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HIPERTENSI

Konsep Dasar :
-Tekanan Darah terjadi akibat kontraksi otot jantung yang
menghadapi tahanan pembuluh darah tepi, jadi

Tekanan darah adalah : Cardiac Output (CO) X Taha


nan Vaskular Sistemik (TVS)

Mean arterial pressure (MAP) : DBP + (SBP DBP) / 3

Basic concept : Hypertension

Evaluasi penderita Hipertensi


- evaluasi penderita hipertensi ada tiga sasaran utama :

1. Menilai gaya hidup dan mengidentifikasi


faktor risiko kardio vaskular lain atau
penyakit comorbid yang dapat
mempengaru hi strategi pengobatan
&prognosis penderita

2. Mencoba mengidentifikasi apa penyebab


dari Hipertensi
Identifiable causes of
hypertension

3. Mengidentifikasi adakah target organ yang


rusak atau Stroke?

Evaluasi penderita Hipertensi :


Anamnesa :
adakah risiko penyakit jantung iskemik : diabetes,
hiperkolesterol
dan riwayat sakit jantung dalam keluarga
riwayat minum obat obatan
soscial historys : merokok, alkohol, level of
stress at work, exercise
Pemeriksaan fisik :
pengukuran tekanan darah yang adekuat
(perbandingan lengan/tungkai
kiri-kanan)
evaluasi fisik lengkap termasuk : funduskopi,
tiroid, auskultasi karotisfemoral, pemeriksaan neurologis dan body mass
index
Laboratorium :
test darah : darah rutin, fungsi ginjal, profil lipid,
gula darah, asam urat

Causes of High Blood Pressure


Essential hypertension
Secondary hypertension
Sleep apnea
Drug-induced
Chronic kidney disease
Primary aldosteronism
Chronic steroid therapy or Cushings syndrome
Pheochomocytoma
Coarctation of the aorta
Thyroid or parathyroid disease

Drug-Induced HTN

Amphetamines
Antidepressants
Corticosteroids
Calcineurin inhibitors
Decongestants
Ergot alkaloids
Erythropoietin stimulating agents
Estrogen-containing oral contraceptives
NSAIDS

Risks
High blood pressure increases risk of:
Heart failure
Myocardial ischemia and infarction
Stroke
Aneurysms and dissection
Kidney disease
Retinopathy
Peripheral vascular disease

Patofisiologi (I) :
- 3 penyebab utama dari hipertensi (esensial) :
1.Predisposisi poligenetis
- secara genetis terbukti seseorang peka terhadap
konsumsi garam,abnor
malitas transportasi natrium-kalsium , respon
sistem saraf pusat terha
dap stimulasi psikososial, presor dan trofik
neurohormonal (Angioten
sin II, katekolamin, tromboksan, fungsi barostat
renal) serta gangguan
metabolisme (glukosa-lipid-resitensi insulin)
2.Faktor lingkungan
- 2 faktor lingkungan terhadap predisposisi genetis
: konsumsi garam /nu
trisi kalori tinggi dan psikososial
- psikososial : kebiasaan hidup, pekerjaan, stres
mental dan status sosial

Patofisiolog
i (II)

TD (MAP) :

CO X

TVS
SV

HR

Blood
Circuit
Viscosity
length

Sympathetic
system

Vagal tone

Diastolic
filling

Inotropic
state

Right atrial
Pressure

Sympathetic nervous system,vagal


tone, Ca2+, contractile protein

Venous compliance
Sympatic system

Arteriolar
radius

Aortic
pressure

Central venous volume


Na : diet & Renal loss

Neural
smooth muscle
receptor

- adrenergic
- adrenergic
-Dopaminergic
-Cholinergic
etc

Humoral

- Nor-epi
- Angitensin II
- Vasopressin
- Serotonin
etc

Local

- ionix flux
Na, K, Ca
- metabolites
- autoregula
tion...etc

Patofisiologi (III)

Patofisiologi (IV)

Pathogenesis of
Hypertension

Kaplan. Clinical Hypertension. 2006

Renin Angiotensin System


Nitric oxide
(NO)

Angiotensinog
en
Renin

AI

Bradykinin
ACE
Degradati
on
products
ACEI site of action

ARB site of
action

A II

AT1
receptor

Hypertrophy/proliferation
Vasoconstriction
Aldosterone release
Antidiuretic hormone release
Symphatetic discharge

CAGE
Cathepsin G
Chymase

t-PA
Cathepsin G
Tonin

AT2
receptor

Antiproliferation
NO Release
Differentiation
Vasodilation

de Gasparo M, et al. Hypertension. Pathophysiology, Diagnosis, and Management. 2nd ed. Dzau
VJ. J Hypertens. 1989;7:933-936.

JNC VII: Klasifikasi tekanan darah


Klasifikasi
tekanan darah
Normal

Sistolik
(mm Hg)

Diastolik
(mm Hg)

<120

<80

Prehipertensi

120-139

80-89

Hipertensi
tingkat 1

140-159

90-99

Hipertensi
Tingkat 2

160

100

The JNC VII. JAMA 2003;289:2560-72

Pengobatan Hipertensi
Non farmakolgis life
modification
Farmakologis

Manfaat (benefit) penurunan Tekanan


Darah
- pengobatan dengan antihipertensi dapat
mengurangi :

kejadian Stroke 35 40 %
kejadian infark miokard 20 25%
kejadian gagal jantung > 50%

Goal therapy of Hypertension :


Non compelling factor : < 140/90 mmhg
Compelling factor (+) (Diabetes, Renal disease ) : <
130/80mmhg

Non- Farmakologis life modification

Rekomendasi JNC VII pola hidup untuk


kontrol TD*
Modifikasi

Rekomendasi

Efek penurunan
tekanan darah

Penurunan berat
badan (BB)

Jaga berat badan normal


(BMI=18.5-24.9)

5-20 mmHg/10 kg
penurunan BB

Diet kaya buah & sayur, rendah lemak


(termasuk produk susu rendah lemak)

8-14 mmHg

Batasi asupan
garam

<2.4 gram natrium/hari


(1/4 sendok teh= 600 g Na)
(1,2 gr anak 4-8 tahun;
1,5 gr >8 tahun) **

2-8 mmHg

Aktifitas fisik

Latihan aerobik rutin minimal 30


menit, 3x/minggu

4-9 mmHg

Batasi alkohol

<2 drinks/day (Laki) and <1 drink/day


(perempuan)
1 drink= 150 ml wine, 45 ml wiski

2-4 mmHg

Diet DASH

DASH= Dietary Approaches to Stop Hypertension


Study
+
Krebs. Pediatrics. 2003;112:424430

* Chobanian AV et al. JAMA. 2003;289:25602572

** Panel of Dietary Intakes for Electrolytes and Water 200

Dasar dasar farmakologis pemilihan Obat Anti


Hipertensi (OAH)
Metoda rasionil menurunkan tekanan darah meliputi :
menurunkan curah jantung
menurunkan resistensi perifer
memperbaiki komplians arteri
mempertahankan perfusi organ

Perlu diingat :
OAH yang efek utama menurunkan curah jantung berarti
menurunkan
tekanan sistolik sehingga tidak selalu disertai penurunan
tekanan dias
tolik bermakna
OAH yang utama mengurangi resistensi perifer(vasodilator)
berarti me
nurunkan tekanan diastolik akan menurunkan tekanan
sistolik
Hipertensi menetap/kronik (masalah resistensi perifer), hati
hati pema

Efek Hemodinamik obat obat


Antihipertensi
1. Menurunkan resistensi perifer, curah jantung
dipertahankan, memper
baiki komplians arteri/perfusi organ :
- penghambat kalsium, penghambat ACE, ARB
2 .Menurunkan resistensi perifer, mempertahankan curah
jantung dan per
fusi, komplians arteri tidak diketahui : penyekat alfa
3. Menurunkan resistensi perifer, mempertahankan curah
jantung dan per
fusi, memperburuk komplians arteri
- vasodilator, penyekat beta dan alfa
4. Menurunkan resistensi perifer, curah jantung dan perfusi:
diuretik

Farmakologis :obat dan dosis (I)

Farmakologis : obat dan dosis (II)

Penanganan Hipertensi

Antihypertension Drugs for Compelling


Factors (+)

Krisis Hipertensi
definisi : tekanan darah >180/120 mmhg dengan
atau ancaman kerusakan target organ (misalnya :
iskemia jantung, edema paru, stroke, gagal ginjal)
klasifikasi : Emergensi dan Urgensi
Emergensi : terbukti adanya kerusakan target organ
Urgensi : tidak terbukti adanya kerusakan target organ

diagnosis : identifikasi kerusakan target organ dan


hipertensi sekunder
penanganan :
Emergensi :
- rawat ICU, obat antihipertensi IV
- MAP diturunkan 10% jam pertama, selanjutnya 1520% 2-3jam berikutnya
Urgensi :
- rawat jalan atau observasi sehari di RS, obat
antihipertensi oral
- MAP diturunkan 25% pada 24 jam pertama

Parenteral Drugs Used for Treatment of Hypertensive


Emergencies

Pharmacologic treatment should be initiated using


one or more agents from 4 medication classes ACE
inhibitors, ARBs, CCBs or thiazide-type diuretics.
These agents should be titrated to the target dose
(see table below). In black hypertensive patients,
initial therapy should include a CCB or thiazide-type
diuretic. Patients with CKD should be started on
an ACE inhibitor or ARB. If patients do not reach
goal BP, add another drug from the 4 recommended
drug classes, but do not combine an ACE inhibitor
with an ARB. Note that beta-blockers are not among
the initial recommended drug classes.

LIST OF DRUGS AND THE TARGET DOSES USED IN CLINICAL


TRIALS

Classification of Recommendations
Based on critical review of high quality randomized controlled trials
Classification of recommendations:
(A) Strong Recommendation: high certainty based on evidence that
the net benefit is substantial
(B) Moderate Recommendation: moderate certainty based on
evidence that the net benefit is moderate to substantial
(C) Weak Recommendation: at least moderate certainty based on
evidence that there is a small net benefit
(D) Recommendation against: at least modest certainty based on
evidence that there is no net benefit or that risks/harms outweigh
benefits
(E) Expert Opinion: Net benefit is unclear because there is insufficient
evidence but this is what the committee recommends. Further
research is necessary.

Summary of Recommendations
General Population 60 yrs
Initiate Tx at BP 150/90 mmHg (Grade A)
Target BP < 150/90 mmHg (Grade A)
Corollary: if BP achieved is lower than target and well tolerated,
no adjustments needed to Tx (Grade E)
General Population < 60 yrs
Initiate Tx at BP 140/90 mmHg
Target BP < 140/90 mmHg
Diastolic goal: (30-59 years Grade A; 18-29 years Grade E)
Systolic goal: (Grade E)
Population 18 yrs with CKD or DM
Initiate Tx at BP 140/90 (Grade E)
Target BP < 140/90 (Grade E)

Summary of Recommendations
General nonblack population DM
Initial Tx should include thiazide-type diuretic, CCB,
ACEI, or ARB (Grade B)
General black population DM
Initial Tx should include a thiazide-type duretic or CCB
(General black population Grade B; black population
w/DMGrade C)
Entire population 18 yrs with CKD
Initial or add-on Tx should include an ACEI or ARB
(Grade B)

Summary of Recommendations
If BP goal not reached within 1 mo of Tx, increase
dose of initial drug or add a second agent
If goal still not reached with two agents titrated
up, third agent from the recommended list (i.e.
Thiazidetype diuretic, CCB, ACEI/ARB)may be
added
Following third agent, if goal still not reached,
refer to a specialist.
Can add antihypertensive agents from other
classes
Do not use ACEI and ARB together

HYPERTENSION GUIDELINE MANAGEMENT ALGORITHM