1

 Suatu keadaan dimana tekanan sistolik berada pada 140 mmHg atau
lebih dan tekanan diastolik berada pada 90 mmHg atau lebih (JNC
VII, 2003)

 Tekanan darah yang sama atau melebihi 140 mmHg sistolik dan atau
sama atau melebihi 90 mmHg diastolik pada seseorang yang tidak
sedang mengkonsumsi antihipertensi.

(Standar Pelayanan Medik, PAPDI, 2005)

 2

Tekanan darah sistolik ≥ 140 mmHg dan atau tekanan

darah diastolik ≥ 90 mmHg, pada pemeriksaan yang
berulang
(Pedoman Tatalaksana Hipertensi pada Penyakit Kardiovaskular, PERKI, 2015)
 3

 Prevalensi Hipertensi pada

 umur >75 tahun adalah 63.8%;
 umur 65-74 tahun adalah 57.6%;
 umur 55-64 tahun adalah 45.9%;
 umur 45-54 tahun adalah 35.6%;
 umur 35-44 tahun adalah 24.8%;
 umur 25-34 tahun adalah 14.7%; dan
 umur  15-24 tahun adalah 8.7% (Kemenkes, 2016)
Faktor Resiko 4

 Race (more common and more severe in blacks)

 Age > 60 years
 Sex (men and postmenopausal women)
 Family history of CVD
 Smoking
 High cholesterol diet
 Co-existing disorders such as DM, obesity, and
hyperlipidemia
 Sodium intake
 High intake of alcohol
 FAKTOR RESIKO 5

 JNC VII
Etiologi 6

 Essential (95%)
 Sekunder  5%-10% kasus
- Renal : renal artery stenosis ; parenchymal disease
- Endocrine : Hyperaldosteronism; hyperthyroidsm ; Cushing
syndr;Exogenous agent
- Vascular: Coarctation of aorta, Aortic insufficiency
- Toxemia of pregnancy
 CLASSIC UNDERSTANDING OF THE RENIN SYSTEM
7

Angiotensinogen

Renin
Ang I

ACE

Ang II Aldosterone
AT1 Receptor

Vasoconstriction
Na /H2O retention
+
Hypertension
Gibbons GH. 1998; Adapted from: Müller DN & Luft FC. 2006
8
9
TARGET KERUSAKAN 10

ORGAN
11
CLASSIFICATION 12
13
 14

Tanda vital ( Tensi, Nadi, RR, Suhu)

Cardiovascular

Thyroid, Paru, abdomen

Neurologic
 15

 Gula darah dan kolesterol

 Natrium dan Kalium

 Thyroid function tests

 Kidney function tests

 16

Source: The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.
 17

 Reduce cardiac output

 -adrenergic blockers
 Ca2+ Channel blockers
 Dilate resistance vessels
 Ca2+ Channel blockers
 Renin-angiotensin system blockers
  adrenoceptor blockers
1
 Reduce vascular volume
 Diuretics
 Direct vasodilators
ANTI HYPERTENSION 18

DRUGS
19
20
21
22
COMBINATION THERAPY 23
COMBINATION THERAPY 24
25
 26

JNC VIII
 27

American Society of Hypertension and the International Society of

 JNC 7: Classification and Management
of Blood Pressure for Adults 28

Initial Drug Therapy

DBP* Without With
BP SBP* (mm Lifestyle Compelling Compelling
Classification (mm Hg) Hg) Modification Indications Indications

Normal <120 and <80 Encourage

Drug(s) for
No antihypertensive compelling
Prehypertension 120–139 or 80–89 Yes
drug indicated. indications.
Thiazide-type diuretic
for most. May consider Drug(s) for
Stage 1 ACEI, ARB, BB, compelling
140–159 or 90–99 Yes
hypertension CCB, indications.
or combination.

Two-drug combination
Other
for most (usually antihypertensive
Stage 2 drugs (diuretic,
≥160 or ≥100 Yes thiazide-type diuretic
hypertension ACEI, ARB, BB,
and ACEI or ARB or
BB or CCB). CCB) as needed.
JNC 7. May 2003. NIH publication 03-5233.
(JNC VIII) 29
30
JNC VIII 31
 FOLLOW UP dan 32


MONITORING
Monitor tekanan darah
 Monitor serum kalium dan kreatinin
 Setelah target tek darah dicapai dan stabil, pasien dapat kembali tiap 3-6 bulan
 Risiko kardiovaskular lainnya harus diterapi
 Menyarankan pasien untuk berhenti merokok
 33

KONDISI OBAT YANG DIANJURKAN

 Kehamilan  Nifedipine, labetalol, hydralazine,

beta-blockers, methyldopa,
prazosin
 Coronary heart
disease  Beta-blockers, ACE inhibitors,
Calcium channel blockers

 Congestive heart  ACE inhibitors, diuretik

failure beta-blockers

1999 WHO-ISH guidelines

 34

Krisis Hipertensi
• HIPERTENSI GAWAT (EMERGENCY)
• HIPERTENSI DARURAT (URGENCY)
Hipertensi Emergensi 35
 Penatalaksanaan HT Emergensi 36

 TD harus turun dalam hitungan menit, ok ada ancaman

kerusakan target organ
 Obat parenteral (i.v):
- sodium nitroprussid
- nitrogliserin
- diltiazem HCl
- hidralazin
 Hypertensive Emergency
Drug Dose Onset Duration Adverse Effects 37
Special Indications
(min) (min)
Sodium 0.25–10 mcg/kg/min Immediate 1–2 Nausea, vomiting, muscle Most hypertensive
nitroprusside intravenous infusion twitching, sweating, emergencies; caution
(requires special thiocyanate and cyanide with high intracranial
delivery system) intoxication pressure, azotemia, or in
chronic kidney disease

Nicardipine 5–15 mg/h 5–10 15–30; Tachycardia, headache, Most hypertensive

hydrochloride intravenous may exceed flushing, local phlebitis emergencies except acute
240 heart failure; caution
with coronary ischemia

Clevidipine 1-2 mg/h intravenous 2-4 5-15 Headache, syncope, Most hypertensive
butyrate infusion; may double dyspnea, nausea, vomiting emergencies except
dose every 90 sec severe aortic stenosis;
initially; maximum: caution with heart failure
32 mg/h; typical
maintenance dose: 4
to 6 mg/h

Fenoldopam 0.1–0.3 mcg/kg/min <5 30 Tachycardia, headache, Most hypertensive

mesylate intravenous infusion nausea, flushing emergencies; caution
DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:A Pathophysiologic Approach, 7th Edition:
http://www.accesspharmacy.com/ with glaucoma
 Hypertensive Emergency
38
Drug Dose Onset Duration Adverse Effects Special
(min) (min) Indications
Nitroglycerin 5–100 mcg/min 2–5 5–10 Headache, vomiting, Coronary
intravenous infusion methemoglobinemia, ischemia
tolerance with prolonged use

Hydralazine 12–20 mg intravenous 10–20 60–240 Tachycardia, flushing, Eclampsia

hydrochloride 10–50 mg intramuscular 20–30 240–360 headache vomiting,
aggravation of angina

Labetalol 20–80 mg intravenous 5–10 180–360 Vomiting, scalp tingling, Most

hydrochloride bolus every 10 min; 0.5– bronchoconstriction, hypertensive
2.0 mg/min intravenous dizziness, nausea, heart block, emergencies
infusion orthostatic hypotension except acute heart
failure
Esmolol 250–500 mcg/kg/min 1–2 10–20 Hypotension, nausea, asthma, Aortic dissection;
hydrochloride intravenous bolus, then first-degree heart block, heart perioperative
50–100 mcg/kg/min failure
intravenous infusion;
may repeat bolus after 5
min or increase infusion
to 300 mcg/min
DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:A Pathophysiologic Approach, 7th Edition:
http://www.accesspharmacy.com/
Hipertensi Urgensi 39

Bersifat mendesak dengan TD Diastolik > 120 mmHg, tetapi

dengan minimal atau tanpa kerusakan organ sasaran dan tidak
dijumpai keadaan pada hipertensi emergensi.
 Hipertensi post operasi.
 Hipertensi tak terkontrol / tanpa diobati pada perioperatif.

 Penanganan
- dalam hitungan jam
- Obat HT diberikan secara per oral, sublingual
 Table 5 : Management of Hypertensive Urgencies
40
ONSET/DURATION OF
AGENT DOSE ACTION PRECAUTIONS
(AFTER
DISCONTINUATION)
Captopril 25 mg p.o., repeat as needed SL, 15-30 min/6-8 h SL, Hypotension, renal
25 mg 15-30 min/2-6 h failure in bilateral renal
artery stenosis
Clonidine 0.1-0.2 mg p.o., repeat hourly as 30-60 min/8-16 h Hypotension,
required to total dose of 0.6 mg drowsiness, dry mouth
Labetalol 200-400 mg p.o repeat every 2-3 h 30 min-2 h/2-12 h Bronchoconstriction,
heart block, orthostatic
hypotension
Amblodipi 2,5-5 mg 1-2 hr/12-18 hr Tachycardia,
n hypotension
Nifedipin 5 mg sl 5-20 min/2-6 hr Tachycardio,
hypotension
Adapted with permission from Vidt DG. Hypertensive crises: emergencies and urgencies. J Clin Hypertens (Greenwich).
2004;6:520-525

Sumber :
- Adaptec etc
- InaSH
- Hebert C.J Hypertensive Crises Prim Care 2008. 35 (3)
 41
 Memperbaiki atau melindungi organ target.

 Obat yang bekerja cepat dengan pilihan tergantung kerusakan organ

target.

 Diturunkan secepat dan seoptimal mungkin tanpa mengganggu perfusi

organ target (tidak perlu sampai normal).

 Penurunan tekanan darah sekiar 20-30% dalam 1 jam untuk untuk

hipertensi gawat darurat, 24 jam hipertensi gawat.
 DAFTAR PUSTAKA 42

 James PA, Oparil S, Carter BL, et al. (2013). 2014 Evidence-Based Guideline for the Management
of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint
National Committee (JNC 8). JAMA. doi:10.1001/jama.2013.284427.pp: E2-E15.
 Kasper, Braunwald, Fauci, et al. Harrison’s principles of internal medicine 17 th edition. New York:
McGrawHill:2008
 Masuyer G, S. S. (2012). Molecular recognition and regulation of human angiotensin-I converting
enzyme (ACE) activity by natural inhibitory peptides. Europe PubMed Central, 2:717.
 Patofisiologi buku
 National Institute of Health. (2003). The seventh report of the JointNational Commitee on:
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH Publication. Pp:3-
20.
 Jnc VII
 Weber, MA, Schiffrin, EL, White, WB, et al. (2011). Clinical Practice Guidelines for the
Management of Hypertension in the Community: A Statement by the American Society of
Hypertension and the International Society of Hypertension. The journal of Clinical Hypertension.
Pp: 1-6
 Riskesdas 2007, Riskesdas 2013, Balitbangkes, Kemenkes