1 mg/kg

5 mg/kg

Tiap 6 jam

Penghambat alfa
Prazosin

0,05 mg/kg

0,5 mg/kg

Tiap 8 jam

Diurettik

Penghambar Adrenergik

19

Tabel 3 b. Dosis Obat anti Hipertensi Oral pada Anak

Antiadrenergik sentral
Kolonidin

0,005 mg/kg

0,03 mg/kg

Tiap 8 jam

5 mg/kg

40 mg/kg

Tiap 6-12
jam

Reserpin

0,02-0,07
mg/kg

2,5 mg kg

Tiap 12 jam

Guanetidin

0,2 mg/kg

2 mg/kg

Sekali sehari

1 mg/kg

5 mg/kg

Tiap 8-12
jam

0,1 mg/kg

1 mg/kg

Tiap 12 jam

Nifedipin

0,25 mg/kg

1 mg/kg

Tiap 12 jam

Diltiazem

2 mg/kg

3,5 mg/kg

Tiap 12 jam

Methildopa
Bekerja pada ujung saraf
simpatetik

Vasodilato langsung
Hidralazin
Minosidil
Calcium Channel Blocker

ACE Inhibiter

20

Hal-hal yang memerlukan perhatian

1.

2.

Krisis hipertensi disertai gagal jantung

maka pengobatan selain anti hipertensi,
diuretika, digitalisasi juga diperlukan.
Krisis hipertensi disertai dengan gagal
ginjal dengan ditandai uremia maka
tindakan dilaisis perlu dilakukan[10]

21