HIPERTEN

SI

KEPANITERAAN KLINIK SMF ILMU PENYAKIT DALAM

FAKULTAS KEDOKTERAN UNS/RSUD DR MOEWARDI
SURAKARTA
2017
Definisi dan Klasifikasi
 Peningkatan tekanan darah ≥140/90 mmHg secara kronis.

NHLBI (2003). Joint National Committee 7 (JNC 7)

Konsep Dasar

Lilly (2011). Pathophysiology of heart disease

 ETIOLOGI

1.
HIPERTENSI PRIMER/ESENSIAL/IDIOPATIK
 Etiologi pasti tidak jelas
a. Genetik :
 Multifktorial - sensitivitas terhadap Na

- kepekaan terhadap stress

- resistensi insulin
- reaktivitas vaskuler
b. Lingkungan :

Intake Na berlebih, stress psikis, obesitas

2. HIPERTENSI SEKUNDER

Hipertensi karena Obat  obat tyroid, amin
 simpatomimetik penyakit lain hipertensi
Hipertensi karena renal,
penyakit endokrin, eklamsia, dll
Sistem Renin – Angiotensin

Lilly (2011). Pathophysiology of heart disease

 FAKTOR RISIKO


Keturunan

Jenis Kelamin  laki- > perempuan
 laki
Usia  laki-laki > 55 thn, perempuan > 65 thn

Merokok

Obesitas

Stress

Inaktivitas Fisik

Intake  Na berlebih, Kalium kurang
Diagnosis

Anamnesis : asimtomatik. Kadang disertai kaku tengkuk , kepala berat,

sakit kepala dll

Pemeriksaan fisik : Nilai tekanan darah diambil dari rerata dua kali
pengukuran pada setiap kunjungan. Apabila TD ≥140/90 pada dua atau lebih
kunjungan HT dapat ditegakkan.
Pemeriksaan penunjang: a) memeriksa komplikasi yang telang atau
sedang terjadi b) dilakukan apabila diuragi hipertensi sekunder
Tatalaksana

Hipertensi Primer

Kriteria
Semua pasien Modifikasi memulai Monitoring
dengan hipertensi gaya hidup antihipertens dan evaluasi
i

Terpenting!!
 Lifestyle Measures: KDIGO

• Weight:
Achieve or maintain a normal weight (BMI 20-25 kg/m²)

• Salt:
< 2 g sodium (5 g salt) per day unless contraindicated

• Exercise:
At least 30 minutes 5 times per week

• Alcohol:
Limit to maximum of 2 standard drinks per day

• Smoking:
No direct effect on long-term BP but cessation reduces CV risk.

KDIGO Blood Pressure Work Group. Kidney Int Suppl 2012

Lifestyle Modification
Kriteria dimulai penggunaan antihipertensi
1.Pasien dengan HT stage 1 dengan minimal
salah satu penyerta berikut:
a.Jejas pada organ target
b.Riwayat penyakit kardiovaskular
c.Penykit ginjal
d.DM
e.Risiko kardiovaskular dalam 10 tahun terakhir
2. Semua pasin HT stage 2
 JNC 8 Hypertension Guideline Algorithm Initial Drugs of Choice for Hypertension
Adult aged ≥ 18 years with HTN
• ACE inhibitor (ACEI)
Implement
Set BP goal, initiate lifestyle modifications
BP-lowering medication based on algorithm
• Angiotensin receptor blocker (ARB)

General Population • Thiazide diuretic

(no diabetes or CKD) Diabetes or CKD present
• Calcium channel blocker (CCB)
Strategy Description
Age ≥ 60 years Age < 60 years All Ages Diabetes All Ages and Races
present No CKD CKD present with or A Start one drug, titrate to maximum
without diabetes dose, and then add a second drug.
BP Goal BP Goal
< 150/90 < 140/90
BP Goal BP Goal B Startbefore
drug one drug, thenmax
achieving adddose
a second
of

< 140/90 < 140/90

first
separate pills or combination pill.
Initiate ACEI or ARB,
Nonblack Black alone or combo C Begin 2 drugs at same time, as
w/another class
Initiate thiazide, ACEI, ARB, Initiate thiazide or CCB, Initial combination therapy is recommended
or CCB, alone or in combo alone or combo if BP is greater than
20/10mm Hg above
Lifestyle goal
changes:
At blood pressure goal? Yes •• Smoking
Control Cessation
blood glucose and lipids
No • Diet
Reinforce lifestyle and adherence
Eat healthy (i.e., DASH diet)
Titrate medications to maximum doses or consider adding another medication (ACEI, ARB, CCB, Thiazide)
Moderate alcohol consumption
At blood pressure goal? Yes
Reduce sodium intake to no
No more than 2,400 mg/day
Reinforce lifestyle and adherence
• Physical activity
Add a medication class not alreadyabove
selected (i.e. beta blocker,
medications to maxaldosterone
(see backantagonist,
of card) others) and titrate
Moderate-to-vigorous

At blood pressure goal? Yes activity

x and monitoring
No Continue t 3-4 days a week averaging
Reinforce lifestyle and adherence : James PA, Ortiz E, et al. 2014
40evidence-based guideline for the management
of high blood pressure in adults: (JNC8). JAMA. 2014 Feb 5;311(5):507-20
Titrate meds to maximum doses, add another med and/or refer to hypertension specialist
min per
loped by Cole Glenn, Pharm.D. session.
& James L Taylor, Pharm.D.
 Compelling Indications
Indication Treatment Choice Hypertension Treatment
Heart Failure ACEI/ARB + BB + diuretic + spironolactone
Post –MI/Clinical CAD ACEI/ARB AND BB
Beta-1 Selective Beta-blockers – possibly safer in patients
CAD ACEI, BB, diuretic, CCB
with COPD, asthma, diabetes, and peripheral vascular
disease:
Diabetes ACEI/ARB, CCB, diuretic
CKD ACEI/ARB •• metoprolol
bisoprolol
Recurrent stroke prevention ACEI, diuretic • betaxolol
Pregnancy labetolol (first line), nifedipine, methyldopa
• acebutolol
Drug Class Agents of Choice Comments
Diuretics HCTZ 12.5-50mg, chlorthalidone 12.5-25mg, indapamide 1.25-2.5mg Monitor for hypokalemia
triamterene 100mg Most SE are metabolic in nature
K+ sparing – spironolactone 25-50mg, amiloride 5-10mg, triamterene Most effective when combined w/ ACEI
100mg Stronger clinical evidence w/chlorthalidone

Spironolactone - gynecomastia and hyperkalemia

furosemide 20-80mg twice daily, torsemide 10-40mg Loop diuretics may be needed when GFR <40mL/min

ACEI/ARB ACEI: lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril 5- SE: Cough (ACEI only), angioedema
(more with ACEI),
10mg, trandolapril 2-8mg hyperkalemia

ARB: candesartan 8-32mg, valsartan 80-320mg, losartan 50-100mg, Losartan lowers uric acid levels; candesartan may

olmesartan 20-40mg, telmisartan 20-80mg prevent migraine headaches

Beta-Blockers metoprolol succinate 50-100mg and tartrate 50-100mg twice daily, Not first line agents – reserve for
post-MI/CHF
nebivolol 5-10mg, propranolol 40-120mg twice daily, carvedilol 6.25-25mg Cause fatigue and decreased heart rate

twice daily, bisoprolol 5-10mg, labetalol 100-300mg twice daily, Adversely affect glucose; mask hypoglycemic awareness

Calcium channel Dihydropyridines: amlodipine 5-10mg, nifedipine ER 30-90mg, Cause edema; dihydropyridines may be safely combined
blockers Non-dihydropyridines: diltiazem ER 180-360 mg, verapamil 80-120mg 3 w/ B-blocker
times daily or ER 240-480mg Non-dihydropyridines reduce heart rate and proteinuria
Vasodilators hydralazine 25-100mg twice daily, minoxidil 5-10mg Hydralazine and minoxidil may cause reflex tachycardia
and fluid retention – usually require diuretic + B-blocker
NHLBI (2003). Joint National Committee 7 (JNC 7) Expre
 Hypertension complication
Eyes Brain
retinopathy stroke Target Organ damage!!

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
Peripheral arterial
presure
disease
Sindroma Nefrotik

 Sindrom yang terdiri dari kumpulan tanda dan gejala berupa:

1. Proteinuria massif >3,5g/24 jam
2. Hiperlipdemia
3. Edema anasarka
4. Hipoalbuminemia <3,5 g/dl
etiologi

 Primer
Glomerulonefrosis

 Sekunder
Nefropati diabetic
SLE, RA
Infeksi
Obat-obatan
Keganasan
Patofisiologi

 Proteinuria : membrane basal dan sel podosit rusak

 Hipoalbuminemia : hilangnya albumin melalu urin
 Edema : rendahnya albumin dan defek sekresi Na
 Hiperlipidemia : peningkatan sintesis LDL,VLDL,Lp(a),
Defek pada lipoprotein lipase perifer, hilangnya HDL
melalui urin
Diagnosis

Manifestasi klinis:

Lemas, urin berbusa, nafsu makan menurun

Hipertensi
Muehrcke’s band
Edema anasarka
Urinalisis : oval fat body
Pemeriksaan penunjang

 Lab
Darah perifer lengkap, hipoalbuminemia, fungsi hati, profil lipid,
elektrolit,
Urinalisisproteinuria, albuminuria, hematuria, sedimen urin.

 Biopsi ginjal
tatalaksana

 Non farmakologis
Diet rendah garam, rendah lemak jenuh, rendah kolesterol
Restriksi cairan
Hindari obat nefrotoxic
farmakologi


Medical
 Diuretics
 ACE-inhibitors/ARBs
 Corticosteroids/immunosuppression
 Dialysis
 Anticoagulation

Surgical
 Renal transplant