HIPERTENSI

&
KESEHATAN
JANTUNG

RSHS
UPF Prev-Rehabilitasi Medik
 Definisi
Hiper : Berlebihan
Tensi : Tekanan/Tegangan

Hipertensi :
Gangguan sistem peredaran darah yang
menyebabkan kenaikan tekanan darah
diatas nilai normal.
 Tekanan Darah

Terdiri dari 2 komponen :

1. Tekanan Sistolik : Tekanan tertinggi saat jantung
memompa (menguncup)
2. Tekanan Diastolik : Tekanan terendah saat jantung
istirahat (mengembang)
Mis : 120/80 ~ 120 : Sistolik
80 : Diastolik
1 Milyar penduduk dunia 
Silent killer !!
 Kapan disebut Hipertensi ?
 Bila tekanan darah > 140/90 mmHg
dari 3 kali pemeriksaan terpisah
(jarak 1 – 2 minggu)
 Diperiksa dalam keadaan
santai
 Bila tinggi sekali  tidak
perlu beberapa kali
Faktor Risiko Utama Penyakit Kardiovaskular
 Hipertensi
 Kegemukan
 Kurang aktivitas fisik
 Merokok
 Dislipidemia ( Kolestrol tinggi )
 Diet tinggi kandungan garam
 Kencing manis – DM
 Obat-obatan ( mis : steroid )
 Mikroalbuminuria
 Usia ( wanita > 55 thn & pria > 45 tahun )
 Riwayat keluarga : hipertensi , stroke
 Penyebab
 Hipertensi Primer
± 90%  Tidak diketahui penyebabnya
 Hipertensi Sekunder
± 10%  Berhubungan dengan:
 Kelainan Ginjal
 Kelainan Hormonal
 Kelainan Pembuluh Darah
 Dll.. : - Kehamilan
- Alat kontrasepsi
- Rokok
Klasifikasi Hipertensi

Klasifikasi T.D Sistolik Diastolik

Normal <120 dan <80

Prehipertensi 120-139 atau 80-89

Hipertensi ST. 1 140-159 atau 90-99

Hipertensi ST. 2 >=160 atau >=100

JNC VII 2003

 Gejala Hipertensi
 »  (-)
 Rasa berat/sakit bagian belakang kepala
 Sulit tidur
 Mudah tersinggung

Diagnosispasti:
Diagnosis pasti Mengukur
: Mengukurtekanan
tekanandarah
darah!!!
 Gejala lain
(+ Penyakit lain)

 Lemah  Mimisan
 Penglihatan kabur  Gelisah/perubahan
 Sakit dada mental
 Napas pendek  Kesadaran turun
 Mual/muntah  Kelumpuhan
 Berdebar
 Komplikasi
 Kerusakan berbagai organ tubuh
 Jantung
 LVH (serambi kiri jantung »)
 Angina - infark otot jantung
 Revaskularisasi koroner
 Gagal jantung
 Komplikasi
 Otak
 Stroke
 TIA
 Ginjal
 Penyakit ginjal kronis
 Pembuluh darah perifer
 Mata
 Retinopati
 Ginjal
Insufisiensi ginjal

Jantung Otak
Hipertrofi ventrikel kiri Hipertensi
Gagal jantung kronik
Infark miokard
Penyakit jantung
kongestif Stroke
Aritmia
Pembuluh darah
Arteriosklerosis
Penyakit pembuluh darah perifer
Penyakit jantung koroner
 Paradigma Perjalanan Penyakit Kardiovaskular

Disritmia
Infark miokard akut Disfungsi diastolik
PVD mati mendadak
plak tidak stabil
Disfungsi sistolik
ventrikel kiri Hipertrofi
ventrikel kiri
Penyakit jantung koroner
remodelling
STROKE Disfungsi endotel
aterosklerosis
Gagal jantung Hipertensi
kongestif Tekanan
glomerulus
Disfungsi endotel Gagal ginjal
Gagal jantung tahap akhir Disfungsi mesangial
Faktor risiko tahap akhir sitokin
Hipertensi
Dislipidemia Proteinuria
KEMATIAN sklerosis & fibrosis
Merokok
Diabetes , dll
 Penatalaksanaan

Perubahan gaya hidup

Gagal mencapai target tekanan darah

Medikamentosa : Obat

Tujuan : Mengurangi morbiditas dan mortalitas akibat penyakit

kardiovaskular dan ginjal
 Perubahan gaya hidup
1. Memperbaiki gaya hidup
 Pelihara agar berat badan dalam rentang normal
 BMI : 18,5 - 24,9
2. Pengaturan pola makan
 Perbanyak sayur & buah
 Makanan rendah lemak kurangi makanan
berkolesterol/kalori naik
3. Kurangi konsumsi garam
4. Olahraga
 Berolahraga teratur, minimal 30' perhari
 Mis : Jalan, renang, bersepeda
5. Hindari minuman beralkohol
6. Berhenti merokok
7. Hindari stress dan emosi
 Hubungan perubahan gaya hidup
dengan tekanan darah
Perubahan gaya hidup Jumlah rata-rata penurunan
tekanan darah

Penurunan berat badan 5–20 mmHg/10 kg BB

Perencanaan makan 8–14 mmHg

Diet rendah garam 2–8 mmHg

Aktivitas fisik 4–9 mmHg

Mengurangi konsumsi 2–4 mmHg

alkohol
Strategi Dasar Penurunan Tekanan Darah
Distribusi TD

Sesudah intervensi Sebelum intervensi

penurunan
TD

Penurunan TD Sistol Pengurangan mortalitas (%)

(mmHg) Stroke PJK Total

2 –6 –4 –3
3 –8 –5 –4
5 –14 –9 –7
 Keuntungan menurunkan
tekanan darah

Persentase pengurangan insidens

Stroke 35–40%

Infark miokard 20–25%

Gagal jantung 50%

PENGOBATAN DALAM RANGKA…..
•PENCEGAHAN PRIMER
•PENCEGAHAN SEKUNDER

MEMERLUKAN KOMBINASI OBAT

DALAM WAKTU LAMA…BERTAHUN-TAHUN

KARENA ITU OBAT-OBAT HARUS YG DAPAT

DITOLERANSI DAN TERJANGKAU
 Kapan minum obat ?
 Bila tekanan darah > 160/100 mmHg
 Terapi biasanya seumur hidup
 Konsultasikan dengan dokter mengenai
obat hipertensi anda !!!

Target tekanan darah < 140/90 mmHg

 Jangan lupa!!

 Kontrol tekanan darah secara teratur dan minum

obat secara teratur
 Tekanan darah hanya dapat diketahui dengan
mengukurnya dan bukan sekedar dengan keluhan
ataupun perasaan
K A S I H
T E R I M A

TH A N K YO U
...It is nice to be an important person but it is important to be a nice person...
 Algorithm for Treatment of
Hypertension
Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

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

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications
Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs
May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB)
or combination. ACEI, or ARB, or BB, or 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.
 Classification and Management of
BP for adults

Initial drug therapy

SBP* DBP* Lifestyle
BP classification Without compelling indication With compelling
mmHg mmHg modification
indications
Normal <120 and <80 Encourage

Prehypertension 120–139 or 80–89 Yes No antihypertensive drug Drug(s) for compelling

indicated. indications. ‡

Stage 1 140–159 or 90–99 Yes Thiazide-type diuretics for most. Drug(s) for the compelling
Hypertension May consider ACEI, ARB, BB, indications.‡
CCB, or combination.
Other antihypertensive
Stage 2 >160 or >100 Yes Two-drug combination for most† drugs (diuretics, ACEI,
Hypertension (usually thiazide-type diuretic and ARB, BB, CCB) as
ACEI or ARB or BB or CCB). needed.

*Treatment determined by highest BP category.

†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
 Definition

HYPERTENSIVE CRISIS
is determined :
- by the rate of BP-rise, rather than actual BP,
- by vascular and organ status.
Form : HYPERTENSIVE EMERGENCY
( Life threatening, uncontrolled hypertension
with acute end-organ damage )
HYPERTENSIVE URGENCY
( Severe but not live threatening )
DEFINITION :
HYPERTENSIVE CRISIS
A severe elevation in BP, generally a SBP > 220 mm Hg and / or
DBP > 120 mm Hg. (JNC-VII, 2004)

1. HYPERTENSIVE EMERGENCIES
Severe elevation in BP complicated by acute target organ
dysfunction, such as coronary ischemia, stroke, intracerebral
hemorrhage, pulmonary edema, or acute renal failure.

2. HYPERTENSIVE URGENCIES
Severe elevations in BP without evidence of target organ
deterioration. Colhum DA. Oparil S, New Engl. J. Med, 323 : 1177, 1990
Risk factor :
Characteristics that related to Increasing
Risk Become Sick / Illness

Cardiovascular Risk Factor :

Characteristics that related to increasing
Risk become Cardiovascular Disease/
Abnormality
 RISK FACTORS OF CORONARY
HEART DISEASE
The Framingham Heart Study, 1948 : the
prevalence of CHD is associated with the
following modifiable or immutable risk factors :
- Advanced aged - Tobacco use
- Male gender - Hypertension
- Family history of CHD - Diabetes mellitus
- Hypercholesterolemia - Sedentary lifestyel
- Low levels of HDL cholesterol
 ATHEROGENESIS

Risk Factors
Fatty streak
Smoking

Hypertension

Hyperlipidemia

Others (diabetes, coagulation

abnormalities,
hemocysteinemia,etc)
 Risk Factors for Atherothrombosis
Hypercoagulable states Life-style (e.g, smoking,
Hyperlipidemia
diet, lack of exercise)

Homocysteinemia Hypertension
Gender
Diabetes

Obesity Infection?

Genetics Age
Atherotrombotic Manifestations
(MI, Ischemic stroke, Vascular death
American Heart Association, Heart and Stroke facts: 1997 Statistical supplement;
Wolf Stroke 1990;21 (SUPPL 2):II-4II-6;Laurila et al. arterioscle TrombVasc bio 1997;17:2910-2913;Grau et
al. Stroke 1997;26;1724-1729; Graham et al JAMA 1997;277: 1775-1781;Brigden Postgrad Med;101(5);249-
262
MAJOR RISK FACTORS FOR CHD
The NCEP Adult (treatment panel identifies Positive Risk Factors (RF)
for CHD

Risk Factors
• Family history of early CHD
parent or sibling <55 years of age if male, <65 years of age if female
• Age :
male >45 years
Female >55 years or premature menopause without estrogen replacement
therapy (ERT)
• Hypertensive (BP > 140/90 mmHg or taking antihypertensive medication)
• Curent smoker
• Type 2 diabetes
• Low HDL-cholesterol (<35 mg/dl)
• Negative Risk factor
• If HDL-C is >60 mg/dl substract one risk factor
 Non traditional Risk factors

Alcohol (moderate consumsumption)

Alcohol raises HDL, stimulates fibrinolysis, reduces fibrinogen levels,
and inhibits aggregation of platelets

Antioxidants
Studies have generally shown reduced CHD risk in individuals
consuming foods high in antioxidant vitamins;

Fibrinogen
Factors associated with elevated fibrinogen include cigarette smoking,
sedentary lifestyle, and high triglyceride levels. Fibric acid
derivatives, estrogen administration, cigarette smoking cessation,
and aerobic reduce fibrinogen levels.
Homocysteine
Deficiencies in folate intake and reduced serum levels elevated
homocystein
Levels. Folate therapy shown to reduce homocysteine levels and improve
Endothelial function. Some hyperhomocysteinemic patients with other
enzyme abnormalities require pyridoxine or vitamin b12

Infectious agents
Local arterial infection (include Chlamydia pneumonia, Helicobacter
pylori, Cytomegalovirus and other herpes virus) cause coronary
atherosclerosis and postangioplasty restenosis.
Causative mechanism include endothelial injury, local inflammation,
smooth muscle proliferation with p53 inactivation, and autoimmunity
 Coronary Heart Disease Risk Factors
AHA scientific position

Non modifiable major risk factors :

Increasing age : About four out of five people who die of
CHD are 65 or older. At older age, women who has heart
attacks are more likely than men to die from them within
a few weeks.

Male sex (gender) : Men have greater risk of heart attack

than women, and they have attacks earlier in life. Even
after menopause when woman’s death rate from heart
diseases increass, it is not as great as men’s.
Heredity (including race)
African Americans have more severe
hypertension than Caucasians and a higher risk
of heart disease. Heart disease risk is also
higher among Mexican Americans, American
Indians, native Hawaiians and some Asian
Americans. Most people with a strong family
history of heart disease have one or more other
risk factors.
The Major risk factors that can be modified, treated
or controlled

 Tobacco smoke. Smoker’s risk of heart attack is >2 that

of nonsmokers. Cigarette smoking is the biggest risk
factor for sudden cardiac death. Smokers have 2 – 4
times the risk of non smokers. Cigarette smoking also
acts with other risk factors to greatly increase the risk for
CHD.

 High Blood Cholesterol. Elevated blood cholesterol

rises the risk of CHD. A cholesterol level is also affected
by age, sex, heredity, and diet.
High blood pressure. High blood pressure increases
heart’s workload, causing the heart to enlarge and
weaken. It also increases your risk of stroke, heart
attack, kidney failure and congestive heart failure.
Physical inactivity. An inactive lifestyle is a risk factor for
CHD. Regular, moderate-to-vigorous physical activity
helps prevent heart and blood vessel disease. Exercise
helps controlling blood cholesterol, diabetes, and
obesity, as well as help lowering the blood pressure
Obesity and overweight. Excess weight increases the
strain on the heart. It also raises blood pressure and
blood cholesterol and Triglyceride levels, and lowers
HDL levels.

Diabetes mellitus. Diabetes increases your risk of

developing cardiovascular disease. Even when glucose
levels are under control, diabetes greatly increases the
risk of heart disease and stroke. About two third of
people with diabetes die of some form of heart or blood
vessel disease.
 Other factors contribute to heart disease risk

Individual response to stress may be a contributing

factor. Some scientis have noted a relationship between
coronary heart disease risk and stress in a person’s life,
their health behaviours and socioeconomic status.
Sex hormones play a role in heart disease. Men have
more heart attacts than women do before women reach
the age of menopause. If menopause is caused by
surgery removing the uterus and ovaries, the risk of
heart attack rises sharply.
Hormones also affect blood cholesterol. Female
hormones tend to raise HDL cholesterol and
lower total blood cholesterol. Male hormones do
the opposite.
If you have had a natural or surgical menopause,
you may be considering estrogen replacement
therapy(ERT) or hormone replacement therapy
(HRT). ERT and HRT may increase your risk of
some diseases and heath conditions.
 The Cardiovascular Continuum:
Targeting Mechanisms and Mediators
Mild Severe
Endothelial Pathological
Target Organ
Tissue injury
Dysfunction remodeling Damage
(MI, stroke)

Vascular disease Target organ dysfunction

(HF, renal)
Vascular
ACEI
dysfunction -
ARB
Risk factors:
Angiotensin II
diabetes
hypertension

Adapted 2003 from Dzau V, Braunwald E. Am Heart J. 1991; Gibbons 1999.

 National Heart, Lung, and Blood Institute
National High Blood Pressure Education Program

U.S. Department of
The Seventh
Health and Human
Services Report of the
Joint National
Committee on
National Institutes
Prevention,
of Health
Detection,
Evaluation, and
Treatment of
National Heart, Lung,
and Blood Institute High Blood
Pressure (JNC 7)
 CVD Risk Factors
 Hypertension*
 Cigarette smoking
 Obesity* (BMI >30 kg/m2)
 Physical inactivity
 Dyslipidemia*
 Diabetes mellitus*
 Microalbuminuria or estimated GFR <60 ml/min
 Age (older than 55 for men, 65 for women)
 Family history of premature CVD
(men under age 55 or women under age 65)

*Components of the metabolic syndrome.

 Chain of events leading to endstage
heart disease
Myocardial
infarction
Coronary Arrhythmia & Sudden death
thrombosis loss of muscle

Myocardial Silent
ischaemia Angina Remodelling
Hibernation

Ventricular
CAD dilatation
Stroke

Atherosclerosis Congestive
LVH heart failure

Risk factors End stage

(CHOL, BP, DM, smoking) heart
platelets, fibrinogen disease