Konsensus Penatalaksanaan

Hipertensi 2019

Perhimpunan Dokter Hipertensi Indonesia

 TALES OF HYPERTENSION
GUIDELINES
ALTITUDE ACCOMPLISH
ON TARGET
ACCF/AHA
HYVET
SPRINT
REIN-2 ESH/ESC ACCORD-BP ESC/ESH

CAMELOTACC/AHA NICE ASH-ISH

2003 2005 2007 2009 2011 2014 2017 2018

JNC 7 JNC 8 ACC/AHA ESC/ESH
 Perlunya Panduan Hipertensi
• Hipertensi masalah kesehatan global
• Prevalensi Hipertensi meningkat
27.8% Riskesdas 2013 34.1% Riskesdas 2018
• PERHI turut mendorong GPH bagian dari GERMAS
• Data & riset hipertensi berkembang perubahan
guidelines hipertensi global ACC/AHA 2017 &
ESC/ESH 2018
• Adopsi panduan hipertensi internasional secara
utuh untuk diterapkan di Indonesia akan menjadi
acuan bagi pasien, klinisi, dan sistem kesehatan
 Memahami Konsensus
• Oleh karena itu,Konsensus Penatalaksanaan Hipertensi PERHI
merupakan sintesa dari berbagai panduan internasional yang dibuat
dengan mengikut-sertakan pertimbangan factor lokal,kebijakan
pemerintah,dan kemudahan untuk diikuti
• Konsensus Medis adalah kesepakatan tentang aspek tertentu dari
pengetahuan medis yang umumnya ditelaah dari berbagai artikel
berbasis bukti,state-of-the-art,penelitian atau pengetahuan dari
sekelompok ahli yang kompeten dalam masalah tersebut
• Tujuan utamanya untuk memberikan advis dan pandangan kepada
dokter secara ringkas tentang cara terbaik atau yang mungkin dan
dapat diterima untuk mengatasi pengambilan keputusan dalam
membuat diagnosis,penatalaksanaan atau pengobatan
 Konsensus Hipertensi PERHI 2019
Mengingat adanya perbedaan antara dua panduan internasional,
PERHI memilih untuk:
• Tetap menggunakan TDS ≥140 mmHg dan/atau TDD ≥90 mmHg
sebagai definisi hipertensi dengan menyadari bahwa risiko
hipertensi meningkat hampir linear dengan peningkatan tekanan
darah
• Melakukan pemeriksaan TD di luar klinik, jika fasilitas tersedia,
dengan ABPM atau HBPM untuk berapa indikasi
• Mencapai target TD lebih rendah dari panduan sebelumya, tetapi
tidak <120/70 mmHg, termasuk bagi mereka yang berusia ≥65
tahun.
• Bagi individu dengan TD 130-139/80-89mmHg direkomendasikan
untuk intervensi gaya hidup, dan penambahan terapi obat jika
terbukti adanya PKV terutama PJK, sesuai dengan guideline spesifik
 Diagnosis Hipertensi
Diagnosis hipertensi ditegakkan bila TDS ≥140 mmHg dan/atau
TDD ≥90 mmHg pada pengukuran berulang di klinik

KATEGORI TDS TDD

Optimal <120mmHg dan <80mmHg

Normal 120-129mmHg dan/atau 80-84mmHg

Normal-tinggi 130-139mmHg dan/atau 85-89mmHg

Hipertensiderajat1 140-159mmHg dan/atau 90-99mmHg

Hipertensiderajat2 160-179mmHg dan/atau 100-109mmHg

Hipertensiderajat3 ≥180mmHg dan/atau ≥110mmHg

Hipertensisistolikterisolasi ≥140mmHg dan <90mmHg
 PENAPISAN DAN DETEKSI HIPERTENSI

TDOptimal TDNormal TD Normal

Hipertensi
<120/80 120-129/80-84 Tinggi
>140/90
130-139/85-89

PengukuranTDdiluar
PikirkanHipertensi klinik (ABPM atau
Terselubung HBPM)
Gunakan
salahsatu
untuk
konfirmasi
diagnosis

UkurTD UkurTD Kontrolulang UkurTDdirumah

UkurTD
setiap5 setiap3 untukukurTDdi (ABPM atau
tahun tahun setiaptahun klinik HBPM)

Indikasiuntuk
ABPM atauHBPM (lihat
Bab2.4 dan2.5)
 BatasanTekanan Darah di Klinik& luar Klinik
untuk Diagnosis Hipertensi
Kategori TDS TDD(mmHg)
(mmHg)
TD Klinik ≥140 dan/atau ≥90

ABPM

Rerata pagi-siang hari (atau bangun) ≥135 dan/atau ≥85

Rerata malam hari (atau tidur) ≥120 dan/atau ≥70

Rerata 24jam ≥130 dan/atau ≥80

Rerata HBPM ≥135 dan/atau ≥85

 Evaluasi Klinis
Tujuan dari evaluasi klinis adalah:
– Menegakkan diagnosis dan derajat hipertensi
– Menapis kemungkinan penyebab sekunder hipertensi
– Identifikasi faktor-faktor yang berkontribusi terhadap perkembangan
hipertensi (gaya hidup, obat lain atau riwayat keluarga)
– Identifikasi faktor risiko kardiovaskular yang lain (termasuk gaya hidup
dan riwayat keluarga)
– Identifikasi penyakit-penyakit penyerta (co-morbid)

– Menentukan ada tidaknya HMOD (Hypertension-mediated Organ

Damage) atau penyakit kardiovaskular, serebrovaskular atau ginjal yang
sudah ada sebelumnya, untuk stratifikasi risiko.
 PENILAIAN HMOD (Hypertension-mediatedorgan damage)
PENAPISAN DASAR INDIKASI DAN INTERPRETASI
EKG12-sandapan Penapisan LVH dan gangguan kardiak lain,serta aritmia fibrilas atrial.
Kriteria EKG LVH:
➢Sokolow-LyonSV1+RV5>35mm,atau R di aVL ≥ 11 mm;
➢Cornell voltage SV3+RaVL > 28mm (laki-laki) ,> 20mm (perempuan)

Albuminuria Protein urin kualitatif untuk deteksi kerusakan ginjal

Funduskopi Deteksi retinopati hipertensi, terutama pada hipertensi derajat 2-3
PENAPISAN LANJUTAN INDIKASI DAN INTERPRETASI
Ekokardiografi Deteksi kelainan struktur dan fungsi kardiak,bila berdampak pada tatalaksana
Ultrasonografi karotis Mengukur intima media thickness dan plak karotis
UltrasonogrFAi-Doppler abdomen Evaluasi ukuran dan strukturginjal,evaluasi aneurisma atau dilatasi aorta
abdominal,evaluasi kelenjar adrenal (CT/MRI jika fasilitas tersedia)
PWV Sebagai indeks kekakuan arteri dan arteriosklerosis:
Tekanan denyut (pada usia tua) > 60 mmHg
PWV karotis-femoral >10m/detik
ABI Penapisan terdapatnya penyakit pembuluh darah tungkai ( ABI < 0,9 )
Uji fungsi kognitif Evaluasi fungsi kognitif pada pasien dengan gejala gangguan kognitif
Pencitraan otak Evaluasi terdapatnya iskemik atauperdarahan otak,terutama pada pasien
Dengan Riwayat stroke atau penurunan fungsi kognitif
 PENILAIANRISIKOPENYAKITKARDIOVASKULAR
Risikosangat
Individudenganhalberikutini:
tinggi PKVterdokumentasi,baiksecaraklinisatausecarameyakinkantampakpada
pencitraan
PKVklinismeliputiinfarkmiokardiumakut,sindromakoronerakut,
revaskularisasikoroneratauarterilain,stroke,TIA,aneurismaaorta
danpenyakitpembuluhdarahperifer.
Secarameyakinkantampakpadapencitraanmeliputiplaksignifikan
(stenosis≥50%)padaangiogrFAiatauultrasonogrFAi.Tidak
termasukdidalamnyapenebalanintima-mediathickness
(IMT)arterikarotis.
Diabetesmellitus(DM)dengankerusakanorgantarget,misalnya
proteinuriaataudisertaiafktorrisikomayormisalnyahipertensi
derajat3atauhiperkolesterolemia.
2
Penyakitginjalkronikberat(eLFG<30mL/min/1.73m)
KalkulasiSCORE10tahun≥10%

Risikotinggi
Individudenganhalberikut:
Kenaikantinggipadasalahsatufaktorrisiko,terutamakadar
kolesterol
>8mmol/L(>310mg/dL)misalnyahiperkolesterolemia
familial,
hipertensiderajat3(TD≥180/110mmHg).
PadakebanyakanorangdenganDM(kecualipadaindividumuda
denganDMtipe1dantanpafaktorrisikomayorlaintermasuk
risiko
sedang).

Hipertrofiventrikelkirihipertensif
2
Penyakitginjalkroniksedang(eLFG30-59mL/min/1.73m)

KalkukasiSCORE10tahun5-10%

Risikosedang Individudengan:
KalkulasiSCORE10tahun≥1%hingga<5%
Hipertensiderajat2
Kebanyakanorangsetengahbayatermasukkategoriini
Risikorendah Individudengan:
KalkulasiSCORE10tahun<1%
Ambang Batas TD untuk Inisiasi Obat
Alur Panduan Inisiasi Terapi Obat Sesuai dengan
Klasifikasi Hipertensi
Target Tekanan Darah di Klinik
Strategi Penatalaksanaan Hipertensi Tanpa Komplikasi
Strategi Pengobatan Hipertensi dan
Penyakit Arteri Koroner
Strategi Pengobatan pada Hipertensi dan PGK
Drug-treatment strategy for
hypertension and HRrEF
Drug-treatment strategy for
hypertension and AF
 ACE i/ARB in HPT pts with Covid-19
Pros vs Con
• Theory and Hypothetical background
• Cases reports??
• Experimental study??
• Evidence base ??......>Retrospektif study
• What’s officional statement ?
• Conclusion / Posision statement ?
A preprint from ChinaXiv from Wu et al (2020) shows how the enzyme furin
plays an important role in this viral life cycle of SARS-CoV-2 and this is
distinctly different than SARS-CoV.
A coronavirus spike protein (red) binds to an
ACE2 receptor (blue) in this illustration.
Now…What in the world is the link between
ACE2 and corona virus?
www.thelancet.com/respiratory
March 11,2020--Vol 8, April 2020
 A statement from the International Society of
Hypertension (ISH) on COVID-19

• The ISH is aware of concern raised by speculation, which was amplified by

the media and which suggested that :
– hypertension increases susceptibility to infection with COVID-19.
– that two commonly used classes of blood pressure lowering agents (ACE-I and ARBs, may
worsen the outcome for those who are infected with COVID-19 (1).

• The ISH completely endorses the content of two recent statements made
by the Council on Hypertension of the ESC and the ESH(2,3) both of which
made clear that there is no good evidence to change the use of ACE-
inhibitors or ARBs for the management of raised blood pressure in the
context of avoiding or treating COVID-19 infection.
 In addition, the ISH would like to highlight the following four critical
pieces of information

1. To date - there is no evidence that people with hypertension are over-represented amongst those
seriously infected by COVID-19. Indeed, the opposite is true given that most such cases occur in those over
60 years in whom hypertension usually affects the majority.
2. There are no clinical data in humans to show that ACE-Inhibitors or ARBs either improve or worsen
susceptibility to COVID-19 infection nor do they affect the outcomes of those infected.
3. In the absence of any such compelling data the ISH strongly recommend that the routine use of ACE-
Inhibitors or ARBs to treat raised blood pressure should continue and should not be influenced by
concerns about COVID-19 infection.
4. It is possible that in light of new data it may be that the management of raised blood pressure should be
modified to reduce susceptibility to or improve outcomes among those infected by COVID-19. However,
currently no such data are available to make such recommendations, and so no changes should be made.

References:References:
• Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for
COVID-19 infection? Lancet Respir Med 2020; https://doi.org/10.1016/S2213-2600(20)30116-8
• Statement by the ESC: https://www.escardio.org/Councils/Council-on-Hypertension-(CHT)/News/position-
statement-of-the-esc-council-on-hypertension-on-ace-inhibitors-and-ang

• Statement by the ESH: https://www.eshonline.org/spotlights/esh-statement-on-covid-19/

The New England Journal of Medicine
March 31, 2020.
 HFSA/ACC/AHA Statement Addresses Concerns
Re: Using RAAS Antagonists in COVID-19
Mar 17, 2020 (posted online)

The following joint statement from the ;

– Heart Failure Society of America (HFSA)
– American College of Cardiology(ACC)
– American Heart Association (AHA)
addresses using renin angiotensin aldosterone system (RAAS) antagonists
in COVID-19.
"The continued highest standard of care for cardiovascular disease
patients diagnosed with COVID-19 is top priority, but there are no
experimental or clinical data demonstrating beneficial or adverse
outcomes among COVID-19 patients using ACE-I or ARB medications," said
Richard J. Kovacs, MD, FACC.
"We urge urgent, additional research that can guide us to optimal care for
the millions of people worldwide with cardiovascular disease and who
may contract COVID-19.
These recommendations will be adjusted as needed to correspond with
the latest research."
 What people with high blood pressure need to know about COVID-19
American Heart Association Guidance

• Could blood pressure-lowering medicines make people with COVID-19

sicker?
• According to the latest guidance from the American Heart Association,
Heart Failure Society of America and the American College of Cardiology,
issued March 17,2020:
• Do not stop taking prescribed angiotensin converting enzyme inhibitors
(ACE-i) or angiotensin receptor blocker (ARB) medications for high blood
pressure, heart failure or heart disease.
• These medications don’t increase your risk of contracting COVID-19. They
are vital to maintaining your blood pressure levels to reduce your risk of
heart attack, stroke and worsening heart disease.
• If you’re a cardiovascular disease patient with COVID-19, your health care
provider should evaluate you before adding or removing treatments.
• Changes should be based on the latest scientific evidence and shared
decision-making.
HFSA/ACC/AHA Statement Addresses Concerns
Re: Using RAAS Antagonists in COVID-19
Mar 17, 2020 (posted online)
Among patients with hypertension, is the use of RAAS
antagonists associated with severe COVID disease or
COVID-related deaths?
April 15, 2020
 Protokol Tatalaksana Panduan
Covid19
• Hipertensi : komorbid paling sering pada pasien Covid-19--- mengalami ARDS.
• SARS-CoV-2, virus berikatan dengan ACE2 (di paru-paru untuk masuk ke dalam cell).
• ACE2 meningkat dengan Th/ ACEi atau ARB sehingga penggunaanya dipertanyakan? (hypothesis).
• ACE inhibitor dan ARB meningkatkan ACE2 sehingga secara teoritis akan meningkatkan ikatan SARS-Cov-2 ke
paru-paru.
• Akan tetapi, ACE2 menunjukkan efek proteksi dari kerusakan paru pada studi eksperimental, dengan bentuk
angiotensin 1-7 dari angiotensin II, sehingga mengurangi efek inflamasi dari angiotensin II dan meningkatkan
potensi efek antiinflamasi dari angiotensin 1-7. ACE inhibitor dan ARB, dengan mengurangi pembentukan
angiotensin II dan meningkatkan angiotensin 1-7, mungkin dapat berkontribusi dalam mengurangi inflamasi
secara sistemik terutama di paru, jantung, ginjal dan dapat menghilangkan kemungkinan perburukan menjadi
ARDS, miokarditis, atau AKI.
• Penggunaan ACE2 rekombinan mungkin menjadi pendekatan terapeutik untuk mengurangi viral load dengan
mengikat SARSCoV-2 di sirkulasi dan mengurangi potensi ikatan ke ACE2 dijaringan.
• Penggunaan obat-obatan ini harus diteruskan untuk mengontrol tekanan darah dan tidak dihentikan,
dengan dasar dari bukti yang ada saat ini.
 ACEI/ARB Treatment May Benefit
Patients With COVID-19 and Hypertension
Florence Chaverneff, Ph.D.
• Treatment of patients with hypertension who are infected with severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) with angiotensin-converting
enzyme inhibitors (ACEIs) or angiotensin II type 1 receptor blockers (ARBs) may
improve clinical outcomes, according to study results published in Emerging
Microbes and Infections.1

• The case fatality rate in patients with SARS-CoV-2 was found to be greater in
patients with cardiovascular disease (10.5%) and hypertension (6.0%) compared
with that in the general population (2.3%).2 The renin-angiotensin system (RAS)
regulates blood pressure via the ACE/Angiotensin (Ang) II/ Ang type 1 receptor
(AT1R) and the ACE2/Ang 1 to 7/Mas receptor signaling pathways. It is believed
that ACEIs and ARBs inhibit and modulate the former and latter pathways,
respectively.

• SARS-CoV-2 enters cells by binding to ACE2 which is expressed at the surface of

cells that include type 2 alveolar epithelial cells in the lungs.3 The level of Ang II
was found to be higher in patients with vs without coronavirus disease 2019
(COVID-19).4
Position on the use of ACEi and ARB given the current COVID 19
pandemic
 ACEI/ARB Treatment May Benefit Patients With COVID-19 and
Hypertension
Two opposite hypotheses have been proposed for the effects of RAS inhibition with
ACEIs or ARBs on the lungs

harmful effects beneficial effects

RAS inhibition upregulates ACE2
expression at the cell surface, thus
promoting SARS-CoV-2 entry.
RAS inhibition reduces the
production of Ang II, which would
otherwise, upon SARS-CoV-2 binding,
activate AT1R, driving inflammation
and fibrosis in the lung.

They retrospectively examined the

clinical data of 417 patients who
were treated at the Shenzhen Third
People’s Hospital, Guangdong
Province, China, for confirmed
COVID-19 between January 11, 2020,
and February 23, 2020
 Renin-angiotensin system inhibitors improve the clinical
outcomes of COVID-19 patients with hypertension
The investigators concluded,
“Taken together, this is
the first clinical evidence
Demonstrating that RAS
inhibitors improve the
clinical outcomes of
[patients with] COVID-19
with hypertension,
suggesting that these
patients could
benefit from the persis
tent or preferential usage
of ACEI/ARB for
antihypertensive
treatment.”

Figure 1. Summarized clinical, inflammatory, immunological, and viral findings in the non-ACEI/ARB group and the ACE/ARB group.
(A) The disease severity distribution of the two groups during hospitalization. (B) The levels of IL-6 and CRP in peripheral blood. (C)
Absolute numbers of CD3+, CD4+, and CD8+ T cells in peripheral blood. (D) Viral load on hospital admission and maximum value
during hospitalization. The data are expressed as the median and IQR. An unpaired t test was used, and P < 0.05 was considered
significant.
Juan Meng, Guohui Xiao, Juanjuan Zhang, Xing He, Min Ou, Jing Bi, Rongqing Yang, Wencheng Di, Zhaoqin Wang, Zigang Li, Hong Gao, Lei Liu & Guoliang Zhang
https://doi.org/10.1080/22221751.2020.1746200
PUBLISHED ONLINE:
31 March 202
 Conclution
Professional societies statements on the topic