Disusun Oleh:
Chemayanti
Surbakti
Fatimah Syam
Khairunnisa
Rambe
Yustika Rahayu
Richa Melisa
Taufik
Febrianto
M. Fadilah
Herry Febrian
Neni Arofiani
Prevalence (millions)
20
30
40
12,200,000
CHF
4,600,000
Stroke
4,400,000
Other
60
50,000,000 (24%)
High BP
CAD
50
2,800,000
47.4 million
hypertensives
26.0% of US
population
21.3
19.2
13
9.5
10
5
23.7
9.6
3.7
18-29
30-39
40-49
50-59
60-69
70-79
80+
Ascultatory method of
blood pressure measurement
BP = CO X TPR
BP = Blood Pressure
CO (Q) = Cardiac Output
SV = Stroke Volume
HR= Heart Rate
TPR
Saraf otonom
HR
Kontraktilitas otot
Volume
sekuncup
Curah jantung
Tekanan darah
Diameter
arteriol
TPR
Viskositas
darah
JNC 7
2003
ESC 2003
ESH-ESC 2003
BP Classification
BP
BP
Optimal
<120 / <80
<120/<80
Normal
120-129 / 8084
120-129 /8084
Prehypertensi
on
High normal
130-139 / 8589
130-139 /
85-89
Prehypertensi
on
Grade 1
Hypertension
(mild)
140-159 / 9099
140-159 /
90-99
Stage 1
Hypertension
Grade 2
Hypertension
(moderate)
160-179 /
100-109
>160 / >100
Stage 2
Hypertension
Grade 3
Hypertension
(severe)
Isolated Systolic
> 140
< 90
JNC VII(2003)
Bp
Classification
Normal
Isolated
Etiologi
Essential Hypertension
hypertension with no apparent cause 90-95%
Secondary Hypertension
hypertension of known cause
FAKTOR PENYEBAB
HIPERTENSI
KRISIS HIPERTENSI
Krisis hipertensi
Suatu keadaan peningkatan tekanan
darah yang mendadak (sistole 180
mmHg dan/atau diastole 120
mmHg), pd penderita hipertensi, yg
membutuhkan
penanggulangan
segera.
13
Risk Factor
Age
Gender
Race
Genetic factors
Other:
obesity
high alcohol intake
high Na intake
abnormal renin values
high stress level
low birth weight
drugs
Complications of Hypertension:
Hypertension
is a risk factor
TIA, stroke
LVH, CHD,
HF
Retinopathy
Peripheral vascular
disease
Renal
failure
16
17
Pemeriksaan laboratorium
Pemeriksaan laboratorium rutin yang direkomendasikan
Sebelum memulai terapi antihipertensi adalah urinalysis,
kadar gula darah dan hematokrit; kalium, kreatinin, dan
kalsium serum; profil lemak (setelah puasa 9 12 jam)
termasuk HDL, LDL, dan trigliserida,Serta
elektrokardiogram.
Pemeriksaan opsional termasuk pengukuran ekskresi albumin
urin atau rasio albumin / kreatinin. Pemeriksaan yang lebih
ekstensif Untuk mengidentifikasi penyebab hipertensi tidak
diindikasikan Kecuali apabila pengontrolan tekanan darah
tidak tercapai.
kegunaan data Lab:
Mengindikasikan apakah terjadi efek HT ke organ target,
faktor risiko
dislipidemia, intoleransi glukose ke arah DM; dsb
FARMAKOTERAPI SKV-HIPERTENSI
18
Tes
Alasan
Glukosa darah
EKG
FARMAKOTERAPI SKV-HIPERTENSI
19
With Compelling
Indications
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension
specialist. JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
TERAPI HIPERTENSI
Non-Farmakologi
Intake Na+
BB
intake alkohol
Olaha raga teratur
/hentikan merokok
Stres
Batasi agen2 yang
menginduksi hipertensi
Kontrasepsi oral
Simpatomimetik
Farmakologi (drug
therapy)
Diuretik
Mempengaruhi simpatetik
Central acting agent
Adrenergik blocking agent
Antagonis alfa
Antagonis beta
Antagonis campuran alfabeta
Direct vasodilator (termasuk
CaCB)
Mempengaruhi RAS
ACEIs
Lifestyle Modification
Modification
Weight reduction
8-14 mmHg
2-8 mmHg
Physical activity
Moderation of alcohol
consumption
4-9 mmHg
2-4 mmHg
JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
Impact of a 5 mmHg
Reduction
Overall Reduction
Stroke
14%
9%
7%
Hypertension 2003;289:2560-2572.
Thiazide
Diuretics
Mechanism: inhibit Na/K pumps in the
distal tubule
Examples:
Hydrocholorthiazide 12.5-25 mg
daily
Chlorthalidone 12.5-50 mg daily
Effective first line agent and provides
synergistic benefit
As single agent more effective if CrCl
>30 ml/min
Compelling indications: HF, High CAD
risk, Diabetes, Stroke, ISH
Aldosterone
Receptor
Antagonists
Mechanism: inhibit aldosterones
effect at the receptor, reducing Na
and water retention
Examples:
Spironolactone 25 mg daily
Can provide as much as 25
mmHg BP reduction on top of 4
drug regimen in resistant
hypertension
Monitor SCr and K
Compelling indications: HF
Nitrates
Mechanism: Direct
venodilation by release of
nitric oxide
Examples:
Isosorbide dinitrate 10
mg TID
IMDUR 30 mg daily
Monitor: SCr, K
Beta
Blockers
Mechanism: Competitively inhibit the
binding of catecholamines to betaadrenergic receptors
Examples:
Diltiazem
and
Verapamil
Mechanism: Decrease calcium
influx into cells of vascular smooth
muscle and myocardium
Examples:
Monitor: HR
Relatively contraindicated in
heart failure
Compelling indications:
Diabetes, High CAD risk
Alpha2 Agonists:
Central Acting
Agents
Mechanism: false neurotransmitters
reduce sympathetic outflow reducing
sympathetic tone
Examples:
Dihydropyridine
Calcium
Channel
Mechanism: Blockers
Decrease calcium influx
into cells of vascular smooth muscle
Examples:
Methyldopa, Guanabenz,
Guanfacine
Monitor: HR
Side effects often limiting: Dry mouth,
orthostasis, sedation
Clonidine patch can be useful in
elderly patients with labile blood
pressure
Felodipine2.5-10 mg PO daily
Vasodilators
Alpha1 Blockers
Mechanism: Inhibit peripheral postsynaptic alpha1 receptors causing
vasodilation
Examples:
Terazosin 1 20 mg daily
Doxazosin 1 16 mg daily
Hydralazine is an alternative in
HF if ACEI contraindicated
Pharmacologic Sites of
Action
Veins
Thiazides
Loops
Aldosterone Ant.
Nitrates
ACEI
ARB
Heart
Beta Blockers
Diltiazem
Verapamil
Via Central
Mechanism:
Clonidine
Arteries
Dihydropyridine
CCBs
Hydralazine
Minoxidil
Alpha1 Blockers
ACEI
ARB
Efek menguntungkan
Efek tidak
menguntungkan
Efek membahayakan
adenoreceptor bloker
CaCB
Gagal jantung
Diuretik
CaCB
adenoreceptor bloker
ACE inhibitor
Penyumbatan jantung
adenoreceptor bloker
Verapamil
Takikardia
Serangan jantung
Raynauds
phenomenon
Prazosin
Penyakit Respiratori
Asma
Penyakit penyumbatan
aliran udara kronis
adenoreceptor bloker
adenoreceptor bloker
Efek menguntungkan
Efek tidak
menguntungkan
Efek membahayakan
Penyakit metabolic
IDDM
Nonselektif
adenoreceptor bloker
NIDDM
Thiazid
Gout
Thiazid
Hiperlipidemia
Kerusakan hati
CaCB
Penyakit
Genitourinari
Prostatism
Kerusakan ginjal
ACE inhibitor
Metildopa
CNS
Migrain
Depresi
Nonselektif
adenoreceptor bloker
Propranolol
Klonidin
Metildopa
adrenoreceptor bloker
ACE inhibitor
Obat lain
Interaksi
NSAIDs
Digoksin
Antiarrhythmics
Lithium
Korticosteroid
Anastetik
Antiaritmia
NSAIDs
Hiperkalemia
Anastetik
Lithium
Suplemen kalium
Hiperkalemia
Diuretik hemat
kalium
Hiperkalemia
Suplemen kalsium
Hiperkalemia
Hiperkalemia
adenoreceptor bloker
Prazosin
Indometasin
CaCB
Digoksin
Levodopa
Lithium
Nitrat
Antiepilepsi
Metildopa
Antidepresan monoamine
oksidase inhibitor
Case Studies 1
A 55 yo west Indian women with
NIDDM, controlled by metformin, is
found on a visit to the clinic to have a
BP of 172/100 mmHg
Question:
1. Should drug therapy be initiated to
control her hypertension?
2. What antihypertensive drugs should
be avoided?
Answers case 1
1. First it is necessary to establish that the BP
reading is correct and consistent over at least
three separate occasions. The fact that her
NIDDM is controlled by metformin suggests she
may have a problem with weight control. It may
be important, therefore, to make sure that the
appropriate-sized cuff was used when her BP
was measure
2. Althought thiazid diuretics are effective
antihypertensive agent, they should be avoided
in diabetic patients because they reduce glucosa
tolerance. This is particularly important in
patient with NIDDM because of their effects on
Case studies 2
A 58 yo hypertensive female has
suffered side effects from a variety of
antihypertensive drugs. She is now
well controlled on enalapril, 20 mg
daily, but complains of a dry cough.
Her serum potassium level has also
risen.
Question: Should her treatment be
changed?
Answer case 2
The dry cough is a side effect of all ACE inhibitor (up
to 20% of patients, particularly middle aged
women, suffer this) but dose not necessary
require that the treatment should be stopped. It
appears to be an adverse effect of all ACE
inhibitors, so changing to an angiotensin II
receptor antagonist should provide similar control
of the BP without the same range of side effect, in
particular the cough. The rise in the serum
potassium level is potentially more serious, and a
possible explanation, such as concurrent therapy
with a potassium-sparing agent, must be explored
before changing to an alternative such as
Case 3: Diagnosis
AB is a 56 yo female with no
significant PMH. Her BMI is 26 kg/m2
and she has a family history positive
for Type 2 Diabetes. Her BP measured
on two consecutive clinic visits is
132/84. What is ABs BP classification?
1.
2.
3.
4.
Normal
Prehypertensive
Stage 1 Hypertension
Stage 2 Hypertension
Case 3: Therapy
What therapy should be initiated for
AB?
1.
2.
3.
4.
Enalapril 5 mg PO daily
Hydrochlorothiazide 25 mg PO daily
No therapy is indicated
Lifestyle modifications including weight
loss and DASH eating plan should be
encouraged
Normal
Prehypertensive
Stage 1 Hypertension
Stage 2 Hypertension
Case 1: 3 years
later
AB, now 59, returns to clinic with
Enalapril 5 mg PO daily
Hydrochlorothiazide 25 mg PO daily
No therapy is indicated
Reinforce lifestyle modifications
including weight loss and the DASH
eating plan.
Case 4: Therapy
What therapy should be initiated for
CD?
1. A 6 month trial of lifestyle changes
should be initiated immediately
2. Hydrochlorothiazide 25 mg PO daily
3. Enalapril 10 mg PO daily
4. Enalapril / Hydrochlorothiazide 5/12.5
mg PO daily