Blood Pressure

Classification(JNC7)
BP
Classification
Normal

SBP
mmHg
<120

and

DBP
mmHg
<80

Prehypertension

120139

or

8089

Stage 1
Hypertension

140159

or

9099

Stage 2
Hypertension

>160

or

>100

Essential (95%)
Secondary about 5%-10% of cases
- Renal : renal artery stenosis ; parenchymal
disease
- Endocrine : Hyperaldosteronism;
hyperthyroidsm ; Cushing syndrome
- Vascular: Coarctation of aorta, Aortic
insufficiency
- Toxemia of pregnancy

RAS (kulit hitam)

Usia > 60th
Jenis kelamin (laki-laki dan wanita menopouse)
Keturunan
Merokok
Kolesterol
Penyakit penyerta, DM, obesitas, and
hyperlipidemia
Tinggi garam
Alkohol

Asupan
garam
berlebih

Jumlah
nefron
berkurang

Retensi
natrium
ginjal

Renin
angiotensin
berlebih

Perubahan
genetis

Obesitas

Perubahan
membran
sel

Hiperinsulinesmia

Konstriksi
vena

CURAH
JANTUNG

Hipertrofi
struktural

Konstriksi
fungsionil

Kontraktilitas

Preload

Hipertensi

Aktivitas
berlebih
saraf
simpatis

Penurunan
permukaan
filtrasi

Volume
cairan

TEKANAN
DARAH

Stress

Bahanbahan yang
berasal dari
endotel

TAHANAN
PERIFER

tahanan perifer

curah jantung
Autoregulasi

Serial blood pressure determinations

Blood pressure in both arms
Funduscopic examination :arteriovenous nicking , hemorrhage, Exudates
Palpation of thyroid
Auscultation
Lungs for wheezing and rales
Cardiac: heart beat; S3 ,S4 murmur , PMI , thrill .
Abdominal and cervical ( check bruit )
Palpation of pulses, especially femoral artery :delayed pulse and decrease
pressure -> coarctation

Routine screen ,including CBC ,biochemistry

Urinalysis : albumin , microalbumin
Serum potassium , Calcium ,Creatinine
Thyroid function , Cortisol level
Cholesterol , TG
EKG
Chest X-Ray
Catecholamines only in presence of diastolic pressure >110
mmHg in patient younger than 30
Echocardiography

Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revasculariztion

Brain

Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease
Retinopathy

 Cerebrovascular

disease:
tromboembolic, intracranial bleeding,
TIA
Cardiovascular disease: MI, HF, CAD
LVH: enhanced incidence of HF,
ventricular arrythmia, sudden cardiac
death
Periveral vascular disease
Renal failure

 Treat

to BP <140/90 mmHg or BP
<130/80 mmHg in patients
with diabetes or chronic kidney
disease.

Lifestyle modifications

Not at goal blood pressure (<140/90 mm Hg)

(<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial drug choices

Without compelling indications

Stage 1 hypertension
(SBP 140159 or DBP 9099 mm Hg)
Thiazide-type diuretic for most.
May consider ACEI, ARB, BB, CCB,
or combination.

Stage 2 hypertension
(SBP 160 or DBP 100 mm Hg)
Two-drug combination for most
(usually thiazide-type diuretic and
ACEI or ARB or BB or CCB).

With compelling indications

Drugs for compelling indications

Other antihypertensive drugs
(diuretic, 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.

SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensinconverting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=-blocker;
CCB=calcium channel blocker

JNC 7. May 2003. NIH publication 03-5233.

JNC 7: Classification and Management

of Blood Pressure for Adults
Initial Drug Therapy
BP
Classificati
on

SBP*
(mm
Hg)

DBP*
(mm
Hg)

Lifestyle
Modificat
ion

Normal

<120

and
<80

Encourage

Prehyperte
nsion

120
139

or 80
89

Yes

Stage 1
hypertensio
n

Stage 2
hypertensio
n

140
159

160

or 90
99

or 100

Yes

Yes

JNC 7. May 2003. NIH publication 03-5233.

Without
Compelling
Indications
No
antihypertensive
drug indicated.
Thiazide-type
diuretic
for most. May
consider ACEI,
ARB, BB, CCB,
or combination.
Two-drug
combination
for most (usually
thiazide-type
diuretic
and ACEI or ARB
or

With
Compelling
Indications
Drug(s) for
compelling
indications.

Drug(s) for
compelling
indications.

Other
antihypertensive
drugs (diuretic,
ACEI, ARB, BB,
CCB) as needed.

Heart Failure:

Post- MI:
High CVD risk:
DM:

CRF

Thiazide/loop, BB, ACEi, ARB,

Aldosterone antagonist
BB, ACE, Aldosterone
antagonist
Thiazide, BB, ACE, Ca channel
blocker
Thiazide, BB, ACE, ARB, CCB

Cr > 1.5 in men

ACE, ARB. For creatinine 2-3
Cr > 1.3 in women
try loop diuretic
S/P CVA

Thiazide, ACE inhibitor

Modification

Recommendations

Approximate Systolic
Blood Pressure
Reduction

Weight Reduction

Maintain normal body

weight (BMI 18.5-24.9)

5-20 mm Hg for each

10 kg weight loss

Adapt eating plan

Consume diets rich in

fruits, vegetables, low
fat dairy and low
saturated fat

8-14 mm Hg

Dietary sodium reduction

Reduce sodium to no
more than 2.4 g/day
sodium or
6 g/day NaCl

2-8 mm Hg

Increase physical activity

Engage in regular
aerobic activity such as
walking
(30 min/day on most
days)

4-9 mm Hg

Moderate alcohol
consumption

Limit alcohol to no more

than 2 drinks/d for men

2-4 mm Hg

Source: The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

 The cardiovascular risk profile

Coexisting disorders
Target organ damage
Interactions with other drugs
Tolerability of the drug
Cost of the drug

Reduce cardiac output

-adrenergic blockers
Ca-channel blockers
Dilate resistance vessels
Ca-channel blockers
Renin-angiotensin system blockers
1 adrenoreceptor blockers
Nitrates
Reduce vascular volume
Diuretics
Direct vasodilators

 CCB

OK for isolated systolic

hypertension (ISH)
For DM: ACEi or ARB with or without
diuretic, then add BB or CCB
When ACEi causes cough, substitute
ARB
Dont use short acting CCB (increases
deaths due to arrhythmias).
Alpha blockers (e.g. clonidine) only as
second line (more side effects).

Lifestyle Modification

Not at goal BP

Initial Drug Choices

W/O Compelling Indications

Stage 1

With Compelling Indications

Stage 2

Thiaz, ACE, ARB, BB, CCB

Drug for Indication

2 Drug Combo

Not at Goal BP

Adjust Dose or add additional agents

THIAZIDE

LOOP DIURETIK

POTASSIUM-SPARING
DIURETICS

ALDOSTERON RESPTOR
BLOKER

BETA BLOKER

ACEI

ARB

CCB