Hipertensi

Diagnosis, Pencegahan dan Terapi

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 Definisi Hipertensi (JNC VII)
 Klasifikasi tekanan darah pada seseorang berumur 18 dan
lebih

Systolic Diastolic
Category
(mm Hg) (mm Hg)
Normal <120 dan <80
Pre Hipertensi 120-139 atau 80-89
Hipertensi
Stage 1 140-159 atau 90-99
Stage 2 > 160 atau >100

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 Risiko Infark Miokard dan Stroke

15

10
5-year risk (%)

MI Stroke

0 100 200 300

Systolic blood pressure (mm Hg)

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Brown, M.J., Lancet 2000;355:653-4
 Cumulative Incidence of CHF : Normotensives and
Stage 1 and 2 Hypertensives

20
Stage 2+ hypertension

15
CHF
Stage 1+ hypertension
Cumulative
Incidence 10
(%)
5
Normal BP
0
5 10 15
Years From Baseline Exam

Lenfant C, Roccella EJ. J Hypertens Suppl. 1999;17:S3-S7.

Data from Levy D et al. JAMA. 1996;275:1557-1562.
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 Hipertensi
Berdasarkan penyebabnya dapat dibedakan :
• Primer (essential)
– tidak ada penyebab yang spesifik yang dapat
diidentifikasi
– 95% dari kasus hipertensi
• Sekunder
– diketahui penyebabnya
– 5% dari kasus hipertensi
– penyakit ginjal merupakan penyebab dari 90% kasus
hipertensi sekunder
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 Etiology Hypertension
( Secondary Hypertension )

 Renal disease :
 Renal arterial disease
 Renal parenchymal disease
 Renal tumors
 Arteritis (polyarteritis
nodosa, neurofibromatosis)
 Endocrine Disorders
 Cushing’s syndrome
 Acromegaly
 Primary aldosteronism
 Pheochromocytoma
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 Etiology Hypertension- cont
 Coarctation of the aorta
 Neurologic disorders
 Increased intra cranial pressure (tumor)
 Drug-induced hypertension
 Corticosteroids
 Amphetamines

 Oral contraceptives

 Psychogenic disorders

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 Komplikasi Hipertensi

Eyes Brain Kerusakan Target Organ!!

retinopathy stroke

Kerusakan yang disebabkan

Heart oleh hipertensi tergantung :
ischaemic heart disease
Kidneys left ventricular hypertrophy • Besarnya peningkatan
renal failure heart failure tekanan darah
• Lamanya kondisi tekanan
darah yang tidak
terdiagnosis dan tidak
Peripheral arterial disease
diobati

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 Symptoms

Headache
Dizziness
Fatigue
Pounding of the heart
Symptoms are not specific and no more frequent than
in patients with normotension.
Symptoms of complications : heart failure,
chest pain, claudication, vision
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 Evaluasi Klinik Hipertensi :
Tujuan :
1. Konfirmasi hipertensi dan tingkatnya
2. Menyingkirkan & menemukan hipertensi sekunder
3. Menentukan kerusakan organ target
4. Mencari faktor risiko kardiovaskuler dan kondisi
klinik lain

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 Riwayat Klinik :

Lama, tingkat TD sebelumnya & hasil terapi

Adanya PJK, gagal jantung, CVA, ginjal, perifer, DM, pirai,
dislipidemia, asma bronkhiale, & informasi obat.
Faktor risiko (diet lemak, Na & alkohol, rokok, DM, riwayat keluarga,
aktifitas fisik & BB)
Riwayat obat-obatan (kontrasepsi, NSAID, kokain, amfetamin)
Faktor pribadi, psikososial dan lingkungan.

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 Pemeriksaan Fisik :

Pemeriksaan fisik & TD yang teliti

TB, BB, & BMI
Sistim kardiovaskuler : ukuran jantung, gagal jantung,
arteri perifer (carotis, aorta, renal)
Paru (ronkhi & wheezing), bising abdomen.
Fundus optikus & sistim syaraf (mengetahui
kerusakan serebro-vaskuler).

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 Diagnosis of Hypertension

Hypertension is defined as:

- BP  140/90 mm Hg
- during 1-5 visits
- with an average of 2 readings per visit

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 Pemeriksaan lain-lain

Laboratorium :
 Urinalisis & mikroskopik urin
 Serum kalium, kreatinin, GDP & 2 jam, profil lemak & asam urat
 Pemeriksaan tambahan :
 Hormonal seperti pengukuran aktifitas renin plasma, aldosteron plasma
dan katekolamin urine atas indikasi khusus (hipertensi sekunder)
EKG & Foto polos dada
Ekhokardiografi (curiga kerusakan organ target /LVH / lainnya)
Ultrasonografi vaskuler (curiga penyakit arteri karotis, aorta atau
perifer lain)
Ultrasonografi renal (curiga penyakit ginjal)
Angiografi

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 Minimal BP Goal of Therapy
Recommendations (SBP/DBP mmHg)
Patient Type JNC VII
Uncomplicated HTN < 140/90
Hypertension with < 130/85
diabetes mellitus < 130/80*
Heart failure < 130/85
Hypertension with < 125/75
renal impairment†
*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.
†Proteinuria > 1 g/24h.

(Bakris GL, et al for the National Kidney Foundation Hypertension and Diabetes Executive
Committees Working Group. Am J Kidney Dis. 2000) (JNC VI. Arch Intern Med. 16 1997)
 Therapy of Hypertension
( non pharmacologic / lifestyle modification )
Modification Approximate SBP
reduction (range)
Weight reduction 5–20 mmHg/10 kg loss
Adopt DASH eating plan 8–14 mmHg
Dietary sodium reduction 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol 2–4 mmHg
consumption
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 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

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 Terapi Hipertensi
Terapi Farmakologis
 tujuan terapi antihipertensi
 Memperbaiki fx. 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

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 Drugs of Choice
Anti Hypertension

Diuretik
Beta-blocker
Antagonis kalsium
ACE-inhibitor
Angiotensin II receptor antagonis
(AIIRA)/ARB
Alpha1-blocker (sentral & perifer)

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 Diuretics

AT1 receptor
-blockers blockers

Calcium
1-blockers
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.
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 Classification and Management
of BP for adults
Initial drug therapy
SBP* DBP* Lifestyle
BP classification
mmHg mmHg modification Without compelling indication With compelling
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.

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

* 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. 22
 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. 23
 Compelling Indications for
Individual Drug Classes
Compelling Indication Initial Therapy Options
Heart failure THIAZ, BB, ACEI, ARB,
ALDO ANT
Postmyocardial BB, ACEI, ALDO ANT
infarction
High CAD risk THIAZ, BB, ACE, CCB
Clinical Trial Basis
ACC/AHA Heart Failure
Guideline, MERIT-HF,
COPERNICUS, CIBIS,
SOLVD, AIRE, TRACE,
ValHEFT, RALES
ACC/AHA Post-MI
Guideline, BHAT, SAVE,
Capricorn, EPHESUS
ALLHAT, HOPE,
ANBP2, LIFE,
CONVINCE
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 Compelling Indications for
Individual Drug Classes
Compelling Indication Initial Therapy Options Clinical Trial Basis

Diabetes THIAZ, BB, ACE, ARB, NKF-ADA Guideline,

CCB UKPDS, ALLHAT
Chronic kidney disease ACEI, ARB NKF Guideline,
Captopril Trial,
RENAAL, IDNT, REIN,
AASK

Recurrent stroke prevention THIAZ, ACEI PROGRESS

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