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 Hipertensi

70
SBP > 140 mm Hg 65
64
prevalence of hypertension (%)
60 DBP > 90 mm Hg
50 54
44
40

30
21
20
4 11
10

0
age (yrs) 18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

 Hypertension complication

Eyes Brain Target Organ damage!!

retinopathy stroke

Damages depend on:

Heart
ischaemic heart disease How high of the blood
Kidneys left ventricular hypertrophy pressures
renal failure heart failure
How long the
uncontrolled and
untreated high blood
presure
Peripheral arterial disease
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
7% reduction in risk
2 mmHg of ischaemic heart
disease mortality
decrease in
mean SBP
10% reduction in risk
of stroke mortality

Lewington et al. Lancet 2002;360:190313

 ASH/ISH

HYPERTENSION
GUIDELINES
 CLASSIFICATION BP SBP DBP
HYPERTENSION and
Optimal <120 <80
BP SBP DBP Normal 120-129and./or 80-84
Normal <120 and <80 High Normal 130-139 85-89
Pre HT 120-139 or 80-89 HT stg 1 140-159 90-99
Stg 1 140-159 or 90-99 HT stg 2 160-179 100-109
Stg 2 160 or 100 HT stg 3 180 110
ISH 140 <90
and
BP SBP DBP
Optimal <120 and <80
JNC 8
Normal <130 and <85
High Nml 130-139 or 85-89 No definition of HT
HT stg 1 140-159 or 90-99
HT stg 2 160-179 or 100-109
HT stg 3 180 or 110
Topic JNC 7 2014 Hypertension Guidelin
Methodology Non systematic literature review by Critical questions and review criteria defined by expert
expert committee including a range panel with input from methodology team
of study design Initial systematic review by methodologist restricted to
Recommendation based on consensus RCT evidence
Subsequent review of RCT evidence and recommendations
by the panel according to a standardized protocol
Definitions Defined hypertension and prehypertension Definision of hypertension and prehypertension not
addressed, but tresholds for pharmacologic treatment
were defined
Treatments Separate treatmen goals defined for Similar treatment goals defined for all hypertensive
Goals uncomplicated hypertension and for populations except when evidence review supports
subsets with various comorbid condition different goals for a particular subpopulation
Lifestyle Recommended lifestyle modifications Lifestyle recommendations recommended by endorsing
Recommendation based on literature review and expert the evidence based recommendations of the Lyfestyle
opinion Work Group
Drug therapy Recommended 5 classes to be considered Recommended selection among 4 specific medications
as initial therapy for most patients without classes ( ACEI or ARB, CCB or Diuretics) and doses based
compelling indication for another class on RCT evidence
Specified particular antihypertensive Recommended specific medication classes based on
medication classes for patients with evidence review for racial, CKD, and diuretics sub group
compelling indication,ie,diabetes,CKD,heart Panel created a table of drugs and doses used in the
failure,myocardial infarction,stroke,high outcome trials
CVD risk
 Included a comprehensive table oral
Antihypertensive drugs including names
and usual dose ranges
Scope of topics Addressed multiple issues ( blood pressure Evidence review of RCTS addressed a limited
measurements methods,patients evaluation number of questions,those judge by the panel
components,secondary hypertension, to be of highest priority
adherence to regimens,resistant hypertension,
and hypertension in special populations) based
on literature review and expert opinion
Review process Reviewed by the National High Blood pressure Reviewed by experts including those affiliated
Prior to Education Program Coordinating Committee, with professional and public organizations and
Publication a coalition of 39 major professional,public, and federal agencies; no official sponsorship by any
voluntary organizations and 7 federal agencies 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 Recommendations
A

N
 Strength of
Recommendation Recommendation

Recommendation 1
Populasi berusia 60 yrs,mulai terapi Grade A
farmakologi SBP150 mmHg, DBP90 mmHg
HYVET, Sys-Eur, SHEP, JATOS, VALISH,
CARDIO-SIS
Corollary Recommendation
Populasi usia 60 yrs, jika terapi farmakologi
mengakibatkan penurunan TD lebih rendah Grade E
(<140/90) dan pengobatan ditoleransi dengan
baik tanpa efek samping, teruskan pengobatan.
Usia ini TD <140 tidak lebih baik disbanding
140-160
Recommendation 2
Populasi usia <60 yrs, terapi farmacologi bila Grade A (30-59 yrs)
DBP90 mmHg . Target DBP<90 mmHg Grade E (18-29 yrs)
HDFP, HT-Stroke Cooperative, MRC,
ANBP, VA cooperative
 Strength of
Recommendation Recommendation

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

Recommendation 4
Populasi usia 18 yrs dengan CKD, terapi
farmacologi bila SBP 140 mmHg or DBP 90 Grade E
mmHg . Target SBP <140 mmHg dan DBP <90
mmHg AASK, MDRD, REIN-2

Recommendation 5
Populasi usia 18 dengan DM, terapi Grade E
farmacologi bila SBP 140 mmHg atau DBP 90
mmHg. Target SBP<140 and DBP <90 SHEP, Syst-Eur, UKPDS, ACCORD,
ADVANCE, HOT
 Strength of
Recommendation Recommendation

Recommendation 6
Pada populasi non black , termasuk dg DM, Grade B
initial anti HTN treatment : a thiazide type
diuretic, CCB, ACEI or ARB VA-cooperative, HDFP, SHEP

Recommendation 7
Populasi kulit hitam, termasuk dg DM, initial Grade B ( No DM)
anti HT: thiazide-type diuretic or CCB Grade C ( DM)

ALLHAT

Recommendation 8
Populasi usia 18 dg CKD dan HTN, initial (or Grade B
add on) anti HTN : ACEI or ARB utk
memperbaiki kidney outcomes. Tanpa melihat
ras atau status DM IDNT, AASK
 Recommendation Strength of
Recommendation
Recommendation 9

Tujuan treatment HTN adalah untik mencapai dan

mempertahankan target BP
Jika target BP tidak tercapai dlm 1 bl, naikkan dosis
atau tambahkan 2nd 1 obat dr rekomendasi 6
(thiazide-type diuretic, CCB, ACEI, or ARB)
Jika target BP tidak tercapai dg 2 obat, tambah dan Grade E
titrasi obat 3rd . Do not use an ACEI and an ARB
together
Jika target BP tidak dapat tercapai dg obat-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.
 Strategies to Dose Antihypertensive Drugs
Strategies Description Details
A Mulai 1 obat naikan sp Jika target BP blm tercapai naikkan dosis
dosis obat 1 sp dosis maksimum sblm
maksimum,kemudian menambahkan obat ke-2 dan ke-3.
tambahkan obat ke-2
B Mulai 1 obat kemudian Tambahkan obat ke-2 sblm obat 1
tambahkan obat ke-2 mencapai dosis maks.Jk Target BP blm
sblm dosis maksimum tercapai,tambahkan obat ke-3 dan
titrasi sp dosis maks.
C Mulai dengan 2 obat Mulai dg 2 obat
(separate or single Bbrp committee merekomendasi:
combination) 2 obat SBP >160 dan/atau DBP
>100, atau SBP >20 mmHg diatas
target dan/atau DBP >10 mmHg
Jika target BP tdk tercapai (2 drugs),
tambahkan obat ke-3 dan titrasi.
Lifestyle Modification
JNC 8
JNC 7
G
Guideline Population Goal BP Initial drugs
U
2014 HT General 60 y <150/90 Non Black: thiazide type diuretic, ACEI,
I
D Guideline ARB or ARB
E General <60 y <140/90 Black: thiazide type-diuretic or CCB
L DM <140/90 Thiazide type diuretic, ACEI, ARB or
I CCB
N CKD <140/90 ACEI or ARB
E General (non <140/90 Bocker, diuretic, CCB, ACEI, ARB
ESH/ESC elderly)
C General elderly <150/90
0 <80 y
M General 80 y <150/90
P DM <140/85 ACEI or ARB
A CKD (no <140/90 ACEI or ARB
proteinemia)
R
CKD + <130/90
I proteinemia
S
CHEP General <80 y <140/90 Thiazide, Blocker (<60y), ACEI (nonblack) or
O
ARB
N General >80 y <150/90
DM <130/80 Add CVD risk: ACEI or ARB
GOAL BP No CVD risk: ACEI/ARB/Thiazide/DHPCCB
INITIAL TX ACEI or ARB
CKD <140/90
 Guideline Population Goal BP Initial drugs
ADA DM <140/80 ACEI or ARB

KDIGO DM and CKD 140/90 ACEI or ARB

alb exc <30
mg/d
DM and CKD 130/80
alb exc >30
mg/d
NICE General <80 y <140/90 <55 y; ACEI or ARB
General 80 y <150/90 55 y or black; CCB

ISHIB Black, lower risk <135/85 Diuretic or CCB

TOD or CVD risk <130/80

JNC 7 General <140/90

CKD <130/80 ACEI or ARB
DM <130/80
 Important Variables For HTN Recommendations
BP NICE ESC/ESH ASH/ISH AHA/AC JNC 7 JNC 8
C/CDC

Definition 140/90 140/90 140/90 140/90 Pre HT 120-139 Not

or 80-89
HTN and Stg 1 HT
addressed
daytime 140-159 or 90-
ABPM 99
135/85 Stg 2 HT
160 or 100

Drug th/ in 160/100 140/90 140/90 140/90 140/90 <60 y,

low risk or daytime 140/90
pts after ABPM 60 y,
non pharm 150/95 150/90
th/

Blocker No Yes No No No No
as 1st line
 NICE ESH/ESC ASH/ISH AHA/ACC JNC 7 JNC 8
/CDC
Diuretic Chorthali- Thiazides THZ THZ THZ THZ
done (THZ), CTD CTD
(CTD) CTD IND IDP
Indapami- ND
de (IND)
Initiate Not Pts w/ 160/90 160/100 160/100 Not
th/ with mentio- markedly mentioned
2 drugs ned elevated BP

BP <140/90 <140/90 <140/90 <140/90 <140/90 <160/90

target 80 y, Elderly <80 80 y, (<60 y)
<150/90 SBP 140- <150/90
150, in fit 60 y,
pts SBP <150/90
<140
Elderly 80
y SBP 140-
150
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 pts 18 - 59 yrs without 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
days of the week

Under the JNC 8 guidelines, patients would receive a 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