Hypertension

How to Choose Antihypertension Drug
Heri Sutrisno, MD Internal Medicine WZ Johannes Hospital - Kupang

DIBAWAKAN PADA SEMINAR IDI WILAYAH KUPANG DALAM RANGKA HUT IDI KE-63 & HARKESNAS 2013
Treatment of hypertension is still an unsolved issue
Kegagalan terapi hipertensi
Sekitar 20% populasi dewasa di dunia menderita hipertensi1
Di AS, hipertensi ditemukan pada 30% penduduk dewasa1-3
Namun, hipertensi terkontrol hanya didapatkanpada 36,8% pasien1-3
Menurut Riskesdas tahun 2007, prevalensi hipertensi di Indonesia sebesar 32,2%4
3
1. 2. 3. 4.
Seminar IDI Wilayah NTT
9 November 2013
Keenan NL, Rosendorf KA. Prevalence of hypertension and conttrolled hypertension. MMWR. 2011: 60 (Supp): 1-116 Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455):217 223. Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, awareness, treatment, and control of hypertension among United States adults 19992004. Hypertension. 2007;49(1):6975. Rahajeng E, Tuminah S. Prevalence of hypertension and its determinants in Indonesia. MKI 2009: 59;580-7
Role of fifty
Hypertension
100
Awareness Unawareness
50
Unregular Treatment Regular Treatment
50
25
Uncontrolled
25
Controlled
12.5
12.5
The reasons for uncontrolled blood pressure

Patient-related
Multifactor disease Ignorance Genetic Environment Compliance
5
Seminar IDI Wilayah NTT 9 November 2013
Drug-related
Relative efficacy / inadequate Tolerance Counter regulation Adverse effect
Doctor-related
Inadequate education
J Cardiovasc Pharmacol 1998 ; 31 (suppl) : S41-S44
ESH 2003 & JNC VII

ESH-ESC BP Classification
Optimal
Normal High normal Grade 1 Hypertension (mild)
Grade 2 Hypertension (moderate) Grade 3 Hypertension (severe) Isolated Systolic Hypertension
BP
BP
JNC VII Bp Classification
<120 / <80
120-129 / 80-84 130-139 / 85-89 140-159 / 90-99
160-179 /100-109
<120/<80
120-129 /80-84 130-139 / 85-89 140-159 / 90-99
Normal
Pre hypertension Pre hypertension Stage 1 Hypertension Stage 2 Hypertension
>160 / >100
> 180 / >110
> 140
< 90
Isolated Systolic Hypertension

9 November 2013
JNC 6 vs JNC 7
9 November 2013
What should we done to patients
with hypertension ?
9 November 2013
3 point evaluation to patients before treatment

1. Exclude secondary causes of hypertension 2. Ascertain the presence or absence of TOD (target organ damage) 3. Assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that affect risk factors, prognosis and guide treatment
9 November 2013
Secondary Causes of Hypertension

10
Sleep apnoea Drug-induced or drug-related Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing syndrome Phaeochromocytoma Acromegaly Thyroid or parathyroid disease Coarctation of the aorta Takayasu Arteritis
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Target Organ Damage

Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularisation Heart failure
Brain
Stroke or transient ischemic attack Chronic kidney disease
Peripheral arterial disease

Retinopathy
11
How to asses TOD ?

Full blood count Urinalysis Measurement of urine albumin excretion or albumin/creatinine ratio Renal function tests (urea, creatinine, serum electrolytes and uric acid) Fasting blood sugar Lipid profile (total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides) Electrocardiogram (ECG) Chest X-ray
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Manifestations of target organ damage (TOD)/ target organ complication (TOC)
13
COMPONENTS OF CARDIOVASCULAR RISK STRATIFICATION IN PATIENTS WITH HYPERTENSION
Major Risk Factors

Smoking Dyslipidemia Diabetes mellitus Age older than 60 years
Sex (men and postmenopausal women)

14
Family history cardiovascular disease: women under age 65 or men under age 55
9 November 2013
COMPONENTS OF CARDIOVASCULAR RISK STRATIFICATION IN PATIENTS WITH HYPERTENSION
Hipertensi Merokok
Obesitas
Kurang aktivitas fisik Dislipidemia Diabetes melitus
Mikroalbuminuria atau estimasi GFR <60 mL/menit Usia (>55 thn untuk pria, >65 thn untuk wanita) Riwayat keluarga dengan penyakit kardiovaskular prematur (<55 thn untuk pria, <65 thn untuk wanita)
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Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42 (6):1206-52
HIGH BLOOD PRESSURE OR HYPERTENSIVE DISEASE

DISEASE CLINICAL EVENTS TIA CEREBROVASCULAR
HIGH BP : - Genetic predisposition - Life stye - Environment
STROKE
DEMENTIA
CARDIOVASCULAR
ANGINA IMA CHF
RENAL
16
ESRD
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Stratification of Risk to Quantify Prognosis

Other Risk Factors & Disease History I. no other risk factors
(mild hypertension) SBP 140-159 or DBP 90-99
Grade 1
(moderate hypertension) SBP 160-179 or DBP 100-109 MED RISK
Grade 2
(severe hypertension) SBP > 180 or DBP > 110 HIGH RISK V. HIGH RISK
Grade 3
LOW RISK
II. 1-2 risk factors III. 3 or more risk factors or TOD1 or diabetes IV. ACC2 17
MED RISK
MED RISK
HIGH RISK
HIGH RISK
V. HIGH RISK V. HIGH RISK
V. HIGH RISK
V. HIGH RISK
Risk strata (typical 10 year risk of stroke or myocardial infarction): Low risk = less than 15%; medium risk = about 15-20% risk; high risk = about 20-30%; very high risk = 30% or more Seminar IDI Wilayah NTT 9 November 2013 1. TOD = Target Organ Damage 2. ACC = Associated Clinical Conditions, including clinical cardiovascular disease or renal disease
Risk Stratification and Treatment

Blood Pressure Stages (mm Hg)
Risk Group A
(No risk factors; No TOD/CCD*)
High-normal 130-139/85-89 Lifestyle modification Lifestyle modification

(up to 12 months)
Stage 1 140-159/90-99 Lifestyle modification Lifestyle modification

(up to 6 months)
Stages 2+3 160/100 Drug therapy
Risk Group B
(At least 1 risk factor; Not including Diabetes; No TOD/CCD)
Drug therapy
Risk Group C
(TOD/CCD and/or Diabetes; with or without other risk factor)
Drug therapy
Drug therapy
Drug therapy
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JNC VI, Arch Intern Med 1997; 157: 2413-46
Goal of Treatment
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Goal of Hypertensive Treatment
To achieve the maximum reduction in the total

risk of cardiovascular, cerebrovascular,
nephrosclerosis morbidity and mortality
( WHO-ISH 1999 )
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9 November 2013
Goals of treatment
JNC VII ( 2003 ) : < 140 / 90 mmHg or < 130 / 80 mmHg for those with Diabetes or Chronic Kidney disease. Achieve SBP goal especially in persons >50
21
years of age.
EUROPEAN SOCIETY of HYPERTENSION ( 2003 )
At least below 140 / 90 mmHg ( lower values if tolerated )
Below 130 / 80 mmHg in Diabetics.

Keeping in mind, however, that systolic below 140 mmHg may be difficult to achieved in elderly (more flexible )
How to Manage Hypertension Patients
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9 November 2013

NON-PHARMACOLOGICAL MANAGEMENT
Weight reduction
Target BMI: 18.5 to 23.5 kg/m2
Practical: reduce minimum 5% BW, + 4.5 kg
Sodium intake
< 6 g (equivalent to <1 teaspoonfuls of salt or 3 teaspoonfuls of MSG)
Avoidance of alcohol intake

<170 mL beer, 300 mL wine, or 60 mL whiskey per day
Regular physical exercise

Brisk walking for 30 60 minutes at least 3 times a week
Healthy eating
Diet rich in fruits, vegetables and dairy products with reduced saturated and total fat
24 Seminar IDI Wilayah NTT Cessation of smoking
9 November 2013
Lifestyle modifications to prevent and manage hypertension
25
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PHARMACOLOGICAL MANAGEMENT
27
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Prinsip terapi: Target tekanan darah <140/90 mmHg atau <130/80 mmHg pada pasien diabetes atau CKD Mayoritas pasien mencapai target tersebut dengan kombinasi 2 obat Modifikasi gaya hidup Panduan Terapi Target tekanan darah tidak Hipertensi berdasarkan tercapai JNC VII Pilihan obat awal
Tanpa indikasi mendesak
Hipertensi stage I (140-159/90-99 mmHg) Diuretik tipe tiazid. Pertimbangkan ACE-i, ARB, BB, CCB, atau kombinasi
Hipertensi stage II (>160/>100 mmHg)

Kombinasi 2 obat (biasanya tiazid dengan ACE-i, ARB, BB, atau CCB)
28
Target tekanan darah tidak tercapai
Dengan indikasi mendesak Lihat panduan agen antihiperten si pada kondisi dengan indikasi mendesak
Optimalisasi dosis atau tambah obat. Konsul ke spesialis 9 November 2013 hipertensi
Prinsip terapi: Target tekanan darah <140/90 mmHg atau <130/80 mmHg pada pasien diabetes atau CKD Mayoritas pasien mencapai target tersebut dengan kombinasi 2 obat Modifikasi gaya hidup Panduan Terapi Hipertensi berdasarkan JNC VII Target tekanan darah tidak tercapai Pilihan obat awal
Tanpa indikasi mendesak
Hipertensi stage II (>160/>100 mmHg) Kombinasi 2 obat (biasanya tiazid dengan ACE-i, ARB, BB, atau CCB)
Dengan indikasi mendesak

Lihat panduan agen antihipertensi pada kondisi dengan indikasi mendesak
Hipertensi stage I (140159/90-99 mmHg) Diuretik tipe tiazid. Pertimbangkan ACE-i, ARB, BB, CCB, atau kombinasi
29
Target tekanan darah tidak tercapai

Optimalisasi dosis atau tambah obat. Konsul ke spesialis hipertensi
Chobanian AV, Bakris GL, Black HR, et al. Seventh reportSeminar of the Joint Prevention, Detection, IDINational WilayahCommittee NTT 9 on November 2013 Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42 (6):1206-52
Principles of drug treatment Independent of particular drugs

30
Low doses to initiate therapy Drugs combination to maximize hypotensive efficacy while minimizing side effects. Changing to a different drug class if there is very little response or poor tolerability Long acting drugs : provide greater protection against target organ damage
Algorithm for treatment of hypertension
Lifestyle Modification
Not at Goal Blood Pressure (<140/90mmHg) (<130mmHg for those who with diabetes or Chronic Kidney Disease)
Initial Drug Choices
Without Compelling Indications
With Compelling Indication
Stage 1 Hypertension
(SBP 140-159 or DPB
90-99 mmHg) Thiazide type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination
Stage 2 Hypertension (SBP > 160 or DPB > 100 mmHg) Two drugs combinationfor most ( usually Thiazide-type diuretics and ECI, or ARB, or BB or CCB
Drugs for the compelling indications. Other antihypertensive drugs (Diuretics, ACEI, ARB, BB, CCB) as needed
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until goal Blood pressure is achieved. Consider consultation with Hypertension specialist
Compelling Indication
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Penggunaan Agen Antihipertensi berdasarkan Indikasi mendesak

Indikasi mendesak Gagal jantung Diuretik BB ACE-i ARB CCB Antagonis aldosteron Dasar uji klinis ACCA/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES
Pasca-infark miokardial
Risiko tinggi PJK Diabetes Gagal ginjal kronik Pencegahan stroke berulang
v
v v v v
v
v v
v
v
v v
v
ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS

ALHAT, HOPE, ANBP2, LIFE, CONVINCE NKF-ADA Guideline, UKPDS, ALLHAT NFK Guideline, Captopril trial, RENAAL, IDNT, REIN, AASK PROGRESS
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Contraindication
34
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How to combine AH ?
AB / CD Scheme
Birmingham Square
35
9 November 2013
The AB / CD Scheme for Optimizing Abtihypertensive Therapy

Angiotensin Inhibitor
Beta Blockers
Calcium Antagonist
Diuretic
AGE
Young (<55)
RENIN
Old (>55)
STEP :
1 :
A or B
C or D
3 : 4 5 :
C or D
A or B C or D
2 :
A or B
Resistant HT : Seminar IDI Wilayah NTT / 36 Intolerance
Add/substitute alpha blocker

9 November 2013
Reconsider secondary causes + trial of spironolactone
BIRMINGHAM SQUARE
DIURETICS
BETA-BLOCKERS
ACE INHIBITORS 37
CALCIUM CHANNEL BLOCKERS

9 November 2013
Effective drug combinations

Diuretic and -blocker Diuretic and angiotensin converting enzyme (ACE) inhibitor (or angiotensin II antagonists). Calcium antagonist (dihydropyridine) and -blocker. Calcium antagonist and ACE inhibitor or Angiotensin II antagonists -Blocker and -blocker.
38
Indications and Contraindications to Major Classes of Antihypertensive Drugs,
According to the Guidelines of

European Society of Hypertension
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9 November 2013
Conditions favoring Class their use Diuretics (thiazide) CHF /elderly / ISH / African origin ESRF / CHF CHF / post-MI Compelling Gout Renal failure Hyperpotasemia Possible Pregnancy Contraindications
Meredith P. Eur Heart J, Supp. (2004)
Class -blockers
Conditions favouring their use Angina pectoris / post-MI /
Contraindications Compelling Asthma COPD A-V block (gr 2-3) Possible PVD Glucose intolerance Athletes / physically active patients
CHF (up-titration)
Pregnancy Tachyarrhytmias Younger people
Class Calcium antagonist (dihydropiridine)
Conditions favouring their use Elderly / ISH / angina / PVD Carotid atherosclerosis Pregnancy
Contraindications Compelling Possible Tachyarrhytmias CHF
Calcium antganoist (verapamil, dilitiazem)
Angina SV tachycardia Carotid atherosclerosis
Compelling A-V block (gr 2 or 3) CHF Possible Meredith P. Eur Heart J, Supp. (2004)
Class ACE inhibitors
Conditions favoring their use CHF/LV dysfunction/post-MI Non-diabetic nephropathy Type-1 diabetes
Contraindications Compelling Pregnancy
Hyperkalemia
Bilateral renal artery stenosis Possible -
Proteinuria
AT1-receptor blockers
Type-2 diabetes Proteinuria Diabetic micoralbuminuria LVH ACE inhibitor cough
Compelling Pregnancy Hyperkalaemia Bilateral renal artery stenosis
Possible
HYPERTENSION IN SPECIAL GROUPS

Hypertension and diabetes mellitus
ACEIs are the agents of choice for patients with diabetes without proteinuria
ACEIs or ARBs are the agents of choice for patients with diabetes and proteinuria Beta-blockers, diuretics or CCBs may be considered if either of the above cannot be used.
Hypertension and the metabolic syndrome

Beta-blockers and thiazide diuretics have the potential to increase the incidence of new onset diabetes and this should be taken into consideration when choosing drugs for patients diagnosed with the metabolic syndrome.
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9 November 2013
Hypertension and non-diabetic renal disease

Target BP should be <130/80 mmHg for those with proteinuria of <1g/24 hours and <125/75 mmHg for those with proteinuria of >1g/24 hours ACEIs are recommended as initial anti-hypertensive therapy
ARBs should be used in patients intolerant to ACEIs

Dietary salt and protein restriction is important Concurrent diuretic therapy is useful in patients with fluid overload Non-dihydropyridine CCBs can be added on if the BP goal is still not achieved
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9 November 2013
KDIGO 2012: Manajemen TD pada pasien CKD-Non dialisis dengan DM
Disarankan pemberian ARB atau ACE-i pada pasien CKD ND dewasa dengan DM dengan ekskresi albumin urin 30-300 mg/24 jam [2D]
Pasien CKD-ND dewasa dengan DM, ekskresi albumin urin < 30 mg/24 jam, TD sistolik >140 mmHg, TD diastolik > 90 mmHg
Pasien CKD-ND dewasa dengan DM, ekskresi albumin urin > 30 mg/24 jam, TD sistolik >130 mmHg, TD diastolik > 80 mmHg
Direkomendasikan untuk diberikan obat penurun TD untuk mempertahankan TD sistolik < 140 mmHg dan TD diastolik < 90 mmHg [1B]
Pasien CKD-ND dengan DM
Disarankan untuk diberikan obat penurun TD untuk mempertahankan TD sistolik < 130 mmHg dan TD diastolik < 80 mmHg [2D]
46
Direkomendasikan pemberian ARB atau ACE-i pada pasien CKD ND dewasa dengan DM dengan ekskresi albumin urin > 300 mg/24 jam [1B]
ARB: angiotensin receptor blockers ACE-i: angiotensin-converting enzyme inhibitor
9 November 2013
Kidney International Supplements (2012) 2, 363-9; doi:10.1038/kisup.2012.54
TD: tekanan darah CKD-ND: Chronic kidney disease nondialisis DM: diabetes melitus
Jadi . . . REKOMENDASI KDIGO 2012

Sudah mulai di balik rekomendasinya, biasanya setiap guideline : ACE or ARB. Tapi dalam Guideline terbaru KDIGO 2012 sudah di balik pilihannya : ARB atau ACE
Hypertension and cardiovascular disease

Hypertensive patients with LVH should receive an ARB as the first line treatment
In CHD, beta-blockers, ACEIs and long acting CCBs are the drugs of choice Beta-blockers, ACEIs and aldosterone antagonists should be considered in patients with CHD especially in post myocardial infarction and when associated with LV dysfunction Beta-blockers need to be cautiously used in patients with peripheral vascular disease. They are contraindicated in patients with severe PVD
Diuretics, ACEIs, beta-blockers, ARBs and aldosterone antagonists are drugs of choice for heart failure
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9 November 2013
Hypertension and stroke

Lowering blood pressure is the key to both primary and secondary prevention of stroke In acute stroke, lowering BP is best avoided in the first few days unless hypertensive emergencies co-exist In primary prevention, a CCB-based therapy is preferred In secondary prevention, the benefits of BP lowering is seen in both normotensive and hypertensive patients ACEI- or ARB- based treatment is preferred in secondary prevention
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9 November 2013
Hypertension in the elderly

Isolated Systolic hypertension is particularly common in the elderly and should be recognized and treated
Standing BP should be measured to detect postural hypotension

Decreasing dietary salt intake is particularly useful When prescribing drugs, remember to start low and go slow
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9 November 2013

Hypertension in pregnancy
Pregnant women who are at high risk of developing preeclampsia should be referred to the obstetrican for screening and commencement of prophylaxis with aspirin
Prophylactic calcium supplementation from early pregnancy is beneficial and recommended
Pregnant women with hypertension should be referred to the obstetrician for further management
The antihypertensives of choice are methyldopa and labetalol Oral nifedipine 10mg stat dose can be used to rapidly control BP in an acute hypertensive crisis prior to transfer to hospital
51
9 November 2013
ACEI dan ARBs memblok RAS dengan cara yang berbeda

Bradikinin/NO Angiotensin I
ACE ACE Inhibitor

Fragmen inaktif Angiotensin II
ACE-independent ANG II formation by Chymase, etc.
ARB RESEPTOR AT1

Vasokonstriksi Retensi natrium Aktivasi SNS Inflamasi Growth-promoting effects Aldosterone Apoptosis
RESEPTOR AT2
Vasodilatasi Natriuresis Regenerasi jaringan Inhibisi pertumbuhan sel yang tidak sesuai Diferensiasi Antiinflamasi Apoptosis
9 November 2013
SNS = sympathetic nervous system Hanon S, et al. J Renin Angiotensin Aldosterone Syst 2000;1:147150; Chen R, et al. Hypertension 2003;42:542547; Hurairah H, et al. Int J Clin Pract 2004;58:173183; Steckelings UM, et al. Peptides 2005;26:14011409
52
Kelemahan ACE-i
Intoleransi ACEi
SPICE (Study of Patients Intolerant of Converting Enzyme Inhibitors)
20% pasien CHF tidak toleran terhadap ACE-i
HOPE trial
Pada HOPE trial, 25% pasien pada grup perlakuan menghentikan pengobatan ACE-i dengan alasan batuk, angioedema, dan hipotensi
Pada studi pasien DM berusia >65 tahun, 38% pasien menghentikan pengobatan karena efek samping ACE-i. Bila agen pengobatan diganti dengan ARB, hanya 8% yang menghentikan terapi (Bogaisky, Allu,
Messenger, 2008)
Penekanan produksi AT II tidak lengkap -Terdapat 2 jaras yang memproduksi AT II pada miokardium -ACE-i tidak memperlihatkan efek penekanan AT II jangka panjang (Kirlin PC, et al. 1995) -Inhibitor kimase secara signifikan menekan pembentukan AT II
9 November 2013 Seminar IDI Wilayah NTT
54
Why ARB ? ( Candesartan / Telmisartan )
P H Y S I C IAN S A CAD E M Y F O R CAR D I O VAS C U LAR E D U CAT I O N
Compliance terhadap terapi antihipertensi selama terapi 1 tahun dan 4 tahun

%
AT1-blocker p<0.02 dibandingkan golongan obat lainnya
70 60 50 40 30 20 1 year 4 years
10
0
AT1-blocker
ACE-I
CCBs
Beta- blockers
Diuretics Conlin et al 2001

56
Efek berbagai terapi antihipertensi yang berbeda terhadap insidens diabetes

Metaanalisis dari 22 uji klinis
ARB
0.57 (0.46, 0.72) p<0.0001 0.67 90.56-0.80) p<0.0001
ACEI
CCB Plasebo
Beta bloker
0.75 (0.62, 0.90) p=0.002

0.77 (0.63, 0.94) p=0.009 0.90 (0.75, 1.09) p=0.30
Diuretik
0.5
1.25 0.7 0.9 Odd rasio insidens diabetes

57 Elliott & Meyer 2007
Why Telmisartan ? (Micardis)
Plasma half life (h)

Kalkuta et al. Int J Clin Pharmacol Res 2005;25:41-46
9 November 2013 Seminar IDI Wilayah NTT 59
Telmisartan improves glucose metabolism more than

Irbesartan in diabetics with metabolic syndrome
0 FPG -5 -10 -15 -20 -25 -30 Irbesartan 150 mg (n=93) Telmisartan 40 mg (n=95) FPI HOMA-IR HbA1c
Study duration = 12 months G. DeRosa et al, Hypertension Research, 2006 9 November 2013 Seminar IDI Wilayah NTT All patients taking rosiglitzone 4 mg/d
60
Meta-Analysis of the Effects of Telmisartan on New Onset Diabetes in PRoFESS and TRANCEND Trials (comparisons againts placebo groups)
Significant anti diabetic effect of telmisartan vs placebo 9 November 2013 Seminar IDI for Wilayah NTT 16% risk reduction diabetes (3% - 28%)
61
Why Candesartan ? (Canderin)
63
Profil Lipid
Candesartan lebih superior dalam menurunkan kolesterol total dan LDL dibanding agen ARB yang lain
9 November 2013
Hellenic J Cardiol, 2006, Effects of Antihypertensive Treatment with Angiotensin II Receptor Blockers on Lipid Profile Seminar IDI Wilayah NTT
64
New-onset Diabetes
BMI
6,0%
P=0.301
<22
22
25
27.5
5,0% 4,0% 3,0% 2,0% 1,0% 0,0% 0
Amlodipine
0% 4% -20%
HR=0.64; 95% CI 0.43-0.97
Candesartan
-40% -41% -47% -60% -62%
12
18
24
30
36
42
48
-80%
P=0.947
P=0.015
P=0.028
P=0.0034
months
Risk Reduction in Candesartan group

65
Uji Klinis Candesartan
Trophy CALM
Pre-hipertensi Hipertensi Mikroalbuminuria
SMART
Albuminuria Proteinuria
DIRECT
Mikroaneurisma
Trophy
NPDR
Nefrosklerosis Gagal ginjal kronik ESRD Edema makular
SCOPE
Pre-hipertensi Hipertensi Demensia TIA
PDR
SCAST
ACCESS
Stroke
Pre-hipertensi
CAD
Hipertensi
Fibrilasi atrial
MI
LVH CHF
KEMATIAN
Trophy
9 November 2013 66 Seminar IDI Wilayah NTT
HOPE-3
CHARM
CATCH
CHARM
CANDESARTAN VS AMLODIPINE
9 November 2013 Seminar IDI Wilayah NTT 67
Perubahan Tekanan darah
68
Perubahan LVMI pada pasien LVH
LVMI = NTT Left Seminar IDI Wilayah
9 November 2013
ventricular mass index
69
Tingkat mortalitas
70
71
SUMMARY
Treatment of hypertension still an unsolved issues Goal of blood pressure is the chief target - < 140/90 mmHg for uncomplicated patients - < 130/80 mmHg for the high risk patients (e.g. Diabetes, CKD) Management of hypertension always start with lifestyle modifications Choice of hypertension drugs depend on : - mode of action - compelling or not compelling indications Drugs combination has a special role in 9 November 2013 hypertensive medical treatment Seminar IDI Wilayah NTT
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73
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9 November 2013

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How to Choose Antihypertension Drug

Heri Sutrisno, MD Internal Medicine WZ Johannes Hospital - Kupang

Treatment of hypertension is still an unsolved issue

Kegagalan terapi hipertensi

Sekitar 20% populasi dewasa di dunia menderita hipertensi1

Di AS, hipertensi ditemukan pada 30% penduduk dewasa1-3

Namun, hipertensi terkontrol hanya didapatkanpada 36,8% pasien1-3

Menurut Riskesdas tahun 2007, prevalensi hipertensi di Indonesia sebesar 32,2%4

Seminar IDI Wilayah NTT

The reasons for uncontrolled blood pressure

J Cardiovasc Pharmacol 1998 ; 31 (suppl) : S41-S44

ESH 2003 & JNC VII

JNC VII Bp Classification

> 180 / >110

Isolated Systolic Hypertension

Seminar IDI Wilayah NTT

Seminar IDI Wilayah NTT

What should we done to patients

Seminar IDI Wilayah NTT

3 point evaluation to patients before treatment

Seminar IDI Wilayah NTT

Secondary Causes of Hypertension

Seminar IDI Wilayah NTT

Target Organ Damage

Peripheral arterial disease

How to asses TOD ?

Seminar IDI Wilayah NTT

Manifestations of target organ damage (TOD)/ target organ complication (TOC)

COMPONENTS OF CARDIOVASCULAR RISK STRATIFICATION IN PATIENTS WITH HYPERTENSION

Major Risk Factors

Sex (men and postmenopausal women)

COMPONENTS OF CARDIOVASCULAR RISK STRATIFICATION IN PATIENTS WITH HYPERTENSION

Seminar IDI Wilayah NTT

HIGH BLOOD PRESSURE OR HYPERTENSIVE DISEASE

ANGINA IMA CHF

Stratification of Risk to Quantify Prognosis

(moderate hypertension) SBP 160-179 or DBP 100-109 MED RISK

V. HIGH RISK V. HIGH RISK

Risk Stratification and Treatment

High-normal 130-139/85-89 Lifestyle modification Lifestyle modification

Stage 1 140-159/90-99 Lifestyle modification Lifestyle modification

Stages 2+3 160/100 Drug therapy

Seminar IDI Wilayah NTT

JNC VI, Arch Intern Med 1997; 157: 2413-46

Seminar IDI Wilayah NTT

Goal of Hypertensive Treatment

To achieve the maximum reduction in the total

nephrosclerosis morbidity and mortality

Seminar IDI Wilayah NTT

EUROPEAN SOCIETY of HYPERTENSION ( 2003 )

At least below 140 / 90 mmHg ( lower values if tolerated )

Below 130 / 80 mmHg in Diabetics.

How to Manage Hypertension Patients

Seminar IDI Wilayah NTT

Avoidance of alcohol intake

Regular physical exercise

24 Seminar IDI Wilayah NTT Cessation of smoking

Lifestyle modifications to prevent and manage hypertension

Seminar IDI Wilayah NTT

Seminar IDI Wilayah NTT

Hipertensi stage II (>160/>100 mmHg)

Target tekanan darah tidak tercapai

Dengan indikasi mendesak

Target tekanan darah tidak tercapai