Hipertensi
&
Hipovolemic
Shock
Prevalensi Hipertensi
prevalence of hypertension (%)
70
60
50
64
65
70-79
80+
54
40
44
30
21
20
10
11
18-29
30-39
0
age (yrs)
40-49
50-59
60-69
Prevalensi :
Berdasar kriteria Hipertensi WHO 1968 (tekanan darah >
160/95 mmHg), prevalensi hipertensi di dunia sekitar 5-18
%. Prevalensi hipertensi di Indonesia tidak jauh berbeda
yaitu sekitar 6-15 %, walaupun dilaporkan adanya
prevalensi yang rendah yaitu :
- Ungaran
1,8 %
- Lembah Balim
0,6 %
serta adanya prevalensi yang tinggi :
- Silungkang
19,4 %
- Talang
17,8 %
Prevalensi Hipertensi di Jawa Timur hampir sama yaitu :
- Sumberpucung
(1976)
10 %
- Lawang
(1987) 11 %
- Kampak
(1987) 17 %
Hypertensive patients
who are treated
but uncontrolled
16%
23%
19%
42%
Hypertensive patients
who are unaware
Klasifikasi Hipertensi
(JNC 7 -
2003)
Category
Normal
Systolic
(mm Hg)
Diastolic
(mm Hg)
<120
dan
<80
Pre Hipertensi
120-139
atau
80-89
Hipertensi
Stage 1
Stage 2
140-159
> 160
atau
atau
90-99
>100
Hipertensi
Berdasarkan penyebabnya dapat dibedakan :
Primer (essential)
tidak ada penyebab yang spesifik yang
dapat diidentifikasi
90-95% dari kasus hipertensi
Sekunder
diketahui penyebabnya
5-10% dari kasus hipertensi
penyakit ginjal merupakan penyebab
tersering kasus hipertensi sekunder
Etiology Hypertension
Secondary Hypertension :
Renal disease :
Cushings syndrome
Acromegaly
Primary aldosteronism
Pheochromocytoma
Endocrine Disorders
Drug-induced hypertension
Corticosteroids
Amphetamines
Oral contraceptives
Psychogenic disorders
Fisiologi
SV=EDV-ESV
CO=SV x HR
BP=CO x PR
PATOPHYSIOLOGY
The factors affecting cardiac output:
- sodium intake, renal function, &
mineralocorticoids
- the inotropic effects occur via extracellular
fluid volume augmentation
- an increase in heart rate and contractility
Peripheral vascular resistance is
dependent upon the sympathetic nervous system,
humoral factors, and local autoregulation
(Sharma, 2003)
Increased CO
Preload
and/or
Contractility
Fluid volume
Increased PR
Vasoconstriction
Fluid volume
Renal sodium
retention
Excess
sodium
intake
Sympathetic
nervous
system
Reninangiotensinaldosterone
system
Genetic
factors
(Adapted from Kaplan, 1994)
Hypertension :
The Disease Continuum
Early Paradigm
Elevated BP
Vascular Dysfunction
A Proposed Future Paradigm
Endothelial
Dysfunction
Vascular
Dysfunction
Elevated BP
Target Organ
Damage
LVH
Renal
Damage
MI
Angina
Pectoris
Stroke
Komplikasi Hipertensi
Eyes
retinopathy
Kidneys
renal failure
Brain
stroke
Heart
ischaemic heart disease
left ventricular hypertrophy
heart failure
Besarnya peningkatan
tekanan darah
CHD
90
80
70
60
50
40
30
Stroke
CHF
20
10
0
<100
120
140
180
Systolic blood pressure (mmHg)
>180
Symptoms
Headache
Dizziness
Fatigue
Pounding of the heart
Symptoms are not specific and no more
frequent than in patients with normotension.
Riwayat Klinis :
Riwayat keluarga HT, DM, dislipidemia, PJK, stroke
Pemeriksaan Fisik :
Pemeriksaan fisik & TD yang teliti
Tinggi, berat, & BMI (Body mass Index)
Sistem kardiovaskuler : ukuran jantung,
2.
The patient should be
relaxed and the arm must
be supported. Ensure no
tight clothing constricts
the arm
3.
The cuff must be level with
the heart. If the circumference
exceeds 33cm, a large cuff
must be used (2/3 of arm).
Place stethoscope diaphram
over brachial artery
4.
The column of mercury
must be vertical. Inflate
to occlude the pulse
(>30 mmHg). Deflate at
2-3 mm/s. measure
systolic ( first sound /
Korotkoff I ) & diastolic
(disappearence /
Korotkoff IV or V ) to
nearest 2 mmHg
Recommended Technique
for Measuring Blood Pressure
Standardized technique:
Have the patient rest for 5 minutes
Use an appropriate cuff size
Use a mercury manometer or a recently
calibrated electronic device
Recommended Technique
for Measuring Blood Pressure (cont.)
Position cuff appropriately
Increase pressure rapidly
Support arm with antecubital fossa or heart
level
To exclude possibility of auscultatory gap,
increase cuff pressure rapidly to 30 mmHg
above level of diseappearance of radial
pulse
Place stethoscope over the brachial artery
Recommended Technique
for Measuring Blood Pressure (cont.)
Drop pressure by 2 mmHg / beat:
- appearance of sound (phase I Korotkoff)
= systolic pressure
- disappearance of sound (phase V
Korotkoff) = diastolic pressure
Take 2 blood pressure measurements, 1
minute apart
Diagnosis of Hypertension
Hypertension is defined as:
- BP 140/90 mm Hg
- during 1-5 visits
- with an average of 2 readings per visit
Pemeriksaan lain-lain
Laboratorium :
Urinalisis & mikroskopik urin
Serum kalium, kreatinin, gula darah puasa & 2 jam dan
profil lemak, asam urat
Pemeriksaan tambahan :
Pemeriksaan hormonal seperti pengukuran aktifitas
renin plasma, aldosteron plasma dan katekolamin
urine atas indikasi khusus (hipertensi sekunder)
JNC VI
Uncomplicated HTN
< 140/90
Hypertension with
diabetes mellitus
< 130/85
< 130/80*
< 130/85
Heart failure
Hypertension with
renal impairment
< 125/75
*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.
Terapi Hipertensi
Terapi Non-farmakologis
Menurunkan berat badan (5-20
mmHg/10 kg)
Latihan dan olah raga (4-9 mmHg)
Menghindari alkohol yang berlebihan
Mengurangi asupan garam (2-8 mmHg)
Stop merokok
Menurunkan asupan lemak jenuh
Lifestyle Modification
Modification
Approximate SBP
reduction (range)
Weight reduction
814 mmHg
28 mmHg
Physical activity
49 mmHg
Moderation of alcohol
consumption
24 mmHg
Terapi Hipertensi
Terapi Farmakologis
tujuan terapi antihipertensi
Memperbaiki fungsi endothel
untuk menurunkan resistensi vaskular
sistemik
mempertahankan curah jantung
mempertahankan suplai darah ke organ
dan jaringan
Pengobatan diberikan seumur hidup
Kepatuhan yang buruk merupakan penyebab
kegagalan terapi antihipertensi yang paling
besar
Pilihan terapi
antihipertensi
Diuretik
Beta-blocker
Antagonis kalsium
ACE-inhibitor
Angiotensin II receptor antagonis
(AIIRA / ARB)
Alpha1-blocker (sentral & perifer)
Diuretics
-blockers
AT1 receptor
blockers
1-blockers
Calcium
antagonists
ACE inhibitors
Possible combinations of different classes of antihypertensive agents.
The most rational combinations are represented as thick lines.
ACE, angiotensin-converting enzyme; AT1, angiotensin II type 1.
England
6
Canada
16
France
24
Spain
20.5
20
Germany
22.5
Scotland
Australia
19
India
17.5
> 65 years
WHO-ISH (1999)
Klasifikasi Derajat Tekanan Darah menurut WHO-ISH
1999 yang diadaptasi dari JNC VI 1997
1
2
3
4
5
6
7
Kategori
Sistolik
(mmHg)
Diastolik
(mmHg)
Optimal
Normal
Normal Tinggi
Hipertensi derajat 1 (ringan)
Subgrup : perbatasan
Hipertensi derajat 2 (sedang)
Hipertensi derajat 3 (berat)
Hipertensi Sistolik
(Isolated Systolic Hypertension)
120
130
130 - 139
140 - 159
140 - 149
160 - 179
180
140
80
85
85 - 89
90 - 99
90 - 94
100 - 109
110
90
Hipertensi
Secondary Hypertension :
Circulating
Liver
Renin inhibitors
Angiotensinogen
Renin
Tissue
Non Renin pathways
- t-PA
- Cathepsin G
- Tonin
Angiotensin I
ACE inhibitor
Converting enzyme
Angiotensin II
Angiotensin
receptors
Non-ACE pathways
- Chymase
- CAGE
- Cathepsin G
10
5
MI
Stroke
0
0
100
200
300
Stage 2+ hypertension
15
CHF
Cumulative
Incidence 10
(%)
Stage 1+ hypertension
5
Normal BP
5
10
Years From Baseline Exam
15
AT1
AT2
Blocked by ARB s
-
Vasoconstriction
Aldosterone release
Oxidative stress
Vasopressin release
SNS activation
Inhibits renin release
Renal Na+ and H2O reabsorption
Cell growth and proliferation
Vasodilation
Antiproliferation
Apoptosis
Antidiuresis/antinatriuresis
Bradykinin production
NO release
5
4
2
1
< 140
mm Hg
mm Hg
140-159 160-179 180-199 200+
< 80
80-89
90-99
100-109
110+
Benefits of Lowering BP
Average Percent Reduction
Stroke incidence
3540%
Myocardial infarction
2025%
Heart failure
50%
Goals of Therapy
(JNC-VII)
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.
US
Canada
Italy
Sweden
England
Spain
Finland
Germany
100
90
80
45
40
%
Patients on Therapy
70
35
% 60
50
30
25
40
30
20
15
20
10
10
5
0
Country
Wolf-Maier K et al. JAMA. 2003;289:2363-2369.
Country
RULE OF HALF
Hypertensive patients
who are treated
but uncontrolled
25%
12.5%
12.5%
50%
Hypertensive patients
who are unaware
Hypertensive patients
who are treated
and controlled
BP Control Rates
Trends in awareness, treatment, and control of high
blood pressure in adults ages 1874
National Health and Nutrition Examination Survey
Percent
II
197680
III
(Phase 1)
198891
III
(Phase 2)
199194
19992000
Awareness
51
73
68
70
Treatment
31
55
54
59
Control
10
29
27
34
Sources: Unpublished data for 19992000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.
-BLOCKER
-BLOCKER
Ca-ANTAGONIST
ACE INHIBITOR
ESC-ESH 2003
Initial combined therapy should be used cautiously in those at risk for orthostatic
hypotension.
Compelling Indications
for
Individual Drug Classes
Compelling Indication Initial Therapy Options Clinical Trial Basis
Heart failure
Postmyocardial
infarction
ACC/AHA Post-MI
Guideline, BHAT,
SAVE, Capricorn,
EPHESUS
ALLHAT, HOPE,
ANBP2, LIFE,
CONVINCE
Hipovolemic Shock