CURRICULUM VITAE

• Nama : Maria Riastuti Iryaningrum

• Lahir : Solo, 11 Mei
• Pendidikan : FK Unika Atma Jaya (dr umum)
FK UNPAD (Sp P. Dalam)
FK UI (Sp2 Ginjal Hipertensi)
 Organisasi : IDI
PAPDI
PERNEFRI
INASH
ASPEN
ESPEN
HIPERTENSI PADA
POPULASI KHUSUS

Dr Maria R Iryaningrum SpPD-KGH

Dr Yunita Maslim SpPD

Dept/SMF Ilmu Penyakit Dalam

FKIK UNIKA ATMA JAYA
 EPIDEMIOLOGI
• Prevalensi Hipertensi menurut World Health Organization
(WHO) pada populasi dewasa sebesar 40%

• Prevalensi Hipertensi nasional berdasarkan Riskesdas

2013 sebesar 25,8%

• dari 25,8% orang yang mengalami hipertensi hanya 1/3

yang terdiagnosis, sisanya 2/3 tidak terdiagnosis

• hanya 0,7% orang yang terdiagnosis hipertensi minum

obat
 EPIDEMIOLOGI (lanj)
• Hipertensi yang tidak mendapat penanganan yang baik
menyebabkan komplikasi seperti Stroke, Penyakit
Jantung Koroner, Diabetes, Gagal Ginjal dan Kebutaan

• Stroke (51%) dan Penyakit Jantung Koroner (45%)

merupakan penyebab kematian tertinggi

• Kerusakan organ target akibat komplikasi Hipertensi akan

tergantung kepada besarnya peningkatan tekanan darah
dan lamanya kondisi tekanan darah yang tidak
terdiagnosis dan tidak diobati.
 EPIDEMIOLOGI (lanj)
• Menurut data Sample Registration System (SRS) Indonesia
tahun 2014, Hipertensi dengan komplikasi (5,3%) merupakan
penyebab kematian nomor 5 (lima) pada semua umur

• Data World Health Organization (WHO) tahun 2011

menunjukkan satu milyar orang di dunia menderita Hipertensi,
2/3 diantaranya berada di negara berkembang yang
berpenghasilan rendah sampai sedang

• Prevalensi Hipertensi akan terus meningkat tajam dan

diprediksi pada tahun 2025 sebanyak 29% orang dewasa di
seluruh dunia terkena Hipertensi.
 KRITERIA HIPERTENSI MENURUT ESH
2018
Category Systolic (mmHg) Diastolic (mmHg)

Optimal < 120 and < 80

Normal 120–129 and/or 80–84

High normal 130–139 and/or 85–89

Grade 1 hypertension 140–159 and/or 90–99

Grade 2 hypertension 160–179 and/or 100–109

Grade 3 hypertension ≥ 180 and/or ≥ 110

Isolated systolic hypertension ≥ 140 and < 90

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018

KRITERIA HIPERTENSI MENURUT ACC DAN AHA
2017

J Am Coll Cardiol. Sep 2017,

 SKRINING PASIEN HIPERTENSI DAN
PENGUKURAN TEKANAN DARAH (TD)
 SKRINING PASIEN HIPERTENSI DAN
PENGUKURAN TEKANAN DARAH (TD) (LANJ)
EVALUASI KLINIS DAN PENILAIAN KERUSAKAN
ORGAN dan PEMERIKSAAN RUTIN :
EVALUASI KLINIS DAN PENILAIAN KERUSAKAN ORGAN :
(PENILAIAN HMOD)
INISIASI MENURUNKAN TEKANAN DARAH

High normal BP Grade 1 hypertension Grade 2 hypertension Grade 3 hypertension

BP 130-139 / 85-89 BP 140-159 / 90-99 BP 160-179 / 100-109 BP ≥ 180/ 110

Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle advice

Consider drug Immediate drug

treatment in very treatment in high or Immediate drug
high risk patients very high risk treatment in all Immediate drug
with CVD, especially patients with CVD, patients treatment in all patients
CAD renal disease or
HMOD

Drug treatment in
low-moderate risk Aim for BP control within Aim for BP control within
patients without 3 months 3 months
CVD, renal disease or
HMOD
after 3-6 months of
lifestyle intervention
if BP not controlled
 MEMULAI TERAPI HIPERTENSI
Office SBP treatment threshold (mmHg) Diastolic
treatment
Age group
threshold
+
Hypertension + Diabetes + CKD + CAD (mmHg)
Stroke/TIA

18−65 years ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 90

65−79 years ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 140 ≥ 90

≥ 80 years ≥ 160 ≥ 160 ≥ 160 ≥ 160 ≥ 160 ≥ 90

Diastolic
treatment
≥ 90 ≥ 90 ≥ 90 ≥ 90 ≥ 90
threshold
(mmHg)
 TARGET TERAPI HIPERTENSI
Office SBP treatment target ranges (mmHg) Diastolic
treatment
Age group target
+ range
Hypertension + Diabetes + CKD + CAD
Stroke/TIA (mmHg)
Target to 130 Target to 130 Target to Target to 130 Target to 130
or lower if or lower if < 140 to 130 or lower if or lower if
18−65 years tolerated tolerated if tolerated tolerated tolerated < 80 to 70
Not < 120 Not < 120 Not < 120 Not < 120

Target to < 140 Target to Target to Target to Target to

65−79 years to 130 < 140 to 130 < 140 to 130 < 140 to 130 < 140 to 130 < 80 to 70
if tolerated if tolerated if tolerated if tolerated if tolerated

Target to < 140 Target to Target to Target to Target to

≥ 80 years to 130 < 140 to 130 < 140 to 130 < 140 to 130 < 140 to 130 < 80 to 70
if tolerated if tolerated if tolerated if tolerated if tolerated

Diastolic
treatment
target < 80 to 70 < 80 to 70 < 80 to 70 < 80 to 70 < 80 to 70
range(mm
Hg)
TARGET TD BERDASARKAN KONDISI KLINIS (ACC)
 PERUBAHAN GAYA HIDUP
Recommendations Class Level

Salt restriction to < 5 g per day is recommended. I A

It is recommended to restrict alcohol consumption to: I A

Less than 14 units per week for men.
Less than 8 units per week for women.

It is recommended to avoid binge drinking. III C

Increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty I A

acids (olive oil), low consumption of red meat, and consumption of low-fat dairy
products are recommended.

Body-weight control is indicated to avoid obesity (BMI > 30 kg/m2 or WC > 102 I A
cm in men and > 88 cm in women) and aim at a healthy BMI (about 20–25
kg/m2) and WC values (< 94 cm in men and < 80 cm in women) to reduce BP
and CV risk.

Regular aerobic exercise (e.g. at least 30 min of moderate dynamic exercise on I A

5–7 days per week) is recommended.

Smoking cessation and supportive care and referral to smoking cessation I B

programs are recommended.
 OBAT ANTI HIPERTENSI

JNC 8
 OBAT ANTI HIPERTENSI

JNC 8
OBAT-OBAT ANTI HIPERTENSI
 STRATEGI TERAPI PADA
HIPERTENSI TANPA KOMPLIKASI

Strategi dapat digunakan pada pasien dengan :

HMOD, penyakit serebrovaskular, diabetes atau PAD
 HIPERTENSI DAN DIABETES MELLITUS

 defined as a sustained blood pressure 140/90 mmHg,

is common among patients with either type 1 or type 2 DM

 Hypertension is a major risk factor for :

- Atherosclerotic cardiovascular disease (ASCVD)
- microvascular complications

 antihypertensive therapy reduces :

- ASCVD events
- heart failure
- microvascular complications.

Diabetes Care Volume 41, Supplement 1, January 2018

 HIPERTENSI DAN DIABETES MELLITUS (LANJ)
Recommendations : (ADA)

 Blood pressure should be measured at every routine clinical visit

 Patients found to have elevated blood pressure (140/90)

should have blood pressure confirmed using multiple readings,
including measurments on a separate day

 All hypertensive patients with DM should monitor

their blood pressure at home

Diabetes Care Volume 41, Supplement 1, January 2018

 HIPERTENSI DAN DIABETES MELLITUS (LANJ)

Recommendation :
For patients with BP 120/80 mmHg :
lifestyle intervention consists of weight loss if overweight or obese

 Dietary Approaches to Stop Hypertension (DASH)

- reducing sodium
- increasing potassium intake
- moderation of alcohol intake
- increased physical activity

Diabetes Care Volume 41, Supplement 1, January 2018

 HIPERTENSI AND DIABETES MELLITUS (lanj)

 Patients with confirmed BP>140/90 mmHg

- addition to lifestyle therapy
- initiation and timely titration of pharmacologic therapy

 Patients with confirmed BP >160/100 mmHg

- addition to lifestyle therapy
- initiation and timely titration of two drugs or a single-pill
combination of drugs (reduce cardiovascular events)

 Treatment for hypertension should include drug classes

(ACE inhibitors, angiotensin receptor blockers, thiazide- like
diuretics, or dihydropyridine calcium channel blockers).

Diabetes Care Volume 41, Supplement 1, January 2018

 HIPERTENSI AND DIABETES MELLITUS (lanj)
 Multiple-drug therapy is generally required to
achieve blood pressure targets

 combinations of ACE inhibitors and ARB

and combinations of ACE inhibitors or ARB with
direct renin inhibitors should not be used

 ACE inhibitor or ARB, recommended first-line treatment

for hypertension in DM and urinary ACR >300 mg/g creatinine
or 30–299 mg/g creatinine

 For patients treated with an ACE inhibitor, ARB, or diuretic,

serum creatinine/e-GFR and serum potassium levels
should be monitored at least annually.

Diabetes Care Volume 41, Supplement 1, January 2018

• Recommendation for the Treatment
of Hypertensision in DM
• Diabetes Care Volume 41, Supplement 1, January 2018
 HIPERTENSI AND DIABETES MELLITUS (lanj)
Recommendations Class Level

Antihypertensive drug treatment is recommended for people with I A

diabetes when office BP is ≥ 140/90 mmHg.

In people with diabetes receiving BP-lowering drugs it is recommended:

 To target SBP to 130 mmHg and lower, if tolerated, but not lower I A
than 120 mmHg.

 In older people (aged ≥ 65 years), to target to a SBP range of I A

130 to < 140 mmHg.

 To target the DBP to < 80 mmHg, but not lower than 70 mmHg. I C

It is recommended to initiate treatment with a combination of an I A

RAS blocker with a CCB or thiazide/thiazide-like diuretic.

Simultaneous administration of two RAS blockers, e.g. and ACE III A

inhibitor and ARB, is not indicated.

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018

 HIPERTENSI AND PENYAKIT GINJAL KRONIK
(PGK)
Recommendations Class Level

In patients with diabetic or non-diabetic CKD, it is recommended that an I A

office BP of ≥ 140/90 mmHg be treated with lifestyle advice and BP-
lowering medication.

In patients with diabetic or non-diabetic CKD:

 It is recommended to lower SBP to a range of 130 to < 140 mmHg. I A

 Individualized treatment should be considered according to its IIa C

tolerability and impact on renal function and electrolytes.

RAS blockers are more effective at reducing albuminuria than other I A

antihypertensive agents, and are recommended as part of the treatment
strategy in hypertensive patients in the presence of
microalbuminuria or proteinuria.

A combination of a RAS blocker with a CCB or a diuretic is recommended I A

as initial therapy.

A combination of two RAS blockers is not recommended. III A

STRATEGI UNTUK HIPERTENSI DAN CKD
 OBAT-OBAT YANG DAPAT MENAIKKAN
TEKANAN DARAH
Medication/substance

Oral contraceptive pill Especially oestrogen containing − cause hypertension in ~5% of women,
usually mild but can be severe

Diet pills For example, phenylpropanolamine and sibutramine

Nasal decongestants For example, phenylephrine hydrochloride and naphazoline hydrochloride

Stimulant drugs Amphetamine, cocaine, and ecstasy – these substances usually cause acute
rather than chronic hypertension

Liquorice Chronic excessive liquorice use mimics hyperaldosteronism by stimulating

the mineralocorticoid receptor and inhibiting cortisol metabolism

Immunosuppressive medications For example, cyclosporin A (tacrolimus has less effect on BP and rapamycin
has almost no effect on BP), and steroids (e.g. corticosteroids,
hydrocortisone)

Antiangiogenic cancer therapies Antiangiogenic drugs, such as VEGF inhibitors (e.g. bevacizumab), tyrosine
kinase inhibitors (e.g. sunitinib), and sorafenib, have been reported to
increase BP

Other drugs and substances that Anabolic steroids, erythropoietin, non-steroidal anti-inflammatory drugs,
may raise BP herbal remedies (e.g. ephedra, ma huang)
HIPERTENSI EMERGENSI DAN URGENSI
Hypertensive emergency or hypertensive crisis:
It means severe elevation of BP (>180/120 mm Hg)
with evidence of impending/ progressive target organ dysfunction.

 hypertensive encephalopathy
(headache, irritability, confusion, altered mental status)
 hypertensive nephropathy
(hematuria, proteinuria, progressive kidney dysfunction)
 intracranial hemorrhage
 aortic dissection
 pre-eclampsia, eclampsia,
 pulmonary edema
 unstable angina or myocardial infarction.

It needs substantial reduction of BP within 1 hour

HIPERTENSI EMERGENSI DAN URGENSI (lanj)
Parenteral therapy is indicated

At first BP should be reduced no more than 25% within minutes

to 1 to 2 hours and then it should be gradually lowered
to a target level of 160/100 mm Hg within 2 to 6 hours.

Excessive reductions in pressure may precipitate

coronary, cerebral or renal ischemia.
 HIPERTENSI EMERGENSI DAN URGENSI (lanj)

Hypertensive urgency :
 severe elevation BP without target organ dysfunction.

 characterized by asymptomatic severe hypertension

(systolic BP > 220 mm Hg or diastolic BP > 125 mm Hg)

 BP must be reduced within a few hours

 slow reduction of BP with relief of symptoms is the goal.

DIAGNOSTIK UNTUK HIPERTENSI EMERGENSI
Common tests for all potential causes

Fundoscopy is a critical part of the diagnostic work-up

12-lead ECG

Haemoglobin, platelet count, fibrinogen

Creatinine, eGFR, electrolytes, LDH, haptoglobin

Urine albumin:creatinine ratio, urine microscopy for red cells, leucocytes, and casts

Pregnancy test in women of child-bearing age

Specific tests by indication

Troponin, CK-MB (in suspected cardiac involvement, e.g. acute chest pain or acute heart failure) and NT-proBNP

Chest X-ray (fluid overload)

Echocardiography (aortic dissection, heart failure, or ischaemia)

CT angiography of thorax and/or abdomen in suspected acute aortic disease (e.g. aortic dissection)

CT or MRI brain (nervous system involvement)

Renal ultrasound (renal impairment or suspected renal artery stenosis)

Urine drug screen (suspected methamphetamine or cocaine use)

 OBAT YANG DIGUNAKAN HIPERTENSI
EMERGENSI
Time line and target for
Clinical presentation First-line treatment Alternative
BP reduction

Malignant hypertension with Several hours Labetalol Nitroprusside

or without acute renal failure Reduce MAP by 20–25% Nicardipine Urapidil

Hypertensive Immediately reduce MAP by Labetalol

Nitroprusside
encephalopathy 20–25% Nicardipine

Immediate reduce SBP to

Acute coronary event Nitroglycerine Labetalol Urapidil
< 140 mmHg

Acute cardiogenic pulmonary Immediately reduce SBP to Nitroprusside OR nitroglycerine Urapidil

oedema < 140 mmHg (with loop diuretic) (with loop diuretic)

Immediately reduce SBP to

< 120 mmHg AND heart rate Esmolol AND nitroprusside OR Labetalol OR
Acute aortic dissection
to nitroglycerine OR nicardipine metoprolol
< 60 bpm

Immediately reduce SBP to Labetalol OR nicardipine AND

Eclampsia and severe pre- Consider delivery
< 160 mmHg AND DBP to magnesium sulphate
eclampsia/HELLP
< 105 mmHg
 KONTRA INDIKASI OBAT_OBAT ANTI
HIPERTENSI
Contraindications
Drug
Compelling Possible
Diuretics  Gout  Metabolic syndrome
(thiazides/thiazide-  Glucose intolerance
type, e.g.  Pregnancy
chlorthalidone and  Hypercalcemia
indapamide)  Hypokalemia
Beta-blockers  Asthma  Metabolic syndrome
 Any high-grade sino-atrial or  Glucose intolerance
atrioventricular block  Athletes and physically active
 Bradycardia (heart rate < 60 beats per patients
min)
Calcium antagonists  Tachyarrhythmia
 Heart failure (HFrEF, class III or
(dihydropyridines) IV)
 Pre-existing severe leg oedema
Calcium antagonists  Any high-grade sino-atrial or AV block  Constipation
 Severe LV dysfunction (LV EF < 40%)
(verapamil,  Bradycardia (heart rate < 60 beats per
diltiazem) min)
ACE inhibitors  Pregnancy  Women of child-bearing potential
 Previous angioneurotic oedema without reliable contraception
 Hyperkalemia (potassium > 5.5 mmol/L)
 Bilateral renal artery stenosis
ARBs  Pregnancy  Women of child-bearing potential
 Hyperkalemia (potassium > 5.5 mmol/L) without reliable contraception
 Bilateral renal artery stenosis
 HIPERTENSI RESISTEN
Resistant hypertension is defined :
average office BP of 130/80 mm Hg or >
in patients adhering to 3 or more antihypertensive agents
from different classes at optimal doses,

Using the former BP target of less than 140/90 mm Hg,

the prevalence has been estimated to be 13%

Risk for :
- myocardial infarction
- stroke
- end-stage renal disease
- death
Annals of Internal Medicine • Vol. 168 No. 5 • 6 March 2018
Synopsis of the 2017 ACC/AHA Hypertension Guideline
 HIPERTENSI RESISTEN (lanj)

 Confirm treatment resistance

 Exclude pseudoresistance
 Identify and reverse contributing lifestyle factors
 Discontinue or minimize interfering substances
 Screen for secondary hypertension
 Maximize diuretic therapy (i.e., substitute chlorthalidone or
indapamide for hydrochlorothiazide)

Add other agents with different mechanisms of action Use loop

diuretics in CKD

Annals of Internal Medicine • Vol. 168 No. 5 • 6 March 2018

Synopsis of the 2017 ACC/AHA Hypertension Guideline
 KARAKTERISTIK HIPERTENSI RESISTEN
DAN PENYEBAB
Characteristics of patients with
resistant hypertension
Demographics
Older age (especially > 75 years)
Obesity
More common in black people
Excess dietary sodium intake
High baseline BP and chronicity of
uncontrolled hypertension
Concomitant disease
HMOD: LVH and/or CKD
Diabetes
Atherosclerotic vascular disease
Aortic stiffening and isolated systolic
hypertension
Causes of secondary resistant Drugs and substances that may cause
hypertension raised BP
More common causes Prescribed drugs
Primary hyperaldosteronism Oral contraceptives
Atherosclerotic renovascular disease Sympathomimetic agents (e.g.
Sleep apnoea decongestants in proprietary cold remedies)
CKD Non-steroidal anti-inflammatory drugs
Cyclosporin
Erythropoietin
Steroids (e.g. prednisolone, hydrocortisone)
Some cancer therapies
Uncommon causes Non-prescription drugs
Phaeochromocytoma Recreational drugs (e.g. cocaine,
Fibromuscular dysplasia amphetamines, anabolic steroids)
Aortic coarctation Excess liquorice ingestion
Cushing’s disease Herbal remedies (e.g. ephedra, ma huang)
Hyperparathyroidism
 KARAKTERISTIK PASIEN YANG PERLU
DICURIGAI HIPERTENSI SEKUNDER
Characteristic

Younger patients (< 40 years) with grade 2 hypertension or onset of any grade of hypertension
in childhood

Acute worsening hypertension in patients with previously documented chronically stable

normotension

Resistant hypertension

Severe (grade 3) hypertension or a hypertension emergency

Presence of extensive HMOD

Clinical or biochemical features suggestive of endocrine causes of hypertension or CKD

Clinical features suggestive of obstructive sleep apnoea

Symptoms suggestive of phaeochromocytoma or family history of phaeochromocytoma

 HIPERTENSI SEKUNDER
Prevalence in
Cause hypertensive Suggestive symptoms and signs Screening Investigations
patients
Snoring; obesity (can be present in non-
Obstructive sleep Epworth score + ambulatory
5–10% obese); morning headache; daytime
apnoea polygraphy
somnolence
Plasma creatinine and electrolytes,
Mostly asymptomatic; diabetes;
Renal parenchymal eGFR; urine dipstick for blood and
2–10% haematuria, proteinuria, nocturia; anaemia,
disease protein, urinary albumin:creatinine
renal mass in adult polycystic CKD
ratio; renal ultrasound

Renovascular disease:

Atherosclerotic Older; widespread atherosclerosis

renovascular disease (especially PAD); diabetes; smoking;
recurrent flash pulmonary oedema; Duplex renal artery Doppler or
1–10% abdominal bruit CT angiography or MR
angiography
Fibromuscular Younger; more common in women;
dysplasia abdominal bruit
Plasma aldosterone and renin, and
aldosterone:renin ratio;
Primary Mostly asymptomatic; muscle weakness
5−15% hypokalaemia (in a minority) –
Aldosteronism (rare)
note hypokalaemia can depress
aldosterone levels
 HIPERTENSI SEKUNDER (lanj)
Prevalence in
Cause hypertensive Suggestive symptoms and signs Screening Investigations
patients
Episodic symptoms − the 5 ‘Ps’: paroxysmal
hypertension, pounding headache,
perspiration, palpitations, pallor; labile BP; BP
Plasma or 24-h urinary fractionated
Phaeochromocytoma < 1% surges precipitated by drugs (e.g. beta-
metanephrines
blockers, metoclopramide,
sympathomimetics, opioids, and tricyclic
antidepressants)
Moon face, central obesity, skin atrophy,
Cushing’s syndrome < 1% striae and bruising; diabetes; chronic steroid 24-h urinary free cortisol
use
Thyroid disease
Signs and symptom of hyper- or
(hyper- or 1−2% Thyroid function tests
hypothyroidism
hypothyroidism)

Hyperparathyroidism < 1% Hypercalcaemia, hypophosphatemia Parathyroid hormone, Ca2+

Usually detected in children or adolescence;

different BP (≥ 20/10 mmHg) between
Coarctation of the upper–lower extremities and/or between
< 1% Echocardiogram
aorta right–left arm and delayed radial-femoral
femoral pulsation; low ABI interscapular
ejection murmur; rib notching on chest X-ray
 HIPERTENSI DAN KEHAMILAN

The definition :

 systolic BP (SBP) > 140 mmHg and/or DBP > 90 mmHg

 distinguishes : - mildly (140–159/ 90–109 mmHg) or

- severely (> 160/110 mmHg)

European Heart Journal (2018) 39, 3165–3241

 HIPERTENSI DAN KEHAMILAN (lanj)
Hypertension in pregnancy is not a single entity but comprises :

 Pre-existing hypertension :
precedes pregnancy or develops before 20 weeks of gestation.
It usually persists for more than 42 days post-partum
(associated with proteinuria)

 Gestational hypertension:
develops after 20 weeks of gestation and
usually resolves within 42 days post-partum

European Heart Journal (2018) 39, 3165–3241

 HIPERTENSI DAN KEHAMILAN (lanj)
 Pre-eclampsia:
gestational hypertension with significant proteinuria
(>0.3 g/24 h or ACR > 30 mg/mmol).
more frequently during :
- the first pregnancy
- multiple pregnancy
- hydatidiform mole
- antiphospholipid syndrome
- pre existing hypertension
- renal disease / diabetes
It is often associated with :
- foetal growth restriction
- placental insufficiency
- common cause of prematurity

The only cure is delivery European Heart Journal (2018) 39, 3165–3241
 HIPERTENSI DAN KEHAMILAN (lanj)
As proteinuria may be a late manifestation of pre eclampsia,
it should be suspected when de novo hypertension is
accompanied by :
- headache
- visual disturbances
- abdominal pain,
- abnormal laboratory
(low platelets and/or abnormal liver function)

 Antenatally unclassifiable hypertension:

when BP is first recorded after 20 weeks of gestation
and hypertension is diagnosed
re-assessment is necessary after 42 days post-partum.

European Heart Journal (2018) 39, 3165–3241

 HIPERTENSI DAN KEHAMILAN (lanj)
 High risk of pre-eclampsia :
- hypertensive disease during a previous pregnancy
- chronic kidney disease
- autoimmune disease (SLE or antiphospholipid syndrome)
- type 1 or type 2 diabetes
- chronic hypertension

 Moderate risk of pre-eclampsia :

- first pregnancy
- age 40 years or older
- pregnancy interval of more than 10 years
- BMI of > 35 kg/m2 at first visit
- family history of pre-eclampsia
- multiple pregnancy

European Heart Journal (2018) 39, 3165–3241

 HIPERTENSI DAN KEHAMILAN (lanj)
Recommendations Class Level

In women with gestational hypertension or pre-existing hypertension I C

superimposed by gestational hypertension, or with hypertension and subclinical
organ damage or symptoms, initiation of drug treatment is recommended when
SBP is ≥ 140 or DBP ≥ 90 mmHg.
In all other cases, initiation of drug treatment is recommended when SBP is ≥ I C
150 mmHg or DBP is ≥ 95 mmHg.
I Methyldopa,
Methyldopa, labetalol, and CCBs are recommended as the drugs of choice for labetalol
the treatment of hypertension in pregnancy. I C (labetalol
or CCBs)
ACE inhibitors, ARBs, or direct renin inhibitors are not recommended during III C
pregnancy.
SBP ≥ 170 mmHg or DBP ≥ 110 mmHg in a pregnant woman is an emergency, I C
and admission to hospital is recommended.
In severe hypertension, drug treatment with i.v. labetalol or oral methyldopa or I C
nifedipine is recommended.
The recommended treatment for hypertensive crisis is i.v. labetalol or I C
nicardipine and magnesium.
In pre-eclampsia associated with pulmonary oedema, nitroglycerin given as an I C
i.v. infusion is recommended.
In women with gestational hypertension or mild pre-eclampsia, delivery is I B
recommended at 37 weeks.
It is recommended to expedite delivery in pre-eclampsia with adverse conditions I C
such as visual disturbances or haemostatic disorders.
 HIPERTENSI DAN KEHAMILAN (lanj)

European Heart Journal (2018) 39, 3165–3241

 HIPERTENSI DAN KEHAMILAN (lanj)

European Heart Journal (2018) 39, 3165–3241

 HIPERTENSI PADA LANJUT USIA

 SBP and DBP increase linearly up to the fifth or sixth decade

of life, after which DBP gradually decreases
while SBP continues to rise

 isolated systolic hypertension

(defined as SBP > 160 mm Hg with DBP <90 mm Hg)

 is the predominant form of

hypertension in older persons

 BP lowering in isolated systolic hypertension

is effective in reducing the risk of fatal and nonfatal stroke
(primary outcome), cardiovascular events, and death
Compelling and possible contraindications to the use of
specific antihypertensive drugs
SOAL _SOAL
NY H 40 tahun, G3P2A0 hamil 7 bulan, datang ke praktek
anda karena sakit kepala, penglihatan kabur, tangan
kesemutan dan kaki bengkak yang memberat dalam 1
minggu ini. Pasien memiliki riwayat hipertensi tidak
terkontrol setelah kelahiran anak ke2. Pasien menyangkal
adanya kejang. Pada pemeriksaan fisik pasien CM
gelisah, TD 170/100mmHg, N 100x/m, S 37 C, RR 22 x/m.
Defisit neurologis (-). Pemeriksaan urine : protein +2.

Diagnosis dan tatalaksana yang paling tepat adalah :

A. Hipertensi esensial superimposed preeklampsia
berat. Th: rujuk Faskes lebih tinggi untuk
antihipertensi intravena dan MgSO4.

A. Hipertensi sekunder superimposed preeklampsia

ringan. Th : pemberian nifedipin 3 x 10 mg po.

A. Hipertensi kronis superimposed preeklampsia berat.

Th : rujuk Faskes lebih tingi untuk antihipertensi
intravena dan MgSO4.

A. Hipertensi kronis superimposed preeklampsia ringan.

Th : pemberian metildopa 3 x 250 mg po.

A. Hipertensi esensial dengan penyulit chronic kidney

disease pada kehamilan. Th : rujuk ke konsultan
ginjal hipertensi.
A. Hipertensi esensial superimposed preeklampsia
berat. Th: rujuk Faskes lebih tinggi untuk
antihipertensi intravena dan MgSO4.

A. Hipertensi sekunder superimposed preeklampsia

ringan. Th : pemberian nifedipin 3 x 10 mg po.

A. Hipertensi kronis superimposed preeklampsia

berat. Th : rujuk Faskes lebih tingi untuk
antihipertensi intravena dan MgSO4.

A. Hipertensi kronis superimposed preeklampsia ringan.

Th : pemberian metildopa 3 x 250 mg po.

A. Hipertensi esensial dengan penyulit chronic kidney

disease pada kehamilan. Th : rujuk ke konsultan
ginjal hipertensi.
Tn Doyok berusia 80 tahun memiliki riwayat hipertensi
dengan tensi tertinggi 140/90 mmHg. Saat ini pasien
melakukan pemeriksaan rutin tanpa keluhan. Didapatkan
tekanan darah 150/80 mmHg. tidak ada komorbid dan
tidak konsumsi obat-obatan lain. Karena pasien merasa
tidak ada keluhan maka pasien tidak minum obat.

Tatalaksana pasien ini adalah :

A. HCT 1 x 12,5 mg po dan edukasi bahwa target
penatalaksaan tekanan darahnya adalah 130-139
mmHg/ 80-89 mmHg
B. captopril 2 x 12,5 mg po dan edukasi bahwa target
penatalaksaan tekanan darahnya adalah 120-130
mmHg/ 70-80 mmHg
C. nifedipin 3 x 10 mg po dan edukasi bahwa target
penatalaksaan tekanan darahnya adalah 140-150
mmHg/ 90-99 mmHg
D. amlodipin 1 x 5 mg po dan edukasi bahwa target
penatalaksaan tekanan darahnya adalah 130-139
mmHg/ 80-89 mmHg
E. candesartan 1 x 8 mg po dan edukasi bahwa target
penatalaksaan tekanan darahnya adalah 130-139
mmHg/ 80-89 mmHg
A. HCT 1 x 12,5 mg po dan edukasi bahwa target
penatalaksaan tekanan darahnya adalah 130-139
mmHg/ 80-89 mmHg
B. captopril 2 x 12,5 mg po dan edukasi bahwa target
penatalaksaan tekanan darahnya adalah 120-130
mmHg/ 70-80 mmHg
C. nifedipin 3 x 10 mg po dan edukasi bahwa target
penatalaksaan tekanan darahnya adalah 140-150
mmHg/ 90-99 mmHg
D. amlodipin 1 x 5 mg po dan edukasi bahwa target
penatalaksaan tekanan darahnya adalah 130-139
mmHg/ 80-89 mmHg
E. candesartan 1 x 8 mg po dan edukasi bahwa
target penatalaksaan tekanan darahnya adalah
130-139 mmHg/ 80-89 mmHg
TN. Rio berusia 50 tahun merupakans seorang guru
Kimia di SMA. Riwayat hipertensi sejak berusia 2
tahun yang lalu. Pasien datang karena kontrol. Pada
pemeriksaan fisik : TD 160/90 mmHg, kardiomegali +.
EKG menunjukkan LVH.

Diagnosis dan th pasien ini :

A. Hipertensi esensial dengan HHD. Th :
candesartan 1 x 8 mg po.

A. Hipertensi sekunder dengan CAD. th : ISDN 3 x

5 mg po

A. Hipertensi esensial dengan HHD dan CAD. th :

ISDN 3 x 5 mg po

A. Hipertensi sekunder dengan HHD dan CAD. Th:

candesartan 1 x 8 mg po

A. Hipertensi urgensi. Th : caproptril sublingual

A. Hipertensi esensial dengan HHD. Th :
candesartan 1 x 8 mg po.

A. Hipertensi sekunder dengan CAD. th : ISDN 3 x

5 mg po

A. Hipertensi esensial dengan HHD dan CAD. th :

ISDN 3 x 5 mg po

A. Hipertensi sekunder dengan HHD dan CAD. Th:

candesartan 1 x 8 mg po

A. Hipertensi urgensi. Th : caproptril sublingual

Tn. Obligasi diantar istrinya ke dokter karena mimisan sejak
semalam yang memberat sejak pagi hari ini. Pasien tidak
ada riwayat trauma kepala/hidung, tidak menggunakan
pengencer darah. Bicara menjadi pelo, tidak ada sakit
kepala, sesak nafas, nyeri dada atau bengkak tungkai.
Pada pemeriksaan KU sakit ringan, Compos mentis, TD
180/110 mmHg. N 80 x/m, S afeb, RR 20 x/m. Epistaksis
anterior dengan perdarahan aktif.

Tatalaksana yang paling tepat adalah :

A. Pemberian nifedipin 10 mg sublingual

A. Pemberian captopril 12,5 mg sublingual

A. Rujuk ke Faskes lebih tinggi untuk mendeteksi

stroke

A. Rujuk ke Faskes lebih tinggi untuk pemeriksaan

jantung

A. Anjurkan untuk pemeriksaan EKG dan ureum

kreatinin di lab terdekat.
A. Pemberian nifedipin 10 mg sublingual

A. Pemberian captopril 12,5 mg sublingual

A. Rujuk ke Faskes lebih tinggi untuk mendeteksi

stroke

A. Rujuk ke Faskes lebih tinggi untuk pemeriksaan

jantung

A. Anjurkan untuk pemeriksaan EKG dan ureum

kreatinin di lab terdekat.
Ny. Kusni berusia 42 tahun sering mengeluhakan
nyeri2 pada kedua lututnya. Pada permeriksaan :
IMT 25 kg/m2, TD 160/100 mmHg. Os mengakui
sering mengkonsumsi pil stelan untuk nyeri nya yang
dibeli dari warung.

Diagnosis dan tatalaksana yang paling tepat adalah :

A. Ny. K menderita hipertensi esensial, th : amlodipin 1 x
5 mg

A. Ny. K menderita hipertensi sekunder, th amlodipin 1x

5 mg

A. Ny. K menderita hipertensi iatrogenik th : stop obat pil

stelan dan pantau TD dulu

A. NY. K menderita hipertensi esensial, th : captopril 3 x

12,5 mg

A. Ny. K menderita hipertensi sekunder, th : captopril 3 x

12,5
A. Ny. K menderita hipertensi esensial, th : amlodipin 1 x
5 mg

A. Ny. K menderita hipertensi sekunder, th amlodipin

1x 5 mg

A. Ny. K menderita hipertensi iatrogenik th : stop obat pil

stelan dan pantau TD dulu

A. NY. K menderita hipertensi esensial, th : captopril 3 x

12,5 mg

A. Ny. K menderita hipertensi sekunder, th : captopril 3 x

12,5
Tn. Ahmad berusia 49 tahun menderita DM sejak 4 tahun
yang lalu. Pasien rutin konsumsi glimepiride 1 x 1 mg dan
metformin 3 x 500 mg. Saat ini pasien datang ke dokter
karena sering merasa mual dan lemas Pemeriksaan fisik;
tekanan darah : 140/90 mmHg, N 92x/m, S afeb, RR 24
x/m. Edema periorbita -, pitting edema + minimal. GDS
120 mg/dL dan urine : protein +3. Ureum 112, kreatinin 2,8
mg/dL.

Diagnosis dan tatalaksana untuk pasien ini adalah :

A. DM tipe 2, hipertensi dan CKD, th : captopril 2 x 12,5
mg po, metformin distop

A. DM tipe 2, hipertensi dan sindrom nefrotik, th :

furosemide 1 x 40 mg po, metformin di stop

A. DM tipe 2, hipertensi dan sirosis, th : spironolactone 1

x 25 mg po, dan metformin di stop

A. DM tipe 2, hipertensi dan CHF, th furosemide 1 x 40

mg po dan metformin di stop

A. DM tipe 2, hipertensi dan CAD, th candesartan 1 x 8

mg po dan metformin di stop
A. DM tipe 2, hipertensi dan CKD, th : captopril 2 x
12,5 mg po, metformin distop

A. DM tipe 2, hipertensi dan sindrom nefrotik, th :

furosemide 1 x 40 mg po, metformin di stop

A. DM tipe 2, hipertensi dan sirosis, th : spironolactone 1

x 25 mg po, dan metformin di stop

A. DM tipe 2, hipertensi dan CHF, th furosemide 1 x 40

mg po dan metformin di stop

A. DM tipe 2, hipertensi dan CAD, th candesartan 1 x 8

mg po dan metformin di stop
Tn. Uno berusia 52 tahun menderita hipertensi sejak 6
bulan yang lalu. Tensi pada saat awal terdiagnosis adalah
180/110 mmhg. Saat itu pasien dianjurkan untuk
mengkonsumsi captopril 3 x 25 mg dan amlodipin 1 x 5 mg
secara rutin. Karena kesibukannya, pasien baru kontrol 1
bulan yang lalu dan didapatkan tekanan darah
170/100mmHg. Pasien mengaku komplains obatnya baik
dan saat itu dianjurkan mengkonsumsi captopril 3 x 25 mg,
dan amlodipin 1 x 10 mg serta HCT 1x 12,5 mg. Saat ini
Tn Uno sedang melakukan perjalanan dinas hingga
berobat ke tempat praktek Anda. Pemeriksaan
menunjukkan TD 180/105 mmHg di tangan kanan dan TD
175/100 mmHg di tangan kiri setelah mengkonsumsi obat-
obatan hipertensinya.

Diagnosis dan terapi pasien adalah :

A. Hipertensi esensial. Th : captopril 3 x 25 mg,
amlodipin 1 x 10 mg, HCT 12,5 mg dan bisoprolol 1 x
2,5 mg
B. Hipertensi sekunder. Th : captopril 3 x 25 mg,
amlodipin 1 x 10 mg, HCT 1 x 12,5 mg dan klonidin 3
x 0,075 mg
C. Hipertensi resisten. Th : captopril 3 x 25 mg,
amlodipin 1 x 10 mg, HCT 1 x 12,5 mg
spironolocaton 1 x 25 mg
D. Hipertensi resisten. Th : captopril 3 x 50 mg,
amlodipin 1 x 10 mg, HCT 1 x 12,5 mg dan klonidin 3
x 0,075 mg
E. Hipertensi persisten. Th : captopril 3 x 50 mg,
amlodipin 1 x 10 mg dan bisoprolol 1 x 2,5 mg serta
klonidin 3 x 0,075 mg.
A. Hipertensi esensial. Th : captopril 3 x 25 mg,
amlodipin 1 x 10 mg, HCT 12,5 mg dan bisoprolol 1 x
2,5 mg
B. Hipertensi sekunder. Th : captopril 3 x 25 mg,
amlodipin 1 x 10 mg, HCT 1 x 12,5 mg dan klonidin 3
x 0,075 mg
C. Hipertensi resisten. Th : captopril 3 x 25 mg,
amlodipin 1 x 10 mg, HCT 1 x 12,5 mg
spironolocaton 1 x 25 mg
D. Hipertensi resisten. Th : captopril 3 x 50 mg,
amlodipin 1 x 10 mg, HCT 1 x 12,5 mg dan klonidin 3
x 0,075 mg
E. Hipertensi persisten. Th : captopril 3 x 50 mg,
amlodipin 1 x 10 mg dan bisoprolol 1 x 2,5 mg serta
klonidin 3 x 0,075 mg.
Wanita 30 tahun G1PoA0 hamil 28 minggu datang
untuk ANC. Pada pengukuran tekanan darah
150/90 mmHg. Tidak ada edema pada
pemeriksaan fisik. Hasil urine lengkap adalah
proteinuria (-).

Diagnosis dan tatalaksana yang paling tepat adalah

:
A. Hipertensi esensial, th : candesartan 1 x 8 mg po

A. hipertensi sekunder, th : metildopa 3 x 250 mg po

A. preeklampsi, th : amlodipin 1 x 5 mg po

A. eklampsi, th : MgSO4 IM

A. hipertensi gestasional, th : metildopa 3 x 250 mg

po
A. Hipertensi esensial, th : candesartan 1 x 8 mg po

A. hipertensi sekunder, th : metildopa 3 x 250 mg po

A. preeklampsi, th : amlodipin 1 x 5 mg po

A. eklampsi, th : MgSO4 IM

A. hipertensi gestasional, th : metildopa 3 x 250

mg po
Ny. Sinta berusia 75 tahun merupakan lansia yang
masih aktif. Karena dalam beberapa minggu terakhir
sering merasa sakit kepala, Ny.S memeriksakan diri ke
dokter. Pada anamnesis, tidak ada riwayat hipertensi,
pasien tidak merokok, tidak ada komorbid dan tidak
konsumsi obat-obatan lain. Tekanan darah pada saat
diperiksa adalah 160/80 mmHg.

Diagnosis dan tatalaksana pasien ini adalah :

A. Hipertensi derajat 3. Th : HCT 1 x 12,5 mg po

A. Hipertensi derajat 2. Th : captopril 3 x 12,5 mg po

A. Hipertensi derajat 1. TH : nifedipin 3 x 10 mg po

A. Hipertensi terisolasi. Th : amlodipin 1 x 5 mg po

A. Hipertensi derajat 2. Th: candesartan 1 x 8 mg po

A. Hipertensi derajat 3. Th : HCT 1 x 12,5 mg po

A. Hipertensi derajat 2. Th : captopril 3 x 12,5 mg po

A. Hipertensi derajat 1. TH : nifedipin 3 x 10 mg po

A. Hipertensi terisolasi. Th : amlodipin 1 x 5 mg po

A. Hipertensi derajat 2. Th: candesartan 1 x 8 mg po

TN. Tito berusia 55 tahun merupakans seorang
pengacara yang memiliki riwayat hipertensi sejak berusia
40 tahun. Pasien datang karena riwayat rasa tidak
nyaman di dada bila sedang sidang, saat ini tidak ada
rasa nyeri. Pada pemeriksaan fisik : TD 170/100 mmHg,
dan ada pembesaran jantung. EKG menunjukkan LVH.

Diagnosis dan th pasien ini adalah :

A. Hipertensi esensial dengan HHD. Th : atenolol 1 x 50 mg
po

A. Hipertensi sekunder dengan CAD. th : ISDN 3 x 5 mg po

A. Hipertensi esensial dengan HHD dan CAD. th :

bisoprolol 1 x 5 mg po

A. Hipertensi sekunder dengan HHD dan CAD. Th:

amlodipin 1 x 10 mg po

A. Hipertensi emergensi. Th : antihipertensi intravena

A. Hipertensi esensial dengan HHD. Th : atenolol 1 x 50 mg
po

A. Hipertensi sekunder dengan CAD. th : ISDN 3 x 5 mg po

A. Hipertensi esensial dengan HHD dan CAD. th :

bisoprolol 1 x 5 mg po

A. Hipertensi sekunder dengan HHD dan CAD. Th:

amlodipin 1 x 10 mg po

A. Hipertensi emergensi. Th : antihipertensi intravena

Ny. Reksadana datang ke dokter dengan nyeri kepala yang
hebat sejak 2 jam yang lalu. Pasien setelah bertengkar
dengan suaminya dan akan mengajukan gugatan cerai.
Pada pemeriksaan Compos mentis gelisah, TD 180/110
mmHg. N 92 x/m, S afeb, RR 24 x/m. Pasien muntah 1 kali
saat di kamar periksa. Defisit neurologis (-).

Tatalaksana yang paling tepat adalah :

A. Pemberian nifedipin 10 mg sublingual karena tekanan
darah harus diturunkan dalam menit hingga jam
B. Pemberian captopril 12,5 mg sublingual karena tekanan
darah harus diturunkan dalam menit hingga jam
C. Rujuk ke Faskes lebih tinggi untuk mendeteksi stroke.
Karena pada stroke tekanan darah tidak boleh
diturunkan terlalu cepat
D. Rujuk ke Faskes lebih tinggi untuk pemeriksaan jantung.
Karena jantung merupakan organ target yang harus
diskrining.
E. Anjurkan untuk pemeriksaan EKG dan ureum kreatinin di
lab terdekat untuk menyingkirkan adanya kerusakan
organ target.
A. Pemberian nifedipin 10 mg sublingual karena tekanan
darah harus diturunkan dalam menit hingga jam
B. Pemberian captopril 12,5 mg sublingual karena tekanan
darah harus diturunkan dalam menit hingga jam
C. Rujuk ke Faskes lebih tinggi untuk mendeteksi
stroke. Karena pada stroke tekanan darah tidak
boleh diturunkan terlalu cepat
D. Rujuk ke Faskes lebih tinggi untuk pemeriksaan jantung.
Karena jantung merupakan organ target yang harus
diskrining.
E. Anjurkan untuk pemeriksaan EKG dan ureum kreatinin di
lab terdekat untuk menyingkirkan adanya kerusakan
organ target.
Ny. Karma berusia 40 tahun rutin menyuntik KB 3 bulan an
di Posyandu. Sejak 2 bulan terakhir, tekanan darah
tertinggi Ny. K adalah 150/100 mmHg.

Diagnosis dan tatalaksana yang paling tepat adalah :

A. Ny. K menderita hipertensi esensial, th : amlodipin 1 x
5 mg

A. Ny. K menderita hipertensi sekunder, th amlodipin 1x 5

mg

A. Ny. K menderita hipertensi iatrogenik th : stop KB

suntik dan pantau TD dulu

A. NY. K menderita hipertensi esensial, th : captopril 3 x

12,5 mg

A. Ny. K menderita hipertensi sekunder, th : captopril 3 x

12,5 mg
A. Ny. K menderita hipertensi esensial, th : amlodipin 1 x
5 mg

A. Ny. K menderita hipertensi sekunder, th amlodipin

1x 5 mg

A. Ny. K menderita hipertensi iatrogenik th : stop KB

suntik dan pantau TD dulu

A. NY. K menderita hipertensi esensial, th : captopril 3 x

12,5 mg

A. Ny. K menderita hipertensi sekunder, th : captopril 3 x

12,5 mg
Tn. Raffi berusia 58 tahun menderita DM sejak 5 tahun yang
lalu. Pasien rutin konsumsi metformin 3 x 500 mg dan
glibenclamide 1 x 5 mg dari puskesmas. Saat ini pasien
datang ke dokter karena wajah yang bengkak di pagi hari
dan bengkak kedua tungkai. Pemeriksaan fisik; tekanan
darah : 140/90 mmHg, N 92x/m, S afeb, RR 24 x/m. Edema
periorbita +, pitting edema +. GDS 245 mg/dL dan urine :
protein +3. Ureum 56, kreatinin 1,9 mg/dL.

Diagnosis dan tatalaksana untuk hipertensi pasien ini

adalah :
A. DM tipe 2, hipertensi dan CKD, th : captopril 2 x 12,5
mg po

A. DM tipe 2, hipertensi dan sindrom nefrotik, th :

furosemide 1 x 40 mg po

A. DM tipe 2, hipertensi dan sirosis, th : spironolactone 1

x 25 mg po

A. DM tipe 2, hipertensi dan CHF, th furosemide 1 x 40

mg po

A. DM tipe 2, hipertensi dan CAD, th candesartan 1 x 8

mg po
A. DM tipe 2, hipertensi dan CKD, th : captopril 2 x
12,5 mg po

A. DM tipe 2, hipertensi dan sindrom nefrotik, th :

furosemide 1 x 40 mg po

A. DM tipe 2, hipertensi dan sirosis, th : spironolactone 1

x 25 mg po

A. DM tipe 2, hipertensi dan CHF, th furosemide 1 x 40

mg po

A. DM tipe 2, hipertensi dan CAD, th candesartan 1 x 8

mg po
NY Sadira usia 48 tahun, datang untuk evaluasi dan
pemeriksaan, berkala, minggu lalu sudah datang dan
didapatkan TD 160/100 mm Hg, setelah beberapa kali
pemeriksaan tetap berkisar 160/90 mmHg.
Paa pemeriksaan didapatkan TD 160/95 mmHg, HR 72
x/mnt, BMI 32
Hasil pemeriksaan laboratorium didapatkan kreatinin 1,1,
gula darah puasa 114, Kalium 3,5, urin dipstik tidak
didapatkan.

Terapi anti hipertensi yang akan diberikan :

A: Amlodipine

B: Lisinopril

C: Losartan

D: Lisinopril and amlodipine

E: Losartan and lisinopril

A: Amlodipine

B: Lisinopril

C: Losartan

D: Lisinopril and amlodipine

E: Losartan and lisinopril

Tn Agung usia 51 tahun, datang untuk follow up, baru
diketahui hipertensi dan diabetes, sudah mulai modifikasi
gaya hidup untuk diabetesnya. Belum mendapat anti
hipertensi.

Pada pemeriksaan didapatkan TD 140/85 mmHg, HR 76,

BMI 33. Lain-lain normal.
Laboratorium menunjukkan kreatinin 1,2, K 3,7 dan protein
+.

Bila akan memberikan obat anti hipertensi, obat apakah

yang akan dipilih ?
A: HCT

B: Lisinopril

C: Lisinopril and amlodipine

D: Lisinopril and HCT

E: Lisinopril and losartan

A: HCT

B: Lisinopril

C: Lisinopril and amlodipine

D: Lisinopril and HCT

E: Lisinopril and losartan