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Rasionalisasi Terapi Hipertensi
Rasionalisasi Terapi Hipertensi
Hipertensi
Dr. Suryono,SpJP.FIHA
Bagian-SMF Kardiologi & Kedokteran Vaskular
FK UNEJ / RSD dr. Soebandi
JEMBER
Category
Systolic
(mm Hg)
Diastolic
(mm Hg)
Normal
Pre Hipertensi
Hipertensi
Stage 1
Stage 2
<120
120-139
dan
atau
<80
80-89
140-159
> 160
atau
atau
90-99
>100
70
60
65
70-79
80+
54
50
44
40
30
20
64
21
4
11
18-29
30-39
10
0
age (yrs)
40-49
50-59
60-69
US
Canada
Italy
Sweden
England
Spain
Finland
Germany
100
90
80
45
40
%
Patients on Therapy
70
35
% 60
50
30
25
40
30
20
15
20
10
10
5
0
Country
Wolf-Maier K et al. JAMA. 2003;289:2363-2369.
Country
Hypertensive patients
who are treated
but uncontrolled
23%
19%
16%
42%
Hypertensive patients
who are unaware
England
6
Canada
16
France
24
Spain
20.5
20
Germany
22.5
Scotland
Australia
19
India
17.5
> 65 years
Diagnosis of Hypertension
Hypertension is defined as:
- BP 140/90 mm Hg
- during 1-5 visits
- with an average of 2 readings per visit
Caused of Hipertension :
I. Primer / essential / idiopathic
II. Sekunder :
A. Renal
B. Endocrine
C. Coartation of the aorta
D. Pregnancy induced hypertension
E. Neurological disorder
F. Drug and other abused substancen
PATOPHYSIOLOGY
The factors affecting cardiac output:
Increased CO
Preload
and/or
Contractility
Fluid volume
Increased PR
Vasoconstriction
Fluid volume
Renal sodium
retention
Excess
sodium
intake
Sympathetic
nervous
system
Reninangiotensinaldosterone
system
Genetic
factors
(Adapted from Kaplan, 1994)
RAA
SNS
Heart rate and cardiac output
Circulating
Liver
Renin inhibitors
Angiotensinogen
Renin
Tissue
Non Renin pathways
- t-PA
- Cathepsin G
- Tonin
Angiotensin I
ACE inhibitor
Converting enzyme
Angiotensin II
Angiotensin
receptors
Non-ACE pathways
- Chymase
- CAGE
- Cathepsin G
AT1
AT2
Blocked by ARB s
-
Vasoconstriction
Aldosterone release
Oxidative stress
Vasopressin release
SNS activation
Inhibits renin release
Renal Na+ and H2O reabsorption
Cell growth and proliferation
Vasodilation
Antiproliferation
Apoptosis
Antidiuresis/antinatriuresis
Bradykinin production
NO release
2.
The patient should be relaxed
and the arm must be
supported. Ensure no tight
clothing constricts the arm
3.
The cuff must be level with
the heart. If the circumference
exceeds 33cm, a large cuff
must be used (2/3 of arm).
Place stethoscope diaphram
over brachial artery
4.
The column of mercury
must be vertical. Inflate
to occlude the pulse
(>30 mmHg). Deflate at
2-3 mm/s. measure
systolic ( first sound /
Korotkoff I ) & diastolic
(disappearence /
Korotkoff IV or V ) to
nearest 2 mmHg
Recommended Technique
for Measuring Blood Pressure
Standardized technique:
Have the patient rest for 5 minutes
Use an appropriate cuff size
Use a mercury manometer or a recently
calibrated electronic device
Recommended Technique
for Measuring Blood Pressure (cont.)
Position cuff appropriately
Increase pressure rapidly
Support arm with antecubital fossa or heart
level
To exclude possibility of auscultatory gap,
increase cuff pressure rapidly to 30 mmHg
above level of diseappearance of radial
pulse
Place stethoscope over the brachial artery
Recommended Technique
for Measuring Blood Pressure (cont.)
Drop pressure by 2 mmHg / beat:
- appearance of sound (phase I Korotkoff)
= systolic pressure
- disappearance of sound (phase V
Korotkoff) = diastolic pressure
Take 2 blood pressure measurements, 1
minute apart
Indikasi
1. Adanya variasi tekanan darah yang
besar
2. Office hypertension
3.Dicurigai adanya episode hipotensi
4. Hipertensi
yang
resisten
terhadap
pengobatan
Symptoms
Headache
Dizziness
Fatigue
Pounding of the heart
Symptoms of complications : heart
failure, chest pain, claudication, vision
Pemeriksaan Fisik :
Pemeriksaan penunjang
Laboratorium
EKG & Foto polos dada
Ekhokardiografi
Ultrasonografi vaskuler
Ultrasonografi renal Angiografi
Komplikasi Hipertensi
Eyes
retinopathy
Kidneys
renal failure
Brain
stroke
Heart
ischaemic heart disease
left ventricular hypertrophy
heart failure
Besarnya peningkatan
tekanan darah
Hypertension :
The Disease Continuum
Early Paradigm
Elevated BP
Vascular Dysfunction
A Proposed Future Paradigm
Endothelial
Dysfunction
Vascular
Dysfunction
Elevated BP
Target Organ
Damage
LVH
Renal
Damage
MI
Angina
Pectoris
Stroke
10
5
MI
Stroke
0
0
100
200
300
Stage 2+ hypertension
15
CHF
Cumulative
Incidence 10
(%)
Stage 1+ hypertension
5
Normal BP
5
10
Years From Baseline Exam
15
100
CHD
90
80
70
60
50
Stroke
40
30
CHF
20
10
0
<100
120
140
180
Systolic blood pressure (mmHg)
>180
5
4
2
1
< 140
mm Hg
mm Hg
140-159 160-179 180-199 200+
< 80
80-89
90-99
100-109
110+
NON-Farmakologis
Farmakologis
Non Pharmacologic
( lifestyle modification )
Modification
Approximate SBP
reduction (range)
Weight reduction
814 mmHg
28 mmHg
Physical activity
49 mmHg
Moderation of alcohol
consumption
24 mmHg
: individualized therapy
Taylored therapy
Therapy of Hypertension
( pharmacologic )
Goal of treatment
Improved endothel function
Decreased systemic vascular resistance
Maintain cardiac output & blood suply to organ
Life long therapy
Bad compliance failed of therapy
Benefits of Lowering BP
Average Percent Reduction
Stroke incidence
3540%
Myocardial infarction
2025%
Heart failure
50%
failed of therapy
Tenaga medis
Asuransi
Pemegang kebijakan
Penderita
bad compliance
JNC VI
Uncomplicated HTN
< 140/90
Hypertension with
diabetes mellitus
< 130/85
< 130/80*
< 130/85
Heart failure
Hypertension with
renal impairment
< 125/75
*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.
Recomendation
Without Compelling
Indications
With Compelling
Indications
Stage 1 Hypertension
Stage 2 Hypertension
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension
specialist.
Postmyocardial
infarction
ACC/AHA Post-MI
Guideline, BHAT,
SAVE, Capricorn,
EPHESUS
ALLHAT, HOPE,
ANBP2, LIFE,
CONVINCE
Diabetes
NKF-ADA Guideline,
UKPDS, ALLHAT
ACEI, ARB
NKF Guideline,
Captopril Trial,
RENAAL, IDNT, REIN,
AASK
Recurrent stroke
prevention
THIAZ, ACEI
PROGRESS
Diuretics
-blockers
AT1 receptor
blockers
1-blockers
Calcium
antagonists
ACE inhibitors
Possible combinations of different classes of antihypertensive agents.
The most rational combinations are represented as thick lines. ACE,
angiotensin-converting enzyme; AT1, angiotensin II type 1.
Terapi Kombinasi
Potensiasi
Sinergisme
Saling melengkapi
Mengurangi efek samping
Fix kombinasi ---- mening kepatuhan
THANK YOU
TERIMA KASIH
MATUR NUWUN
SAKALANGKONG
KASOON
Mba Marijan
Risk Group B
(At Least 1 Risk
Risk Group A
Factor, Not Including
Blood Pressure Stages (No Risk Factors Diabetes; No
(mmHg)
No TOD/CCD)
TOD/CCD)
Risk Group C
(TOD/CCD and/or
Diabetes, With or
Without Other Risk
Factors)
High-normal
(130-139/89-89)
Lifestyle
modification
Drug therapy
Stage 1
(140-159/90-99)
Lifestyle
Lifestyle
modification
modification
(up to 12 months) (up to 6 months)
Drug therapy
Stages 2 and 3
(> 160/> 100)
Drug therapy
Drug therapy
Lifestyle
modification
Drug therapy
For example, a patient with diabetes and a blood pressure of 142/94 mmHg plus left ventricular
hypertrophy should be classified as having stage 1 hypertension with target organ disease (left
ventricular hypertrophy) and with another major risk factor (diabetes). This patient would be categorized
as Stage 1, Risk Group C, and recommended for immediate initiation of pharmacologic treatment.