TATALAKSANA HIPERTENSI

PADA ORANG DEWASA

 DEFINISI
Tekanan darah sistolik --> > 139 mmHg dan/ atau diastolik > 89
mmHg.

Berdasarkan rata-rata atau dua atau lebih properti yang diukur,

pembacaan tekanan darah saat duduk.

Pada setiap dua atau lebih kunjungan kantor

Peningkatan berkelanjutan kronis dari tekanan darah arteri sistemik

Rekomendasi Jnc 8
Pengelompokan Target Tekanan darah Target Tekanan darah
sistolik (mmHg) diastolik (mmHg)

> = 60 thn < 150 < 90

< 60 thn < 140 < 90
> 18 thn dengan ckd < 140 < 90
> 18 thn dengan diabetes < 140 < 90

CKD = Chronic Kidney Disease

 KATEGORI TEKANAN DARAH
PADA ORANG DEWASA
JNC 8
Kategori tekanan darah Tekanan darah sistolik Tekanan darah diastolik
(mmHg) (mmHg)

Normal <120 mm Hg and/or <80 mm Hg

Pre hipertensi 120–139 mm Hg and/or 80- 89 mm Hg

Hypertensi

Stage 1 140–159 mm Hg and/or 90–99 mm Hg

Stage 2 ≥160 mm Hg and/or ≥100 mm Hg

PANDUAN KLINIS HIPERTENSI BERDASARKAN JNC 8

Kategori Sistolik(mmHg) Diastolik(mmHg) Terapi awal

Pre hipertensi Tidak ada terapi

DM < 140 <90 LSM + no anti hipertensi

CKD ** (<= 70) < 140 < 90 Sebelumnya kurang dari

130/80

Target <150 < 90 LSM+ ACE or ARB or

Diuretik + CCB

LSM: Life Style Modification

DETEKSI WHITE COAT HYPERTENSI ATAU HIPERTENSI TERSELUBUNG
PADA PASIEN YANG *TIDAK MENJALANI TERAPI OBAT

Office Blood Pressure: Office Blood pressure:

≥130/80 mm Hg but <160/100 mm Hg 120–129/<80 mm Hg
setelah 3 bulan percobaan modifikasi gaya setelah 3 bulan percobaan modifikasi gaya hidup
hidup dan suspek white coat hipertensi dan suspek hipertensi terselubung

Daytime Daytime
ABPM or ABPM or
HBPM HBPM
BP <130/80 mm BP ≥ 130/80
Hg mm Hg
Ye N Ye N
s o s o
White Coat Hypertension Masked Hypertension Elevated BP
Hypertension • Lanjutkan modifikasi Lanjutkan modifikasi gaya • Modifikasi gaya hidup
• Modifikasi gaya hidup gaya hidup dan mulai hidup dan mulai terapi obat • ABPM tahunan atau HBPM
• ABPM tahunan atau terapi obat antihipertensi(Class IIa) untuk mendeteksi Ht
HBPM untuk mendeteksi antihipertensi(Class terselubung atau
perkembangan(Class IIa) perkembangan (Class IIa)
IIa)
TES LABORATORIUM DASAR DAN
TAMBAHAN HIPERTENSI PRIMER

Pemeriksaan dasar Gula darah puasa*

Hitung darah lengkap
Profil lipid
Serum kreatinin dengan eGFR*
Serum sodium, potassium, kalsium*
Hormon stimulasi tiroid
Urinalisis
Electrokardiogram

Pemeriksaan Ekokardiogram
tambahan Asam urat
Rasio albumin dan kreatinin urin
 REKOMENDASI AMBANG BATAS TEKANAN DARAH DAN UNTUK PENGOBATAN
DAN TINDAK LANJUT

Normal BP BP <120/80 Elevated BP (BP 120–129/<80 Stage 1 Hypertension (BP 130–139/ Stage 2
mm Hg) mm Hg) 80-89 mm Hg) Hypertension
(BP ≥ 140/90 mm
Hg)
Promote Nonpharmacologi Clinical ASCVD
optimal c therapy or estimated 10-y CVD
lifestyle habits (Class I) risk
Ye ≥10%* N
Reassess in 1 y Reassess in 3–6
s o
Nonpharmacologic Nonpharmacologic therapy and Nonpharmacologic therapy and
(Class IIa) mo (Class I) BP-lowering medication BP-lowering medication
therapy (Class I)
(Class I) (Class I)
Pasien dengan DM atau CKD secara otomatis ditempatkan dalam
kategori risiko tinggi. Untuk inisiasi dari penghambat RAS atau terapi Reassess in 3– Reassess in 1
diuretik, kaji tes darah untuk elektrolit dan fungsi ginjal 2 sampai 4 6 mo (Class I) mo (Class I)
minggu setelah memulai terapi.
† Pertimbangkan memulai terapi farmakologis untuk hipertensi st 2
dengan 2 agen antihipertensi dari kelas yang berbeda. Penderita BP goal
hipertensi stadium 2 dan TD ≥160 / 100 mm Hg harus segera diobati, met
dipantau dengan hati-hati, dan patuh pada penyesuaian dosis obat yang Ye N
diperlukan untuk mengontrol TD. Penilaian ulang meliputi pengukuran s
Assess and optimize o
TD, deteksi hipotensi ortostatik pada pasien tertentu (misalnya, lebih tua Reassess in 3–6 mo
atau dengan gejala postural), identifikasi hipertensi white coat, adherence (Class I)
dokumentasi kepatuhan, pemantauan respons terhadap terapi, penguatan to therapy
pentingnya kepatuhan , pentingnya pengobatan, dan bantuan dengan
pengobatan untuk mencapai target BP.
Consider intensification
of therapy
AMBANG BATAS TEKANAN DARAH DAN TUJUAN TERAPI
FARMAKOLOGIS PADA PASIEN HIPERTENSI MENURUT
KONDISI KLINIS
Kondisi klinis Ambang tekanan darah Target tekanan
(mm Hg) darah (mm Hg)
Umum
CVD klinis atau risiko ASCVD 10 tahun ≥ 10% ≥130/80 <130/80
Tidak ada CVD klinis dan risiko ASCVD 10 tahun <10% ≥140/90 <130/80
Orang yang lebih tua (≥65 tahun; tidak dilembagakan, ≥130 (SBP) <130 (SBP)
rawat jalan, orang dewasa yang tinggal di komunitas)
Komorbiditas Khusus
Diabetes mellitus ≥130/80 <130/80
Penyakit ginjal kronis ≥130/80 <130/80
Penyakit ginjal kronis pasca transplantasi ginjal ≥130/80 <130/80
Gagal jantung ≥130/80 <130/80
Stable ischemic heart disease ≥130/80 <130/80
Pencegahan stroke sekunder ≥140/90 <130/80
Penyakit arteri perifer ≥130/80 <130/80
MANAGEMEN HIPERTENSI PADA
PENYAKIT JANTUNG ISKEMIK
Hypertension With SIHD

Reduce BP to <130/80 mm Hg with

GDMT beta blockers*, ACE inhibitor, or ARB†
(Class I) Penghambat beta GDMT untuk
BP goal not met mengontrol tekanan darah atau
menghilangkan angina termasuk
carvedilol, metoprolol tartrate,
Angina metoprolol succinate, nadolol,
pectoris bisoprolol, propranolol, dan timolol.

Yes N Hindari penghambat beta dengan

o aktivitas simpatomimetik intrinsik.
Add Add
dihydropyridine dihydropyridine CCBs, Beta blocker atenolol tidak boleh
CCBs thiazide-type digunakan karena kurang efektif
if diuretics, daripada plasebo dalam mengurangi
needed and/or MRAs
as needed kejadian kardiovaskular.
(Class † Jika diperlukan untuk pengendalian
I) (Class I)
BP.
MANAGEMEN HIPERTENSI PADA PASIEN DENGAN
INTRACEREBRAL HEMORAGIK AKUT

Acute (<6 h from symptom

onset) Spontaneous ICH

SBP 150–220 mm Hg SBP >220 mm Hg

SBP diturunkan ke Penurunan SBP dengan

<140 mm Hg infus IV terus menerus
(Kelas III) & pemantauan TD
Membahayakan ketat (Kelas IIa)
MANAGEMEN HIPERTENSI PADA
PENYAKIT CKD
Pengobatan hipertensi pada CKD

BP goal <130/80 mm Hg
(Class I)

Albuminuria
(≥ 300 mg/d or ≥300 mg/g
creatinine
Ye N
s o
ACE Usual “first line”
inhibitor medication choices
(Class IIa)

ACE inhibitor
intolerant
Ye N *CKD stadium 3 atau lebih tinggi
s o atau stadium 1 atau 2 dengan
ARB* ACE inhibitor* albuminuria ≥300 mg / d atau
(Class IIb) (Class IIa) ≥300 mg / g kreatinin.
 DIAGNOSIS DAN MANAGEMEN HIPERTENSI KRISIS
SBP >180 mm Hg and/or DBP >120 mm
Hg

* Gunakan obat pada Target organ damage new/

tabel antihipertensi progressive/worsening
intravena
Ye No
s
Hypertensiv Markedly
e elevated
emergency BP
Admit to Reinstitute/intensify oral
ICU antihypertensive drug therapy
(Class I) and arrange follow-up
Conditions
• Aortic dissection;
• Severe pre-eclampsia or
eclampsia;
• Pheochromocytoma crisis
Ye No
s Reduce BP by max 25% over 1st h†,
Reduce SBP to <140 mm Hg during 1st then to 160/100–110 mm Hg over next 2–6 h, then
h*and to <120 mm Hg in aortic to normal over next 24–48 h
dissection† (Class I)
OBAT ANTI
HIPERTENSI
ORAL
Class Drug Usual Dose, Daily Comments

Range (mg per Frequency

day)*
Primary Agents
Thiazide or thiazide- Chlorthalidone 12.5–25 1 • Chlorthalidone preferred based on prolonged half-life
type diuretics Hydrochlorothiazide 25–50 1 and proven trial reduction of CVD
Indapamide 1.25–2.5 1
• Monitor for hyponatremia and hypokalemia, uric acid
Metolazone 2.5–5 1
and calcium levels.
• Use with caution in patients with history of acute gout
unless patient is on uric acid-lowering therapy.
ACE Inhibitors Benazepril 10–40 1 or 2 • Do not use in combination with ARBs or direct renin
inhibitor
• Increased risk of hyperkalemia, especially in patients
with CKD or in those on K+ supplements or K+-
sparing drugs
• May cause acute renal failure in patients with severe
bilateral renal artery stenosis
• Do not use if history of angioedema with ACE
inhibitors.
• Avoid in pregnancy
 
 
ARBs Azilsartan 40–80 1 • Do not use in combination with ACE inhibitors or direct renin
Candesartan 8–32 1 inhibitor
Eprosartan 600–800 1 or 2
• Increased risk of hyperkalemia in CKD or in those on K+
Irbesartan 150–300 1
supplements or K+-sparing drugs
Losartan 50–100 1 or 2
Olmesartan 20–40 1 • May cause acute renal failure in patients with severe bilateral renal
Telmisartan 20–80 1 artery stenosis
Valsartan 80–320 1
• Do not use if history of angioedema with ARBs. Patients with a
history of angioedema with an ACEI can receive an ARB beginning
6 weeks after ACEI discontinued.
• Avoid in pregnancy

CCB— Amlodipine 2.5–10 1 • Avoid use in patients with HFrEF; amlodipine or felodipine may be
Felodipine 2.5–10 1 used if required
dihydropyridi
Isradipine 5–10 2
nes • Associated with dose-related pedal edema, which is more common in
Nicardipine SR 60–120 2
women than men
Nifedipine LA 30–90 1
Nisoldipine 17–34 1
CCB— Diltiazem ER 120–360 1 • Avoid routine use with beta blockers due to increased risk of
Verapamil IR 120-360 3 bradycardia and heart block
nondihydrop
 Class Drug Usual Dose, Daily Comments
Frequency
Range (mg
per day)*
Secondary Agents
Diuretics—loop Bumetanide 0.5–2 2 • Preferred diuretics in patients with symptomatic HF.
Furosemide 20–80 2 Preferred over thiazides in patients with moderate-to-
Torsemide 5–10 1 severe CKD (e.g., GFR <30 mL/min)
Diuretics— potassium sparing Amiloride 5–10 1 or 2 • Monotherapy agents minimally effective
Triamterene 50–100 1 or 2 antihypertensives
• Combination therapy of potassium sparing diuretic
with a thiazide can be considered in patients with
hypokalemia on thiazide monotherapy
• Avoid in patients with significant CKD (e.g., GFR
<45 mL/min)
Diuretics— aldosterone antagonists Eplerenone 50–100 1 or 2 • Preferred agents in primary aldosteronism and
resistant hypertension
• Spironolactone associated with greater risk of
gynecomastia and impotence compared to eplerenone
• Common add-on therapy in resistant hypertension
• Avoid use with K+ supplements, other K+-sparing
diuretics or significant renal dysfunction
• Eplerenone often requires twice daily dosing for
adequate BP lowering
 Beta blockers— cardioselective Atenolol 25–100 2 • Beta blockers are not recommended as first-line
Betaxolol 5–20 1 agents unless the patient has IHD or HF
Bisoprolol 2.5–10 1 • Preferred in patients with bronchospastic airway
Metoprolol tartrate 100–200 2 disease requiring a beta blocker

Metoprolol succinate 50–200 1 • Bisoprolol and metoprolol succinate preferred in

patients with HFrEF
• Avoid abrupt cessation

Beta blockers— cardioselective and Nebivolol 5–40 1 • Induces nitric oxide-induced vasodilation
vasodilatory
• Avoid abrupt cessation

Beta blockers— noncardioselective Nadolol 40–120 1 • Avoid in patients with reactive airways disease
Propranolol IR 80–160 2 • Avoid abrupt cessation
Propranolol LA 80–160 1

Beta blockers— intrinsic sympathomimetic Acebutolol 200–800 2 • Generally avoid, especially in patients with IHD or
activity Penbutolol 10–40 1 HF
Pindolol 10–60 2 • Avoid abrupt cessation
Table is continued in the next page
 Usual Dose, Daily
Class Drug Range (mg per Comments
Frequency
day)*
Secondary Agents (continued from previous page)
Beta blockers— Carvedilol 12.5–50 2 • Carvedilol preferred in patients with HFrEF
combined alpha- and Carvedilol phosphate 20–80 • Avoid abrupt cessation
beta-receptor 1
Labetalol 200–800 2
Do not use in combination with ACE inhibitors or ARBs
Direct renin inhibitor Aliskiren 150–300 1 • Aliskiren is very long acting
• Increased risk of hyperkalemia in CKD or in those on K+ supplements or K+
sparing drugs
• May cause acute renal failure in patients with severe bilateral renal
artery stenosis
• Avoid in pregnancy
Alpha-1 blockers Doxazosin 1–16 1 • Associated with orthostatic hypotension, especially in older adults
Prazosin 2-20 2 or 3 • May consider as second-line agent in patients with concomitant BPH
Terazosin 1–20 1 or 2

Central Alpha2- agonists Clonidine oral 0.1–0.8 2 • Generally reserved as last-line due to significant CNS adverse effects,
and other centrally acting Clonidine patch 0.1–0.3 1 weekly especially in older adults
drugs Methyldopa 250–1000 2 • Avoid abrupt discontinuation of clonidine, which may induce hypertensive
Guanfacine 0.5–2 1 crisis; clonidine must be tapered to avoid rebound hypertension

Direct vasodilators Hydralazine 100-200 2 or 3 • Associated with sodium and water retention and reflex tachycardia; use
Minoxidil 5–100 1 -3 with a diuretic and bet
a blocker
• Hydralazine associated with drug-induced lupus- like syndrome at higher
doses
• Minoxidil associated with hirsutism and requires a loop diuretic. Can
induce pericardial effusion
 OBAT ANTI HIPERTENSI
INTRAVENA PADA HIPERTENSI
EMERGENSI
 OBAT ANTIHIPERTENSI INTRAVENA PADA HIPERTENSI EMERGENSI
Agen Obat Rentang Dosis Biasa Comments
CCB- Nicardipine Initial 5 mg/h, Contraindicated in advanced aortic stenosis; no dose adjustment needed
dihydropyridines increasing every 5 min by 2.5 mg/h to maximum 15 for elderly.
mg/h.
Clevidipine Initial 1–2 mg/h, doubling every 90 s until BP Contraindicated in pts with soybean, soy product, egg, and egg product
approaches target, then increasing by < double allergy and in pts with defective lipid metabolism (e.g., pathological
every 5–10 min; maximum dose 32 mg/h; hyperlipidemia, lipoid nephrosis or acute pancreatitis). Use low-end dose
maximum duration 72 h. range for elderly pts.
Vasodilators- Sodium Initial 0.3–0.5 mcg/kg/min; increase in increments Intra-arterial BP monitoring recommended to prevent “overshoot”. Lower
nitric oxide nitroprusside of 0.5 mcg/kg/min to achieve BP target; maximum dosing adjustment required for elderly. Tachyphylaxis common with
dependent dose extended use.
10 mcg/kg/min; duration of treatment Cyanide toxicity with prolonged use can result in
as short as possible. For infusion rates irreversible neurologic changes and cardiac arrest.
≥4–10 mcg/kg/min or duration >30 min, thiosulfate
can be coadministered to prevent cyanide toxicity.
Nitroglycerin Initial 5 mcg/min; increase in incre- ments of 5 Use only in pts with acute coronary syndrome and/ or acute pulmonary
mcg/min every 3–5 min to a maximum of 20 edema. Do not use in volume- depleted pts.
mcg/min.
Vasodilators- Hydralazine Initial 10 mg via slow IV infusion (maximum initial BP begins to decrease within 10–30 min and the fall lasts 2–4 h.
direct dose 20 mg); repeat every 4–6 h as needed. Unpredictability of response and
prolonged duration of action do not make hydralazine
a desirable first-line agent for acute treatment in most pts.
Adrenergic blockers Esmolol Loading dose 500–1,000 mcg/ kg/min over 1 min Contraindicated in pts with concurrent beta-blocker therapy, bradycardia
beta1 receptor followed by a 50 mcg/kg/min infusion. For and/or decompensated HF Monitor for bradycardia.
selective antagonist additional dosing, the bolus dose is repeated and May worsen HF.
the infusion increased in 50 mcg/kg/min increments Higher doses may block beta2 receptors and impact lung function in
as needed to a maximum of 200 mcg/kg/ min. reactive airway disease.
 OBAT ANTIHIPERTENSI INTRAVENA PADA
HIPERTENSI EMERGENSI
Agen Obat Rentang Dosis Biasa Comments
Adrenergic Labetalol Initial 0.3–1.0 mg/kg dose (maximum 20 mg) slow Contraindicated in reactive airways disease or chronic obstructive
blockers- combined IV injection every 10 min or 0.4–1.0 mg/kg/h IV pulmonary disease. Especially useful in hyperadrenergic syndromes. May
alpha1 and infusion up to 3 mg/kg/h. Adjust rate up to total worsen HF and should not be given in pts with 2nd or 3rd degree heart
nonselective beta cumulative dose of 300 mg. This dose can be block or bradycardia.
receptor antagonist repeated every 4–6 h.

Adrenergic Phentolamine IV bolus dose 5 mg. Additional bolus doses every Used in hypertensive emergencies induced by catecholamine excess
blockers- non- 10 min as needed to lower BP to target. (pheochromocytoma, interactions between monamine oxidase
selective inhibitors and other drugs or food, cocaine toxicity, amphetamine
alpha receptor overdose or clonidine withdrawal).
antagonist

Dopamine1- Fenoldopam Initial 0.1–0.3 mcg/kg/min; may be increased in Contraindicated in pts at risk for increased intraocular pressure
receptor selective increments of 0.05–0.1 mcg/kg/min every 15 min (glaucoma) or intracranial pressure and those with sulfite allergy.
agonist until target BP is reached. Maximum infusion rate
1.6 mcg/kg/min.

Angiotensin Enalaprilat Initial 1.25 mg over a 5 min period. Doses can be Contraindicated in pregnancy and should not be used in acute MI or
converting enzyme increased up to 5 mg every 6 h as needed to bilateral renal artery stenosis. Mainly useful in hypertensive
inhibitor achieve BP target. emergencies associated with high plasma renin activity.
Dose not easily adjusted.
Relatively slow onset of action (15 min) and unpredictability of
BP response.
THANK YOU…