TATALAKSANA HIPERTENSI OPTIMAL

UNTUK MENCEGAH STROKE

Dr. Sapto Priatmo, Sp.PD

RS BETHESDA YOGYAKARTA
4 November 2017
 HIPERTENSI
Suatu keadaan klinis dimana tekanan darah
seseorang lebih tinggi daripada tekanan
darah normal (>140/90 mmHg)

• Epidemiologi :
• Jumlah penderita hipertensi di seluruh dunia :
1 milyar
• USA : 65 juta
• Indonesia: 27,6% (SKRT, 2004)

Conlin PR, Int J Clin Pract 2005; 59(2):214-24

 Klasifikasi tekanan darah (JNC VII)
BP category SBP DBP
(mmHg) (mmHg)
Normal <120 and <80

Pre-hypertension 120–139 and/or 80–89

Stage 1 140–159 and/or 90–99

Stage 2 > 160 and/or > 100

Chobanian et al. JAMA. 2003;289:25602572.

 2013 ESH/ESC Guidelines for the management of arterial hypertension

Definitions and classification of office BP levels (mmHg)*

Hypertension:
SBP >140 mmHg ± DBP >90 mmHg

Category Systolic Diastolic

Optimal <120 and <80

Normal 120–129 and/or 80–84

High normal 130–139 and/or 85–89

Grade 1 hypertension 140–159 and/or 90–99

Grade 2 hypertension 160–179 and/or 100–109

Grade 3 hypertension ≥180 and/or ≥110

Isolated systolic hypertension ≥140 and <90

* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic
hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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 CLASSIFICATION BP SBP DBP
HYPERTENSION and
Optimal <120 <80
BP SBP DBP Normal 120-129and./or 80-84
Normal <120 nd <80 High Normal 130-139 85-89
a HT stg 1 140-159 90-99
Pre HT 120-139 o r 80-89 HT stg 2 160-179 100-109
Stg 1 140-159 o r 90-99 HT stg 3 ≥180 ≥110
Stg 2 ≥160 r ≥100 ISH ≥140 <90
and
BP o SBP DBP
Optimal <120 and <80
JNC 8
Normal <130 and <85
High Nml 130-139 or 85-89 No definition of HT
HT stg 1 140-159 or 90-99
HT stg 2 160-179 or 100-109
HT stg 3 ≥180 or ≥110
 Prevalensi hipertensi dunia

60 55
Prevalence of hypertension (%)
47 49 49
45 42
38 38

30 28

15

0
US Italy Sweden England Spain Finland Japan* Germany

Adults aged 35–64 years (data are age- and sex-adjusted), except* (adults aged ≥ 30 years)
Hypertension defined as BP  140/90 mmHg or on treatment

Wolf-Maier et al. JAMA. 2003;289:23632369; Sekikawa, Hayakawa. J Hum Hypertens. 2004; 2004;18:911–912.
 Prevalensi hipertensi meningkat dengan
pertambahan usia
Prevalence of hypertension (%) 100
Men 80
80 Women 71
60 61
60
45 42
40 33
21 23
20 14
10
6
0
20-29 30-39 40-49 50-59 60-69 70
Age (Years)
Data for established market economies:
Australia, Canada, England, Germany, Greece, Italy, Japan, Spain, Sweden, USA
Kearney et al. Lancet. 2005;365:217223.
 Komplikasi hipertensi

Eyes Brain Target Organ damage!!

retinopathy stroke

Damages depend on:

Heart
ischaemic heart disease
• How high of the blood
Kidneys left ventricular hypertrophy pressures
renal failure heart failure
• How long the
uncontrolled and
untreated high blood
presure
Peripheral arterial disease
 03
20 Treat Hypertension in the Context of Overall
Cardiovascular Risk

Grade 1 Grade 2 Grade 3

SBP 140-159 or SBP 160-179 or SBP ? 180
Other Risk Factors &
DBP 90-99 DBP 100-109 or DBP ? 110
Disease History
(mild hypertension) (moderate hypertension) (severe hypertension)

I. No other risk
Low risk Medium risk High risk
factors

II. 1-2 risk factors Medium risk Medium risk V high risk
III. 3 risk factors or
TOD or De novo High risk High risk V high risk
diabetes
IV. ACC or Diabetes V high risk V high risk V high risk

Risk strata (typical % 10 year risk of stroke, myocardial infarction or death)

<15% 15-20% 20-30%  30%

© Adapted
Continuing MedicalRecommendations
from WHO/ISH Implementationon Hypertension. Chalmers J et al.
…...bridging
J Hyper 1999;17:151-85.
the care gap
Canadian Hypertension Education Program Recommendations 37
 Risiko mortalitas meningkat 2x dengan
peningkatan tekanan darah 20/10 mmHg
10
SBP/DBP (mmHg)
Fold increase in relative
8
8X
8-fold
CV risk

4X
3
2X
1X
0
115/75 135/85 155/95 175/105
• Meta-analysis of 61 prospective, observational studies
• 1 million adults aged 40–69 years with BP > 115/75 mmHg
• 12.7 million person–years

Lewington et al. Lancet. 2002;360:1903–1913.

 Penurunan tekanan darah sistolik 2 mmHg
menurunkan risiko mortalitas 7-10%

• Meta-analysis of 61 prospective, observational studies

• 1 million adults aged 40–69 years with BP > 115/75 mmHg
• 12.7 million person-years 7% reduction in risk
of ischaemic heart
disease and other
2 mmHg vascular disease
decrease in mortality
mean SBP
10% reduction in risk
of stroke mortality

Lewington et al. Lancet. 2002;360:1903–1913.

FAKTA HIPERTENSI
PADA STROKE
 AHA Stroke Statistics 2016

 Approximately 77% of those who had first stroke have BP >140/90 mmHg (ARIC,
CHS, and FHS Cohort and Offspring studies)

 For each 10 mm Hg increase in levels of SBP, the increased stroke risk in whites is
≈8%; however, a similar 10 mm Hg increase in SBP in African Americans is
associated with a 24% increase in stroke risk, an impact 3 times greater than in
whites.

 Diabetic subjects with BP <120/80 mm Hg have appx half the lifetime risk of stroke
of subjects with hypertension.

 Large accelerated reductions in stroke mortality due to Median SBP decline

(16 mmHg) between 1959 and 2010 for different age groups
 Average 41% reduction in stroke incidence with SBP reductions of 10 mm Hg
with anti-HTN therapy
 AHA Stroke Statistics 2016

 Several studies have shown significantly lower rates of

recurrent stroke with lower BPs.
 Most recently, the BP- reduction component of the
SPS3 trial showed that targeting an SBP <130 mmHg
was likely to reduce recurrent stroke by ≈20%
(P=0.08) and significantly reduced ICH by two thirds.
What is the goal BP?
Group BP Goal (mm Hg)
General DM* CKD**
JNC 8: <60 yr: <140/90 < 140/90 < 140/90
>60 yr: <150/90 Goal BP
ESH/ESC: < 140/90 < 140/85 < 140/90

Elderly 140-150/90 (SBP < 130 if proteinuria)

(<80 yr: SBP<140)
ASH/ISH < 140/90 < 140/90 < 140/90
>80 yr: <150/90 (Consider < 130/80 if proteinuria)
AHA/ACC < 140/90 < 140/90 < 140/90

**KDIGO: <140/90 w/o albuminuria

*ADA: < 140/80 or lower
<130/80 if >30 mg/24hr
 JNC 8 ESH/ESC AHA/ACC ASH/ISH

>140/90

Threshold >140/90 < 60 yr Eldery SBP >160 >140/90 <80 yr

Comparison of Recent
for Drug Rx >150/90 >60 yr Consider SBP >140/90 >150/90 >80 yr
Guideline Statements
140-150 if <80 yr

B-blocker No Yes No No
First line Rx

Initiate Therapy >160/100 "Markedly >160/100 >160/100

w/ 2 drugs elevated BP"
TATALAKSANA
HIPERTENSI
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Lifestyle changes for hypertensive patients

Recommendations to reduce BP and/or CV risk factors

Salt intake Restrict 5-6 g/day

Moderate alcohol intake Limit to 20-30 g/day men,

10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal 25 kg/m2

Waist circumference goal Men: <102 cm (40 in.)*

Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7 days/week

(moderate, dynamic exercise)
* Unless contraindicated. BMI, body mass index.

Quit smoking

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
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Lifestyle Modification
 CHS January 2004
Considerations for individualization of anti-hypertensive therapy
Indication Initial Therapy Second line Rx Notes/Cautions
DM with nephropathy ACE-i or ARB addition thiazide, * - *Cardioselective
blockers , LA-CCB,  -blockers
ACE/ARB combo If CR >150 mmol/l use
DM without ACE-i or ARB Combo1st line Rx or *- loop diuretic for volume
blockers, LA-CCB control
nephropathy or thiazide
Angina  -blockers + strongly LA-CCB Avoid short acting
consider ACE-i nifedipine
Prior MI  -blockers + ACE-i Combine additional Rx
CHF  -blockers + ACE-i + Hydralazine /ISDN: Avoid non DHP-CCB
spironolactone (ARB if thiazide or loop diuretics (diltiazem, verapamil)
ACE-i intolerant ) as additive therapy
Prior CVA or TIA ACE-i/diuretic BP reduction  recurrent
combination events
Renal Disease ACE-i/diuretic as ARB if ACE-i intolerant Avoid ACE-i if bilateral
additive Rx Combo other agents Renal artery stenosis
LVH ACE-I, ARBs, DHP- Avoid hydralazine and
CCB, thiazide,  - minoxidil
blockers < 55 yr
JNC 8
 Strategies to Dose Antihypertensive Drugs
Strategies Description Details
A Mulai 1 obat naikan sp Jika target BP blm tercapai naikkan dosis
dosis obat 1 sp dosis maksimum sblm
maksimum,kemudian menambahkan obat ke-2 dan ke-3.
tambahkan obat ke-2
B Mulai 1 obat kemudian Tambahkan obat ke-2 sblm obat 1
tambahkan obat ke-2 mencapai dosis maks.Jk Target BP blm
sblm dosis maksimum tercapai,tambahkan obat ke-3 dan
titrasi sp dosis maks.
C Mulai dengan 2 obat • Mulai dg 2 obat
(separate or single • Bbrp committee merekomendasi:
combination)  ≥2 obat SBP >160 dan/atau DBP
>100, atau SBP >20 mmHg diatas
target dan/atau DBP >10 mmHg
 Jika target BP tdk tercapai (2 drugs),
tambahkan obat ke-3 dan titrasi.
JNC 7
G
Guideline Population Goal BP Initial drugs
U
2014 HT General ≥60 y <150/90 Non Black: thiazide type diuretic, ACEI,
I
D Guideline ARB or ARB
E General <60 y <140/90 Black: thiazide type-diuretic or CCB
L DM <140/90 Thiazide type diuretic, ACEI, ARB or
I CCB
N CKD <140/90 ACEI or ARB
E • General (non <140/90 βBocker, diuretic, CCB, ACEI, ARB
ESH/ESC
elderly)
C • General elderly <150/90
0 <80 y
M • General ≥ 80 y <150/90
P • DM <140/85 ACEI or ARB
A • CKD (no <140/90 ACEI or ARB
proteinemia)
R • CKD + <130/90
I proteinemia
S
CHEP General <80 y <140/90 Thiazide, βBlocker (<60y), ACEI (nonblack) or
O ARB
N General >80 y <150/90
DM <130/80 Add CVD risk: ACEI or ARB
GOAL BP No CVD risk: ACEI/ARB/Thiazide/DHPCCB
INITIAL TX ACEI or ARB
CKD <140/90
 Guideline Population Goal BP Initial drugs
ADA DM <140/80 ACEI or ARB

KDIGO • DM and CKD ≤140/90 ACEI or ARB

alb exc <30
mg/d
• DM and CKD ≤130/80
alb exc >30
mg/d
NICE General <80 y <140/90 <55 y; ACEI or ARB
General ≥80 y <150/90 ≥55 y or black; CCB

ISHIB Black, lower risk <135/85 Diuretic or CCB

TOD or CVD risk <130/80

JNC 7 General <140/90

CKD <130/80 ACEI or ARB
DM <130/80
 Important Variables For HTN Recommendations
BP NICE ESC/ESH ASH/ISH AHA/AC JNC 7 JNC 8
C/CDC
Definition ≥140/90 ≥140/90 ≥140/90 ≥140/90 Pre HT 120-139 Not
or 80-89
HTN and Stg 1 HT addressed
daytime 140-159 or 90-
ABPM 99
≥135/85 Stg 2 HT
≥160 or ≥100

Drug th/ in ≥160/100 ≥140/90 ≥140/90 ≥140/90 ≥140/90 • <60 y,

low risk or daytime ≥140/90
pts after ABPM • ≥60 y,
non pharm ≥150/95 ≥150/90
th/

βBlocker No Yes No No No No
as 1st line
 NICE ESH/ESC ASH/ISH AHA/ACC JNC 7 JNC 8
/CDC
Diuretic Chorthali- Thiazides THZ THZ THZ THZ
done (THZ), CTD CTD
(CTD) CTD IND IDP
Indapami- ND
de (IND)
Initiate Not Pts w/ ≥160/90 ≥160/100 ≥160/100 Not
th/ with mentio- markedly mentioned
2 drugs ned elevated BP

BP <140/90 <140/90 <140/90 <140/90 <140/90 <160/90

target ≥80 y, • Elderly <80 ≥80 y, (<60 y)
<150/90 SBP 140- <150/90
150, in fit ≥60 y,
pts SBP <150/90
<140
• Elderly ≥80
y SBP 140-
150
Under JNC 8, in all cases, targets BP should be reached within
a month of starting treatment either by increasing the dose or
by using a combination drugs

In patients ≥60 yrs who do not have DM or CKD, the goal BP

level is <150/90 mm Hg

In pts 18 - 59 yrs without major comorbidities target BP

<140/90, and in patient ≥ 60 yrs without DM, CKD, or both, the
new goal BP is <150/90 mm Hg

JNC 8 panel recommended thiazide-type diuretics as initial

therapy for most patients (include newly diagnosed HTN)
JNC 8 also recommend lifestyle interventions include use of the
DASH eating plan, weight loss, reduction in sodium intake to
<2.4 gr/day, and at least 30 minutes of aerobic activity most
days of the week

Under the JNC 8 guidelines, patients would receive a dosage

adjustment and combinations of the 4 first-line & later line
therapies ACEI/ARB, CCB, and thiazide-type diuretic

The JNC 8 does not recommend β-blockers and α-blockers as 1st

therapy due to 1 trial that showed a higher rate of CV events
with use of βB compared with use of an ARB, and another trial
in which αB resulted in inferior CV outcomes compared with use
of a diuretic
When initiating therapy, patients of African descent
without CKD should use CCBs and thiazides instead of ACE
inhibitors

ACE inhibitors and ARBs should not be used in the same

patient simultaneously