PENATALAKSANAAN

HIPERTENSI TERKINI :
FOKUS PADA JNC 8

WACHID PUTRANTO
Divisi Ginjal Hipertensi
Fakultas Kedokteran UNS/RS.Dr.
Moewardi
Surakarta

Suatu keadaan klinis dimana tekanan

darah seseorang lebih tinggi
daripada tekanan darah normal
Epidemiologi :
Jumlah penderita hipertensi di seluruh
dunia : 1 milyar
USA : 65 juta
Indonesia ? : belum ada data resmi
Conlin PR, Int J Clin Pract 2005;
59(2):214-24

Prevalensi

prevalence of
hypertension (%)

7
0
6
0
5
0
4
0
3
0
2
0
1
0
0

age
(yrs)

Hipertensi

SBP > 140

mm Hg DBP
> 90 mm
Hg

1829

1
1
3039

4
4

6
5

6
4

5
4

2
1

4049

50-59

60-69

70-79

80+

Franklin, S.S., J Hypertens 1999; 17 (suppl

Hypertension complication
Brai
n
strok
e

Eyes
retinopathy

Kidneys
renal
failure

Hear
ischaemic heart t
disease left ventricular
hypertrophy
heart
failure
Peripheral arterial
disease

Target Organ
damage!!
Damages depend on:

How high of the blood

pressures

How long the

uncontrolled and
untreated high blood
presure

Blood Pressure Reduction Of 2 mmHg

Reduces The Risk Of CV Events by 710%
Meta-analysis of 61 prospective, observational
studies
1 million adults
12.7 million person-years
2 mmHg
decreas
e in
mean
SBP

7% reduction
disease
in risk of
mortality
ischaemic
heart
10% reduction
in risk
of stroke
mortality
Lewington et al. Lancet
2002;360:190313

ASH/I
SH
HYPERTEN
SION
GUIDELINE
S

CLASSIFICA
TION
SBP HYPERTEN
DBP
SION
<120 nd
<80

BP
Normal

a
Pre HT
Stg 1

120-139 r

o
140-159

BP
Stg 2
Optimal

80-89
r

9099

SBP
DBP
160 r 100
<120
<80
o
and

Normal
High Nml
HT stg 1
HT stg 2

<130 and <85

130- or 85-89
139
140- or 90-99
159
160- or
100179
109

B
P
Optim
al
Norm
al
High
Normal
HT stg
1
HT stg
2
HT stg
3 IS
H

SB
DB
P
P
an
<120
<80 d
120-129and./or
80-84
130-139
89

85-

140-159
99
140
160-179
<90 an
109
d

90-

180

JNC 8

100110

No definition
of HT

Top
ic
Methodolo
gy

Definitio
ns

JNC
Non 7systematic literature
review by expert committee
including a range of study
design
Recommendation based on
consensus
Defined hypertension and
prehypertension

Treatme
Separate treatmen goals defined
nts
for uncomplicated
Goals
hypertension and for subsets
Lifesty
with various comorbid condition
le
Recommended
lifestyle review
Recommendation
based on literature
modifications
and expert
Drug
Recommended
opinion
5 classes to be
therapy
considered as initial therapy for
most patients without compelling
indication for another class
Specified particular
antihypertensive medication
classes for patients with
compelling

2014 Hypertension
Guidelin
Critical questions
and review criteria
defined by expert panel with input from
methodology team
Initial systematic review by methodologist
restricted to
RCT evidence
Subsequent review of RCT evidence and
recommendations by the panel according to a
standardized protocol Definision of
hypertension and prehypertension not
addressed, but tresholds for pharmacologic
treatment were defined
Similar treatment goals defined for all
hypertensive populations except when
evidence review supports different goals
for a particular subpopulation
Lifestyle recommendations recommended by
endorsing the evidence based
recommendations of the Lyfestyle Work
Group
Recommended selection among 4 specific
medications classes ( ACEI or ARB, CCB or
Diuretics) and doses based on RCT evidence

Scope of
topics

Review
process
Prior to
Publication

Included a comprehensive
table oral Antihypertensive
drugs including names and
usual dose ranges
Addressed multiple issues ( blood
pressure measurements
methods,patients evaluation
components,secondary
hypertension, adherence to
regimens,resistant hypertension,
and hypertension in special
populations) based on literature
review and expert opinion
Reviewed by the National High
Blood pressure Education
Program Coordinating Committee,
a coalition of 39 major
professional,public, and
voluntary organizations and 7
federal agencies

Evidence review of RCTS

addressed a limited number of
questions,those judge by the
panel to be of highest priority
Reviewed by experts including
those affiliated with professional
and public organizations and
federal
agencies;
no
official
sponsorship by any organization
should be inferred

The Process
Literature review 1/1/1966
12/31/2009
Inclusion Criteria
(1) HTN
(2) 2000 participants
(3) multisenter
(4)Kriteria inklusi/eksklusi.

9
Recommendatio
ns

A
B
C
D
E
N

Strength
Recommend
ation
Recommendation 1

of
Recommend
ation
Grade A

Populasi berusia 60 yrs,mulai terapi

farmakologi
SBP150
mmHg,
DBP90 mmHg
HYVET, Sys-Eur, SHEP,
JATOS, VALISH, CARDIOSIS

Corollary Recommendation
Populasi usia 60 yrs, jika terapi
farmakologi
mengakibatkan
penurunan
TD
lebih
rendah
(<140/90) dan pengobatan ditoleransi
dengan
baik tanpa efek samping,
teruskan pengobatan.
Usia ini TD
<140 tidak lebih baik disbanding 140160

Recommendation 2
Populasi

usia

<60

yrs,

terapi

Grad
eE

Grade A (30-59
yrs)
Grade E (18-29

Strength
of
Recommend
ation

Recommendation
Recommendation 3
Populasi usia <60 yrs, terapi
farmacologi bila SBP 140
mmHg.Target SBP<140 mmHg

Grade E

Recommendation 4
Populasi usia 18 yrs dengan
terapi
farmacologi bila SBP
140 mmHg or DBP
90
mmHg . Target SBP
mmHg dan
DBP <90
mmHg

CKD,

Grade E
<140
AASK, MDRD, REIN-2

Recommendation 5
Populas usia 1
i
8

denga
n

DM, terap
i

Grade E

Strength
Recommendation

of
Recommend
ation

Recommendation 6
Pada populasi
non black
termasuk
dg DM,
initial anti HTN treatment : a
thiazide type
diuretic, CCB, ACEI or ARB

Grade B

VA-cooperative, HDFP,
SHEP

Recommendation 7
Populasi kulit hitam, termasuk dg
DM, initial
anti HT: thiazide-type diuretic or CCB

Grade B ( No DM)
Grade C ( DM)
ALLHAT

Recommendation 8
Populasi usia 18 dg CKD dan HTN,
initial (or
add on) anti HTN : ACEI or ARB utk

Grade B

Recommendation
Recommendat
ion 9
Tujuan treatment
HTN adalah
untik
mencapai
dan
mempertahankan target BP
atau
Jika target
1 obat dr BP tidak
2n
tercapai dlm diuretic,
tambahkan
(thiazide-type
1d
rekomendasi
CCB, ACEI,
bl,ornaikkan
ARB)
Jika
dosistarget BP tidak tercapai
6
dg 2 obat,
tambah dan
titrasi
. Do not use an ACEI
3r
obat
and an ARB
d
Jika
togethe
target BP tidak dapat tercapai dg obatr
obat
pada
recommendasi
6
krn
kontraindikasi atau butuh >3 obat, obat
antiHT dari kelas lain bias digunakan.
Referral kepada hypertension specialist jika
BP tidak tercapai atau untuk management
komplikasi.

Strength
of
Recommend
ation

Grad
eE

Strategies to Dose
Antihypertensive Drugs

Strategies
Description
Mulai 1 obat
A

naikan sp dosis
maksimum,kemu
dian tambahkan
obat
Mulaike-2
1 obat
kemudian
tambahkan obat
ke-2 sblm dosis
maksimum
Mulai dengan 2
obat (separate
or single
combination)

Details

Jika target BP blm tercapai

naikkan dosis obat 1 sp dosis
maksimum sblm menambahkan
obat ke-2 dan ke-3.
Tambahkan obat ke-2 sblm obat
1
mencapai dosis maks.Jk
Target
BP
blm
tercapai,tambahkan obat ke-3
dan titrasi sp dosis maks.

Mulai dg 2 obat
Bbrp
committee
merekomendasi:
2 obat SBP >160 dan/atau
DBP
>100, atau SBP >20
mmHg diatas target

Lifestyle Modification

JNC
8

JNC
7

G
U
I
D
E
L
C

Guideli
ne
2014
HT
Guideli
ne
ESH/E
SC

I
0
N
M
E
P
A
R
I
GOAL
BP
S
INITIAL

CHE
P

Populat
ion

General
60 y
General
<60 y DM
CK
D
General

(non
elderly)
General
elderly
<80 y
General
80 y
DM
CKD (no
proteinem
General
<80ia)
y
CKD +
General
>80proteine
y DM
mia
CK

Goal
BP

<150/
90
<140/
90
<140/
<140/
90
90
<140/
90
<150/
90
<150/
90
<140/
85
<140/
<130/
90
<140/
90
<150/
90
<130/
80
<140/

Initial
drugs

Non Black: thiazide type

diuretic, ACEI, ARB or ARB
Black: thiazide type-diuretic
or CCB
Thiazide type
diuretic, ACEI, ARB or CCB
ACEI or ARB
Bocker, diuretic, CCB,
ACEI, ARB

ACEI or
ARB
ACEI or
ARB
Thiazide, Blocker (<60y), ACEI
(nonblack) or
ARB
Add CVD risk: ACEI or ARB
No CVD risk:
ACEI/ARB/Thiazide/DHPCCB ACEI
or ARB

Guidelin Populatio
e
n
DM
ADA
DM and
KDIGO

NICE

ISHIB
JNC 7

CKD alb
exc <30
mg/d
DM and
CKD alb
exc >30
mg/d
General
<80 y
General
80 y
Black, lower
risk TOD or
CVD risk
Gener
al
CKD

Goal BP
<140/80
140/90

Initial drugs
ACEI or ARB
ACEI or ARB

130/80

<140/90
<150/90

<55 y; ACEI or ARB

55 y or black; CCB

<135/85
<130/80

Diuretic or CCB

<140/90
<130/80

ACEI or ARB

Important Variables For HTN

Recommendations
BP
Definiti
on HTN

Drug th/
in low
risk pts
after
non
pharm
th/
Block
er as
1st line

NICE

ESC/ESH ASH/ISH
AHA/AC
C/CDC

140/90 140/90
and
dayti
me
ABPM
135/8
5
140/90
140/90
160/1
00
or
daytime
ABPM
Yes
150/95
No

140/90 140/90

JNC 7
Pre HT 120139
or 80-89
Stg 1 HT
140-159 or
9099
Stg 2 HT
160 or 100

140/90
140/90

JNC 8
Not
addresse
d

<60 y,
140/9
0
60 y,
150/9
0

No
No

No

No

NICE
Diureti
c

Initiat
e th/
with
2
drugs
BP
target

Chortha
li- done
(CTD)
Indapa
mi- de
(IND)
Not
menti
oned

ESH/ES
C

ASH/IS AHA/ACC JNC 7

H
/CDC

JNC 8

Thiazid
es
(THZ),
CTD
ND

TH
Z
CT
D
IN
D
160/9
0

THZ
CTD
IDP

Pts w/
markedly
elevated
BP

<140/90 <140/90
<140/90
80 y,
Elderly
80 y,
<80
<150/90
SBP 140- <150/90
150, in fit
pts SBP
<140
Elderly
80
y SBP

THZ

160/10
0

<140/90

THZ

160/10
Not
0
mentione
d
<140/90 <160/90
(<60 y)

60 y,
<150/90

Under JNC 8, in all cases, targets BP should

be reached within
a month of starting
treatment either by increasing the dose or
by using a combination drugs
In patients 60 yrs who do not have DM or
CKD, the goal BP
level is <150/90 mm Hg
In pts18 - 59 yrswithout
major
comorbidities target BP
<140/90, and in patient 60 yrs without DM,
CKD, or both, the new goal BP is <150/90
mm Hg
JNC 8 panel
recommended
thiazide-type
diuretics as
initial
therapy for most patients (include newly
diagnosed HTN)

JNC 8 also recommend lifestyle interventions

include use of the DASH eating plan, weight
loss, reduction in sodium intake to
<2.4
gr/day,
and
at least
30
minutes of aerobic activity
most
Under the JNC 8 guidelines, patients would
days of thea week
receive
dosage
adjustment
and
combinations of the 4 first-line & later line
therapies ACEI/ARB, CCB, and thiazide-type
diuretic
The JNC 8 does not recommend -blockers and
-blockers as 1st therapy due to 1 trial that
showed a higher rate of CV events with use of
B compared with use of an ARB, and another
trial
in which B resulted in inferior CV
outcomes compared with use of a diuretic

When initiating therapy, patients of

African descent without CKD should use
CCBs and thiazides instead of ACE
inhibitors
ACE inhibitors and ARBs should not be
used in the same
patient simultaneously