TERAPI HIPERTENSI MENURUT JNC 7

ADITIAWARMAN SMF PENY DALAM RS PROF MARGONO SOEKARJO PURWOKERTO

Why JNC 7?
Publication of many new studies. Need for a new, clear, and concise guideline useful for clinicians. Need to simplify the classification of BP.

Pendahuluan
Hipertensi masih jadi masalah: Prevalensi meningkat Banyak yang belum diobati,diobati ttp belum mencapai target Penyakit penyerta dan komplikasi

Epidemiologi
> 50 % lansia (>65 tahun) Hipertensi primer merupakan 95% kasus hipertensi Insiden pada dewasa di Amerika: 29-31% Pengendalian hanya tercapai pada 34% dari seluruh penderita hipertensi

Patogenesis
Penyakit multifaktorial yang timbul karena interaksi antara faktor-faktor risiko tertentu Faktor risiko: diet, stres, ras, obesitas, merokok, genetis Sistem saraf simpatis Keseimbangan modulator vasodilatasi dan vasokonstriksi Pengaruh pada sistem otokrin setempat yang berperan pada RSAA

Keuntungan menurunkan tekanan darah

Average Percent Reduction Insiden Stroke Infark miokard 3540% 2025%

Gagal jantung

50%

Teknik mengukur tekanan darah

Method In-office Brief Description Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm. Indicated for evaluation of white-coat HTN. Absence of 1020% BP decrease during sleep may indicate increased CVD risk.

Ambulatory BP monitoring

Self-measurement

Provides information on response to therapy. May help improve adherence to therapy and evaluate white-coat HTN.

Cara mengukur tekanan darah

Posisi duduk setelah istirahat 5 menit Kaki di lantai lengan setinggi jantung Ukuran dan letak manset harus benar Stetoskop korotkoff fase 1 dan fase 5 Diukur 2 kali, > kalau perlu Kunjungan pertama ukur juga kontra lateral Hipotensi ortostatik? : sambil berdiri

Self-Measurement of BP
Provides information on: 1. Response to antihypertensive therapy 2. Improving adherence with therapy 3. Evaluating white-coat HTN Home measurement of >135/85 mmHg is generally considered to be hypertensive. Home measurement devices should be checked regularly.

JNC VII Classification of Hypertension

SBP (mmHg)
Normal Pre-hypertension Stage 1 Stage 2
SBP = systolic blood pressure DBP = diastolic blood pressure

DBP (mmHg)
and < 80 or 80-89 or 90-99 or > 100

< 120 120-139 140 - 159 > 160

Kerusakan organ target

Jantung - hipertrofi ventrikel kiri - angina atau infark miokardiumm - gagal jantung Otak : stroke atau transient ischemic attack Penyakit ginjal kronis Penyakit arteri perifer retinopati

Faktor risiko kardiovaskular

Merokok Obesitas Kurang aktivitas fisik Dislipidemia DM Mikroalbuminuria atau LFG < 60 ml/mnt Umur (pria>55 th; wanita>65 th) Riwayat keluarga dg penyakit jantung kardiovaskular prematur (pria<55 th; wanita<65 th)

Pemeriksaan laboratorium
Routine Tests Electrocardiogram Urinalysis Blood glucose, and hematocrit Serum potassium, creatinine, or the corresponding estimated GFR, and calcium Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides Optional tests Measurement of urinary albumin excretion or albumin/creatinine ratio More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

Treatment Overview
Goals of therapy

Lifestyle modification
Pharmacologic treatment Algorithm for treatment of hypertension

Classification and management of BP for adults

Followup and monitoring

Goals of Therapy
Reduce CVD and renal morbidity and mortality.

Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.
Achieve SBP goal especially in persons >50 years of age.

Lifestyle Modification
Modification Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Approximate SBP reduction (range) 520 mmHg/10 kg weight loss 814 mmHg 28 mmHg 49 mmHg

Moderation of alcohol consumption

24 mmHg

Algorithm for Treatment of Hypertension

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling Indications

With Compelling Indications

Stage 1 Hypertension
(SBP 140159 or DBP 9099 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

Stage 2 Hypertension
(SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)

Drug(s) 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.

Classification and Management of BP for adults

BP classification Normal SBP* mmHg <120 DBP* mmHg and <80 Lifestyle modification Encourage Yes Yes No antihypertensive drug indicated. Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Drug(s) for compelling indications. Drug(s) for the compelling indications. Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Initial drug therapy Without compelling indication With compelling indications

Prehypertension 120139 or 8089 Stage 1 Hypertension 140159 or 9099

Stage 2 Hypertension

>160

or >100

Yes

*Treatment determined by highest BP category. Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

Followup and Monitoring

Patients should return for followup and adjustment of medications until the BP goal is reached. More frequent visits for stage 2 HTN or with complicating comorbid conditions. Serum potassium and creatinine monitored 12 times per year.

Followup and Monitoring

(continued)
After BP at goal and stable, followup visits at 3- to 6-month intervals. Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits.

Compelling Indications for Individual Drug Classes

Compelling Indication Heart failure Initial Therapy Options THIAZ, BB, ACEI, ARB, ALDO ANT Clinical Trial Basis ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ALLHAT, HOPE, ANBP2, LIFE, CONVINCE

Postmyocardial infarction

BB, ACEI, ALDO ANT

High CAD risk

THIAZ, BB, ACE, CCB

Compelling Indications for Individual Drug Classes

Compelling Indication Initial Therapy Options Clinical Trial Basis

Diabetes Chronic kidney disease

THIAZ, BB, ACE, ARB, CCB ACEI, ARB

NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK
PROGRESS

Recurrent stroke prevention

THIAZ, ACEI

 BP target of <140/90 mm Hg for patients with uncomplicated hypertension without compelling indications BP target of <130/80 mm Hg for patients with diabetes

Combinations of 2 or more drugs are usually needed to achieve target BP goal

BP target of <130/80 mm Hg for patients with chronic renal disease*

Combinations of 3 or more drugs are often needed to reach target BP goal

*Chronic kidney disease = GFR <60 mL/min per 1.73 m2 or presence of albuminuria (>300 mg/d or 200 mg/g creatinine). Chobanian AV et al. JAMA. 2003;289:2560-2572. American Diabetes Association. Diabetes Care. 2003;26(Suppl 1):S33-S50. Guidelines Committee. J Hypertens. 2003;21:1011-1053.

JNC VII Management of Hypertension

Drug Combination

Diuretic
(Thiazide)

ACEI ARB

or

Beta
Blocker

CCB

Reference Card