HIPERTENSI

FRANZESKA ANNA
Tekanan darah sistolik ≥140 dan atau tekanan darah
diastolik ≥90
>140 mmHg
KLASIFIKASI TEKANAN DARAH KLINIK
PENAPISAN DAN DIAGNOSIS HIPERTENSI
BATASAN TEKANAN DARAH UNTUK
DIAGNOSIS HIPERTENSI
TUJUAN EVALUASI KLINIS
• 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
• Menentukan ada tidaknya HMOD atau penyakit kardiovaskular,
serebrovaskular atau ginjal yang sudah ada sebelumnya, untuk
stratifikasi risiko.
KLASIFIKASI
RISIKO
HIPERTENSI
FAKTOR RISIKO
KARDIOVASKULAR
 KATEGORI RISIKO PKV DALAM 10 TH
(SCORE SYSTEM)
RISIKO SANGAT TINGGI
PKV terdokumentasi, baik secara klinis atau secara meyakinkan tampak pada pencitraan.
• PKV klinis meliputi infark miokard akut, sindroma koroner akut, revaskularisasikoroner atau
arteri lain, stroke, TIA, aneurisma aorta dan penyakit pembuluh darah perifer.
• Secara meyakinkan tampak pada pencitraan meliputi plak signifikan (stenosis ≥50%) pada
angiografi atau ultrasonografi. Tidak termasuk didalamnya penebalan intima-media thickness
(IMT) arteri karotis.
• Diabetes melitus (DM) dengan kerusakan organ target, misalnya proteinuria atau disertai
faktor risiko mayor misalnya hipertensi derajat 3 atau hiperkolesterolemia.
• Penyakit ginjal kronik berat (eLFG <30 mL/min/1.73m2)
• Kalkulasi SCORE 10 tahun ≥10%
 KATEGORI RISIKO PKV DALAM 10 TH
(SCORE SYSTEM)
RISIKO TINGGI
• Peningkatan nyata dari salah satu faktor risiko, terutama kadar kolesterol-total (>310 mg/dL)
misalnya pada hiperkolesterolemia familial, hipertensi derajat 3 (TD ≥180/110 mmHg).
• Pada individu dengan DM umumnya (kecuali pada individu muda dengan DM tipe 1 dan
tanpa faktor risiko mayor lain termasuk risiko sedang).
• Hipertrofi ventrikel kiri hipertensif.
• Penyakit ginjal kronik sedang (eLFG 30-59 mL/min/1.73m2).
• Kalkukasi SCORE 10 tahun 5-10%.
 KATEGORI RISIKO PKV DALAM 10 TH
(SCORE SYSTEM)
RISIKO SEDANG
• Kalkulasi SCORE 10 tahun ≥1% hingga<5%
• Hipertensi derajat 2
• Individu berusia setengah-baya umumnya termasuk kategori ini

RISIKO RENDAH
• Kalkulasi SCORE 10 tahun <1%
• Catatan: Diagram tsb adalah
diagram SCORE untuk negara-
negara risiko rendah. Etnis Asia
Timur masih dianggap memiliki
risiko lebih rendah dibanding
Kaukasia, data Asia Tenggara saat
ini belum ada.
INDIKASI MERUJUK KE FKTL
• Pasien dengan kecurigaan hipertensi sekunder
• Pasien muda (<40 tahun) dengan hipertensi derajat 2 keatas (sudah
disingkirkan kemungkinan hipertensi sekunder)
• Pasien dengan hipertensi mendadak dengan riwayat TD normal
• Pasien hipertensi resisten
• Pasien dengan penilaian HMOD lanjutan yang akan mempengaruhi
pengobatan
• Kondisi klinis lain dimana dokter perujuk merasa evaluasi spesialistik
diperlukan
KOMPLIKASI
HIPERTENSI
AMBANG BATAS TD UNTUK INISIASI OBAT
ALUR PANDUAN
INISIASI TERAPI
OBAT

Intervensi gaya hidup:

• Pembatasan konsumsi
garam & alcohol
• Peningkatan konsumsi
sayuran dan buah
• Penurunan berat badan
& menjaga BB ideal
• Aktivitas fisik teratur
• Berhenti merokok *Inisiasi terapi obat pada kelompok pasien ini disarankan
untuk dikonsultasikan kepada spesialis dengan target
tatalaksana disesuaikan dengan panduan penyakit spesifik
TARGET
PENGOBATAN
(TD DI KLINIK)
OBAT ANTIHIPERTENSI ORAL
OBAT ANTIHIPERTENSI ORAL
EFEK SAMPING ANTIHIPERTENSI
KOMBINASI OBAT ANTIHIPERTENSI
 ALGORITMA TERAPI OBAT UNTUK
HIPERTENSI
• Inisiasi pengobatan pada sebagian besar pasien dengan kombinasi 2
obat. Bila memungkinkan dalam bentuk SPC untuk meningkatkan
kepatuhan pasien
• Kombinasi 2 obat yg sering digunakan adalah RAS blocker (ACEi
atau ARB) dengan CCB atau diuretic
• Kombinasi beta blocker dengan diuretic ataupun obat golongan lain
dianjurkan bila ada indikasi spesifik, misalnya angina, pasca IMA,
gagal jantung, dan untuk control denyut jantung
• Pertimbangkan monoterapi bagi pasien hipertensi derajat 1 dengan
risiko rendah (TDS <150 mmHg), pasien dengan tekanan darah
normal-tinggi dan berisiko sangat tinggi, pasien usia sangat lanjut (≥
80 tahun)atau ringkih
 ALGORITMA TERAPI OBAT UNTUK
HIPERTENSI
• Penggunaan kombinasi 3 obat yg terdiri dari RAS blocker (ACEi atau
ARB), CCB, dan diuretic jika TD tidak terkontrol dengan kombinasi 2
obat
• Penambahan spironolactone untuk pengobatan hipertensi resisten,
kecuali ada kontraindikasi
• Penambahan obat golongan lain pada kasus tertentu bila TD belum
terkendali dengan obat golongan di atas
• Kombinasi 2 penghambat RAS tidak direkomendasikan
STRATEGI PENATALAKSANAAN HT TANPA KOMPLIKASI
STRATEGI PENGOBATAN PADA HT
& PENYAKIT ARTERI KORONER
STRATEGI PENGOBATAN PADA HT & PGK
 STRATEGI PENGOBATAN HT & GAGAL
JANTUNG DENGAN FRAKSI EJEKSI MENURUN
STRATEGI PENGOBATAN HT & AF
Hipertensi Emergensi:
HT st 3 + HMOD Akut
OBAT HIPERTENSI EMERGENSI DI INDONESIA
PENURUNAN
TEKANAN
DARAH PADA
HIPERTENSI
EMERGENSI
HIPERTENSI DALAM
KEHAMILAN
PENATALAKSANAAN HT DALAM KEHAMILAN
• Ibu dengan hipertensi gestasional, pre-existing hypertension (hip[pertensi
kronik) dengan superimposed hipertensi gestasional, atau dengan hipertensi
dan kelainan organ subklinis direkomendasikan mendapat pengobatan bila
TDS ≥ 140 atau TDD ≥ 90 mmHg
• Pada kasus lainnya, inisiasi pengobatan dilakukan bila TDS ≥150 atau TDD
≥95 mmHg
• Pilihan obat meliputi metildopa, labetalol, dan CCB
• ACEi, ARB, atau direct renin inhibitor tidak direkomendasikan diberikan
selama kehamilan
• TDS ≥170 atau TDD ≥110 adalah keadaan gawat darurat, direkomendasikan
untuk rawat inap
• Pada hipertensi berat, direkomendasikan penatalaksanaan dengan labetalol
intravena, metildopa oral, atau nifedipin
• Pada PE dengan edema paru, direkomendasikan pemberian infus
nitrogliserin intravena
TINDAK LANJUT PASIEN HIPERTENSI
• Pemantauan efektivitas pengobatan
Target tekanan darah diharapkan tercapai dalam waktu 3 bulan
• Kepatuhan dalam berobat
• Deteksi dini HMOD
Dilakukan saat pasien pertama kali berobat dan pengobatan
disesuaikan dengan kondisi dasar pasien
KEY POINTS
• Pada populasi umum, terapi farmakologis sebaiknya dimulai apabila
tekanan darah ≥150/90 mmHg pada orang dewasa usia ≥ 60 tahun,
atau bila tekanan darah ≥140/90 pada orang dewasa berusia <60
tahun
• Pada pasien dengan hipertensi dan DM, terapi farmakologi sebaiknya
dimulai bila tekanan darah ≥140/90 tanpa memandang usia
• Terapi antihipertensi inisial sebaiknya meliputi diuretik thiazid, CCB,
ACE inhibitor atau ARB pada nonblack population dan diuretik thiazid
dan CCB pada black population
• Jika target tekanan darah belum tercapai dlaam 1 bulan setelah
inisiasi terapi, maka dosis obat awal perlu dinaikkan, atau ditembah
dengan obat antihipertensi kedua
 KOR
PULMONAL
What is cor pulmonale?
Cor pulmonale is a Latin word that means “pulmonary heart”
Cor pulmonale is a condition that causes the right side of the heart to fail from long-standing
pulmonary artery high blood pressure (hypertension).
Pulmonary hypertension complicating chronic respiratory disease is generally defined by the
presence of a resting mean pulmonary artery pressure (PAP) > 20 mm Hg.
Cor pulmonale can be defined as an alteration in the structure (e.g., hypertrophy or dilatation)
and function of the right ventricle (RV) of the heart caused by a primary disorder of the lungs
(respiratory system) resulting in pulmonary hypertension 3.
What is cor pulmonale?
Can be acute or chronic.
Acute cor pulmonale occurs after a sudden and severe stimulus with RV dilatation and failure
but no RV hypertrophy. It is most commonly caused by massive pulmonary embolism.
Chronic cor pulmonale has a slow and progressive course resulting from worsening lung
disease that leads to RV dilatation and hypertrophy.
Cor pulmonale is most often caused by chronic obstructive pulmonary disease (COPD)
EPIDEMIOLOGY
The exact prevalence of cor pulmonale is difficult to determine, as physical examination and
routine tests are relatively insensitive for the detection of pulmonary hypertension and right
ventricle (RV) dysfunction.
Cor pulmonale is estimated to account for 6% to 7% percent of all types of adult heart disease in
the United States 1.
Globally, the incidence of cor pulmonale varies widely among countries, depending on the
prevalence of cigarette smoking, air pollution, and other risk factors for various lung diseases.
GLOBAL DISTRIBUTION OF PULMONARY HYPERTENSION

Hoeper MM, Humbert M, Souza R, et al. A global view of pulmonary hypertension. Lancet Respir Med 2016;4: 306–322
Pulmonary hypertension refers to elevated pulmonary arterial pressure of mean PAP >25 mmHg
SYMPTOMS
Dyspnea on exertion
Fatigue
Lethargy
Fainting spells during activity
Chest discomfort, usually in the front of the chest
Exertional syncope
Exertional chest pain
Symptoms of lung disorders, such as wheezing or
coughing or phlegm production
Bluish lips and fingers (cyanosis)
Swelling (edema) of the feet or ankles
SIGNS
Jugular venous distension: Prominent jugular V wave, indicating the presence of tricuspid
regurgitation
Peripheral (ankle) edema: The best sign of RHF, but it is not specific and can arise from other
causes
Cardiovascular: Palpable left the parasternal lift, loud S2 (accentuation of the pulmonary
component of the second heart sound) narrow splitting of S2, a holosystolic murmur of tricuspid
regurgitation at the left lower sternal border, right-sided S4 heart sound
Abdomen: Hepatomegaly and ascites (abdominal edema or distension).
CAUSES
Autoimmune diseases that damage the lungs, such as scleroderma
Chronic blood clots in the lungs
Cystic fibrosis (CF)
Scarring of the lung tissue (interstitial lung disease)
Severe curving of the upper part of the spine (kyphoscoliosis)
Obstructive sleep apnea, which causes stops in breathing because of airway inflammation
Idiopathic (no specific cause) tightening (constriction) of the blood vessels of the lungs
Pulmonary hypertension associated with disorders of the respiratory system and/or hypoxaemia
◦ Alveolar hypoventilation disorders
◦ Chronic exposure to high altitude
◦ Neonatal lung disease
◦ Alveolar capillary dysplasia
◦ Other
Hoeper MM, Humbert M, Souza R, et al. A global view of pulmonary hypertension. Lancet Respir Med 2016;4: 306–322
DIAGNOSIS
CHEST X-RAY RIGHT HEART CATHETERIZATION

CT SCAN OF THE CHEST ARTERIAL BLOOD GAS

ECG BNP

ECHOCARDIOGRAM LUNG BIOPSY

V/Q SCAN
RADIOGRAPHIC
FINDINGS
ECG ABNORMALITIES IN PH
Shown below is an example of right ventricular hypertrophy and right atrial enlargement in a patient
with chronic PH. Note P pulmonale that is a P wave amplitude >2.5mm in inferior leads (II, III, AVF) and
the T wave inversion in leads II, III, aVF, V2, V3, V4, V5.
ECHOCARDIOGRAPHY

The non-invasive diagnosis of

pulmonary hypertension is
presently based on
echocardiography.
Continuous-wave Doppler
Echocardiography allows the
calculation of the transtricuspid
pressure gradient from the peak
velocity of the tricuspid
regurgitant jet
Relevant echocardiographic
parameters found in acute
pulmonary embolism. This
figure shows the most
common findings that can
be found in the setting of
acute pulmonary embolism.
(a) Ratio between right
ventricular (RV) and left
ventricular (LV) basal
diameters, often enough > 1,
meaning a RV dilatation.
(b) Right atrio-ventricular
gradient, rarely above 60
mm Hg in the acute setting.
(c) Tricuspid annular plane
systolic excursion (TAPSE),
which in acute setting is not
necessarily reduced
compared with controls.(d)
Reduced RV longitudinal
strain
Relevant echocardiographic
parameters found in chronic cor
pulmonale. This figure shows
the most common findings that
can be found in the setting of
chronic cor pulmonale. (a) Ratio
between right ventricular (RV)
and left ventricular (LV) basal
diameters, often enough > 1,
meaning a RV dilatation. (b) High
right atrio-ventricular gradient,
typical of chronic pulmonary
hypertension. (c) Reduced
tricuspid annular plane systolic
excursion (TAPSE), reflecting a
reduced RV longitudinal
function. (d) Reduced RV
longitudinal strain
RIGHT HEART CATHETERIZATION
A right heart cath is a gold standard for diagnosis,
assessment of Pulmonary hypertension severity. Right
heart catheterization reveals evidence of right
ventricular (RV) dysfunction (mean pulmonary artery
pressure (PAP) above 25 mmHg) without left ventricular
(LV) dysfunction. Differentiating left-sided from the
right-sided disease includes measuring the pulmonary
capillary wedge pressure (PCWP), which is an
estimation of left atrial pressure. Thus, right ventricular
(RV) dysfunction is also defined as having a pulmonary
capillary wedge pressure below 15 mmHg.
TREATMENT
Treatment is aimed primarily at treating the underlying condition; the aim is improving
oxygenation and right ventricular (RV) function by increasing RV contractility and decreasing
pulmonary vasoconstriction.
Oxygen therapy relieves hypoxemic pulmonary vasoconstriction, which then improves cardiac
output, lessens sympathetic vasoconstriction, alleviates tissue hypoxemia, and improves renal
perfusion.
Diuretics are used to decrease the elevated right ventricular (RV) filling volume in patients with
chronic cor pulmonale.
The use of cardiac glycosides, such as digitalis in patients with cor pulmonale has been
controversial, and the beneficial effect of these drugs is not as obvious as in the setting of left
heart failure. Digoxin is indicated only if atrial fibrillation is present.
PULMONARY REHABILITATION
Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with
chronic respiratory impairment. It is individually tailored and designed to optimise each person's
physical and social performance and autonomy
Ensure that people with cor pulmonale caused by COPD are offered optimal COPD treatment,
including advice and interventions to help them stop smoking
 KEY POINTS
Cor pulmonale is right ventricular dysfunction from long-standing pulmonary hypertension.
All primary lung diseases can cause PH and thus cor pulmonale.
Dyspnea on exertion is the most common symptom.
Primarily, treatment aims to treat the underlying condition.
Cor pulmonale can be defined as pulmonary arterial hypertension resulting from diseases affecting the structure and/or
function of the lungs. PH results in right ventricular enlargement and may lead with time to right heart failure
COPD is by far the main cause of chronic respiratory insufficiency and cor pulmonale
In COPD alveolar hypoxia is the first cause of pulmonary hypertension. Acute hypoxia causes pulmonary vasoconstriction
and chronic longstanding hypoxia induces pulmonary vascular remodelling
In chronic respiratory disease pulmonary hypertension is of mild to moderate degree, but it may worsen during exercise,
sleep, and acute exacerbations of the disease
Many patients with advanced COPD will never develop right heart failure, but other patients experience episodes of
right heart failure during exacerbations of the disease accompanied by a worsening of pulmonary hypertension
Long term oxygen therapy is at present the best treatment for pulmonary hypertension in chronic respiratory failure.
Future treatment may combine oxygen therapy and specific vasodilators