ANATOMI JANTUNG

.
.
.
.
.
 .

.
P WAVE : RIGHT AND LEFT ATRIAL DEPOLARISATION
ATRIAL DEPOLARISATION WAS COMPLETED
DELAYED IN AV NODE FOR SECURITY
VENTRICLE DEPOLARISATION
VENTRICLE REPOLARISATION
 SISTEM KONDUKSI
AV NODE : PINTU PENGHUBUNG ATRIAL &
VENTRIKEL [ 0,12 – 0,22 DT ]
< 0,12 DT : PRE – EKSITASI
> 0,22 DT : AV BLOK DERAJAD I

HIS BUNDLE : JALAN RANGSANG INTRAVENTRIKEL

[ < 0,12 DT ]
0,12 DT ATAU LEBIH : BBB KANAN ATAU
KIRI
 .
• .
 .

P : ATRIAL DEPOLARISATION

QRS : VENTRICLE DEPOLARISATION

ST : VENTRICLE REPOLARISATION
T : VENTRICLE REPOLARISATION

U : LATE REPOLARISATION
 NOMENKLATUR

GELOMBANG P, T, SEGMEN PR & ST DITULIS

DENGAN HURUF BESAR

GELOMBANG R : < 5 [ KOTAK KECIL ] HURUF : r

S : < 5 DITULIS : s
Q : LEBAR 0,04 DT ATAU LEBIH
DALAM 1/3 R
TERDAPATNYA PADA r
 .
• .
 SADAPAN [ LEAD ]

EXTREMITAS: TANGAN KANAN – TANGAN KIRI [LEAD I]

TANGAN KANAN – KAKI KIRI [LEAD II]
TANGAN KIRI – KAKI KIRI [LEAD III]

TANGAN KIRI – JANTUNG [LEAD aVL]

TANGAN KANAN – JANTUNG [LEAD aVR]
KAKI KIRI - JANTUNG [LEAD aVF]

PRECORDIAL : V1 V2 V3 V4 V5 V6
 .
• .
 .
• .
 HASIL REKAMAN EKG

ADA 12 PANDANGAN :
6 LEAD EKSTREMITAS : I II III aVR aVL aVF
6 LEAD PRE-KORDIAL : V1 V2 V3 V4 V5 V6

EKSTREMITAS LEAD:
PROYEKSI BIDANG FRONTAL

PRE-KORDIAL LEAD :
PROYEKSI BIDANG HORISONTAL
 .
• .
 .
• .
.
 URUTAN BACA EKG
• IRAMA JANTUNG
• FREKUENSI JANTUNG
• POSISI ARAH RANGSANG VENTRIKEL
• AKSIS ARAH RANGSANG VENTRIKEL
• ZONA TRANSISI
• INTERVAL: PR
QRS
QT
 .

IRAMA JANTUNG
 .

SA NODE : IRAMA SINUS

AV NODE : IRAMA JUNCTIONAL

ATRIAL : IRAMA ATRIAL

VENTRIKULER : IRAMA VENTRIKULER

VENTRICLE REPOLARISATION
 IRAMA SUPRA-VENTRIKULER
• .
 IRAMA SINUS
DI LEAD II GELOMBANG P UPRIGHT
GELOMBANG QRS NORMAL ATAU MELEBAR [ BBB ]

FREKUENSI : > 60 < 100/MENIT

ARITMIA SINUS: BRADIKARDI, TAKHIKARDI,

SINUS ARITMIA, SA ARREST
.
 .

.
.
.
 .

.
 IRAMA JUNCTIONAL

• JUNCTIONAL ATAS:
P DIDEPAN QRS & INVERTED DI LEAD II

FREKUENSI : 50 - 60/MENIT

PADA LEBIH DARI 60/MNT: ACCELERATED JR

PADA LEBIH DARI 100/MNT: TAKHIKARDI J
.
.
 JUNCTIONAL TENGAH
P TIDAK TERLIHAT DI SEMUA LEAD

FREKUENSI : 50 – 60/MENIT

> 60 < 100: ACCELERATED JTR

>100/MENIT: TAKHIKARDI JT
IRAMA JUNCTIONAL BAWAH
P INVERTED & DIBELAKANG QRS DI LEAD II

FREKUENSI : 50 - 60/MENIT

 60 < 100 : ACCELERATED JBR

>100/MNT : TAKHIKARDI JB
 .

.
 IRAMA ATRIAL
NORMAL TIDAK TERDETEKSI DENGAN EKG

ATRIAL TAKHIKARDI : FREKUENSI > 150/MENIT

ATRIAL FLUTTER : P BENTUK GERGAJI

ATRIAL FIBRILLASI : COARSE & FINE

• RESPONSE VENTRIKEL: RAPID, NORMAL DAN

SLOW
 .

.
 .

.
 .

.
 .

.
 IRAMA VENTRIKULER
QRS LEBAR TANPA GELOMBANG P DIDEPANNYA

FREKUENSI : 30 s/d 40 / MENIT

ACCELERATED V RHYTHM : > 40 s/d <100 / MENIT

TACHYCARDI VENTRICULAR: 100 / MENIT / LEBIH

VENTRICULAR FLUTTER : > 250/MENIT

VENTRICULAR FIBRILLASI : TUMPUL

 IRAMA VENTRIKULER
• .
 .

.
 .
• .
 .

.
 OVER DRIVE
PENGAMBIL ALIHAN RITME SECARA SEMENTARA

PREMATURE BEAT : ATRIAL, ATRIAL DENGAN

ABBERANT CUNDUCTION, VENTRIKEL

RUN OF: ATRIAL TAKHIKARDI, ATRIAL DENGAN

ABBERANT CONDUCTION TAKHIKARDI, VENTRIKEL
TAKHIKARDI

BIASANYA TEMPORER KECUALI ATRIAL FLUTTER &

FIBRILLASI BISA TEMPORER ATAU PERMANEN
 .

.
 .

.
 .

.
.
 LATIHAN TENTUKAN IRAMA
IRAMA SINUS : TANDANYA ?
FREKUENSINYA ?

IRAMA JUNCTIONAL : ADA BERAPA TIPE ?

TANDA MASING 2 ?
BEDA DNG SINUS ?

IRAMA ATRIAL :

IRAMA VENTRIKULER : BEDA DNG SUPRA ?

 HEART RATE
RUMUS UMUM : 300 / R – R

ATRIAL FLUTTER DAN ATRIAL FIBRILLASI:

300 / [R1 – R11] / 10 RATE VENTRIKEL

TOTAL AV BLOCK : 300 / R – R RATE VENTRIKEL

300 / P – P RATE ATRIUM
 .

..
 .
• .
 .

.
 LATIHAN RATE
RUMUS NORMAL BAGAIMANA ?

BAGAIMANA PADA ATRIAL FLUTTER ?

BAGAIMANA PADA ATRIAL FIBRILLASI ?

BAGAIMANA PADA AV BLOK TOTAL ?

 .

POSISI & AXIS

 .

• .
 VENTRIKEL BIDANG FRONTAL
DILIHAT GELOMBANG KOMPLEKS QRS
POSITIP : R > Q + S
NOL :R=Q+S
NEGATIP : R < Q + S

CARI YANG NOL, AXIS PASTI TEGAK LURUS PADANYA

LIHAT aVL & aVF + I [VERTIKAL] OR + II [HORISONTAL]

 POSISI & AKSIS QRS
aVL + aVF + INTERMEDIATE 30*
aVL ++ aVF + INTERMEDIATE 20*
aVL + aVF ++ INTERMEDIATE 40*

aVL 0 aVF + SEMI VERTICAL 60*

aVL + aVF 0 SEMI HORIZONTAL 0*

aVL – aVF + LEAD I 0 AXIS 90*

+ AXIS 80*
– AXIS 100* [ LPHB ]
aVL + aVF – LEAD II 0 AXIS – 30*
+ AXIS – 20*
– AXIS – 40* [ LAHB ]
 .

ZONA TRANSITION
 .
• .
 .

NORMAL : V3 – V4

COUNTER CLOCK WISE ROTATION :

V1 – V2 V2 V2 – V3 V3

CLOCK WISE ROTATION :

V4 V4 – V5 V5 V5 – V6
 .

INTERVAL P QRST
 .
• .
 .

• PR : 0,12 – 0, 22 SECOD
SHORT : PRE-EKSITASI
PROLONG : AV BLOK GRADE I

• QRS : < 0,12 SECOND

0,12 OR MORE : HIS BUNDLE BLOCK

• QT : < 0,40
0,40 OR MORE : LONG QT SINDROM
.
 PEKERJAAN RUMAH
TENTUKAN:

1. IRAMA & FREKUENSI

2. POSISI & AKSIS

3. TRANSISI ZONE

4. INTERVAL : PR QRS QT
 KEMAMPUAN EKG
ARITMIA : SINUS ATRIAL JUNCTIONAL
VENTRIKULER

GANGGUAN KONDUKSI :
PRE – EKSITATION : WPW & LGL
AV NODE
HIS BUNDLE

HIPERTROFI ATRIUM & VENTRIKEL

PENYAKIT JANTUNG KORONER

 PACEMAKER
.

KONDUKSI

. JANTUNG
 .
• .
PACEMAKER .

SA NODE

AV NODE

ATRIAL

VENTRIKEL
KONDUKSI
.
 .
• .
 GANGGUAN KONDUKSI
PRE – EKSITASI : SINDROMA WPW & LGL

AV NODE :
GRADE I
GRADE II WENCKEBACH [ MOBITZ I ]
MOBITZ TYPE II
High Degrea AV Block
GRADE III [ TOTAL ]
HIS BUNDLE : RBBB LBBB
LAHB LPHB
 PRE-EKSITATION
WOLFF PARKINSON WHITE SYNDROME:
SHORT PR
DELTA WAVE
T INVERTION

LOWN GANONG LEVINE SYNDROME:

SHORT PR
NORMAL QRS
T UP-RIGHT
 BLOK PADA KONDUKSI AV
AV BLOK DERAJAD I :
P SELALU DIIKUTI QRS ST & T
INTERVAL PR > 0,22 DETIK

AV BLOK DERAJAD II :
MOBITZ TIPE I INTERVAL PR PROGRESIF
MOBITZ TIPE II INTERVAL PR SAMA
ADA DROB BEAT PADA MOBITZ I & II

AV BLOK DERAJAD III :

P DENGAN PACEMAKER SINUS
QRS DENGAN PACEMAKER JUNCTIONAL
ATAU VENTRIKULER
 .

.
 BLOK PADA SERABUT HIS

RBBB KOMPLET : rSR’ DI V1

WIDE S DI LEAD I

LBBB KOMPLET : RR’ DI LEAD I, V5 ATAU V6

RBBB & LBBB INKOMPLET KOMPLEKS QRS

NORMAL

LAHB : AKSIS – 40 LPHB : AKSIS + 100

 LATIHAN
PACEMAKER NORMAL SINUS
NORMAL JUNCTIONAL A/T/B
NORMAL VENTRIKULER
ARITMIA SINUS, ATRIAL
JUNCTIONAL & VENTRIKULER

GANGGUAN KONDUKSI :
PRE – EKSITASI
BLOK AV NODE
BLOK SEABUT HIS
 .

OTOT JANTUNG

ATRIAL
VENTRIKEL
 OTOT [MIOKARD] ATRIAL .

PEMBESARAN :
ATRIUM KANAN
ATRIUM KIRI
.
 VENTRIKEL
PEMBESARAN :
VENTRIKEL KANAN
VENTRIKEL KIRI
.
 PENYAKIT JANTUNG KORONER
• ISKEMIA : DEPRESI ST & INVERSI T
• INJURI : ELEVASI ST
• INFARK : Q PATHOLOGIS

• HARUS DITENTUKAN FASENYA: HIPER AKUT, AKUT

RECENT DAN OLD

• HARUS DITENTUKAN LOKASI :

INFERIOR
ANTERIOR : SEPTAL, APIKAL, LATERAL
POSTERIOR
.
.
 .

.
.
 .

.
 HYPO & HYPER - KALEMIA

HYPOKALEMIA :
U WAVE PROMINENT

HYPERKALEMIA
SYMITRICAL TALL T WAVE
 .

LAPORAN EKG
RITME / IRAMA : SINUS, JUNCTIONAL, ATRIAL OR
VENTRIKULER
.

FREKUENSI : SVT ST NSR SB

POSITION & AXIS QRS : LAHB NORMAL LPHB

ZONA TRANSISI : CCWR NORMAL OR CWR

INTERVAL PR : AV BLOCK GRADE I, LGL / WPW

QRS : BUNDLE BRANCH BLOCK
QT : LONG QT SYNDROME

TANDA PEMBESARAN RUANG, ADANYA GELOMBANG FIBRILLASI,

FLUTTER, EKSTRA SISTOLE, RUN OF, DROB BEAT, ST ELEVASI
ATAU DEPRESI, Q PATHOLOGIS, U PROMINEN, T TENDA

KESIMPULAN :
 .

HUBUNGAN ANTARA ATRIUM &

VENTRIKEL
1. ATRIAL & VENTRIKEL SATU PACEMAKER
FREKUENSI ATRIUM & VENTRIKEL SAMA
.

2. ATRIAL IN FLUTTER ATAU FIBRILLASI

PACEMAKER ATRIUM & VENTRIKEL SAMA NAMUN FREKUENSINYA
BERBEDA

3. PRE EKSITASI SATU PACEMAKER ADA 2 JALAN

HIS DAN ASESORIS [KENT]

4. AV BLOK DERAJAD I, SATU PACEMAKER DENGAN

INTERVAL PR PANJANG
5. AV BLOK DERAJAD II SATU PACEMAKER DENGAN
ADANYA DROB BEAT
6. AV BLOCK TOTAL: PACEMAKER ATRIUM DI SA NODE, VENTRIKEL DI
JUNCTIONAL / VENTRIKULER
 .

..
 .
• .
.
.
.
 .

.
 .

NADI TAK ADA INTERMITEN

 .

.
 .

.
Ekstra sistole junctional atas.
 GAMBARAN EKG MIRIP
RITME SINUS & RITME JUNCTIONAL ATAS

BUNDLE BRANCH BLOCK & RITME VENTRIKULER

ISKEMIA ANTERO – LATERAL & LVH

ATRIAL FIBRILLASI FINE & JUNCTIONAL TENGAH

AV BLOCK GRADE II & III

SINDROMA LGL & RITME JUNCTIONAL ATAS

.
 .
• .
 .
• .
 .

.
APA YANG HARUS DICARI
ADANYA OVER-DRIVE DI SEMUA LEAD : I S/D V6

TANDA RVH [ V1, V3R ] RBBB [ I, V1 ]

LVH [V1, V5-6 ] LBBB [ I, V5-6 ]

TANDA PENYAKIT JANTUNG KORONER:

II, III, aVF [INFERIOR]
I & aVL [HIGH LATERAL]
V1 – V6 [ANTERIOR]
V7 – V9 [POSTERIOR]
V3R – V5R [DEXTRA]
 EKG YANG HARUS TAHU

IRAMA SINUS

ATRIAL PREMATURE BEAT, TAKHIKARDI, FLUTTER,

FIBRILLASI

VENTRIKEL PREMATURE BEAT, LVH

RBBB COMPLETE & INCOMPLETE

PJK INFERIOR HIGH LATERAL ANTERIOR

.
.
.
 .

.
.
.
 .
• .
 .
• .
.
 .
• .
 ARTI KLINIS NADI YANG HILANG
• HAMPIR SELALU DIAKIBATKAN OLEH OVER-DRIVE

• PADA AV BLOK ATAU SA ARREST : PJK

• INDIKASI TREADMILL TEST

• INDIKASI PRIKSA FAKTOR RISIKO

• TIDAK MENGGANGGU/TIDAK PERLU TERAPI

 EKG YANG SERING DITEMUI

• ATRIAL FLUTTER
• ATRIAL FIBRILLASI
• SUPRA – VENTRIKULER TAKHIKARDI
• RAH
• LAH
• LVH
• RBBB
• ISKEMIA INFERIOR
• AMI HIPER – AKUT RECENT OMI
• OVER - DRIVE
 ARITMIA SUPRA-VENTRIKULER
• ATRIAL TAKHIKARDI, FLUTTER & FIBRILLASI HARUS
DICARI KEMUNGKINAN ADANYA HIPERTIREOID
• PASTIKAN ADA TANDA GAGAL JANTUNG /TIDAK
• ATRIAL TAKHIKARDI & FLUTTER/FIBRILLASI
DENGAN RAPID VENTRIKULER RESPONS HARUS
DIBERI OBAT KONTROL RATE
• ATRIAL TAKHIKARDI TIDAK PERNAH PERMANENT
• ATRIAL FLUTTER & FIBRILLASI HARUS DIBERI ANTI
PLATELET
• HARUS SELALU DICARI PENYEBAB DASARNYA
 ARITMIA VENTRIKULER
• IRAMA VENTRIKULER BAIK SEBAGAI AV BLOK
TOTAL ATAU IDIOVENTRIKULER RITME PERLU
PACEMAKER

• RUN VT, VT, VF, R on T, BIGEMINI, BERPASANGAN

PERLU ANTI ARITMIA & KONSULTASI KE
KARDIOLOGIST

• TANDA KLINIS YANG SERING: SINKOPE / PINGSAN

 GANGGUAN KONDUKSI
• AV BLOK DERAJAD I, II TANPA KELUHAN KLINIS
TIDAK PERLU OBAT TAPI CARI FAKTOR RISIKO
• AV BLOK III DENGAN SINKOPE/HR < 45 HARUS
PAKAI PACEMAKER
• RBBB, LAHB, LPHB BANYAK YANG NORMAL DAN
TIDAK ADA ARTI KLINIS SAMA SEKALI
• LBBB HARUS SELALU DICARI KEMUNGKINAN HHD
DAN PJK
• PRE EKSITASI ADA RISIKO SVT
 HIPERTROFI ATRIUM
• ATRIUM KIRI HARUS DIPIKIRKAN KEMUNGKINAN
MITRAL STENOSES, INSUFFICIENSI ATAU HHD

• ATRIUM KANAN HARUS SELALU DICARI

KEMUNGKINAN PENYAKIT PARU

• KEDUA ATRIUM HARUS DIPIKIRKAN ADANYA

GAGAL JANTUNG AKIBAT HHD, STENOSIS
ATAUPUN INSUFFICIENSI MITRAL
 HIPERTROFI VENTRIKEL
• VENTRIKEL KANAN HAMPIR SELALU DIAKIBATKAN
OLEH GAGAL JANTUNG KIRI
• JARANG TERJADI TANPA HIPERTROFI VENTRIKEL
KIRI
• PADA ANAK DAN BAYI GAMBARAN RVH : NORMAL

• VENTRIKEL KIRI MEMBESAR PALING SERING PADA

ATLIT, HIPERTENSI & PENYAKIT JANTUNG
KORONER
• HARUS SELALU DICARI PENYEBABNYA
 DIAGNOSA EKG TANPA ARTI
KLINIS
• LAHB, LPHB, SEBAGIAN BESAR RBBB

• SEBAGIAN EKSTRA SISTOLE ATRIAL/VENTRIKEL

• LEFT AXIS DEVIATION, RIGHT AXIS DEVIATION

• COUNTER CLOCK-WISE ROTATION DAN CLOCK-

WISE ROTATION

• IRAMA JUNCTIONAL, AV BLOK DERAJAD I

 Heart and coronary artery
• Plaque formation
 Atherosclerosis and its clinical impact
Cerebrovascular disease
• Transient ischaemic attack (TIA)
• Stroke

Cardiovascular disease
• Angina
• Heart attack
• Heart failure

Others
• Claudicatio intermiten
• Gangren

CRE027/Jul07-Jul08/TEP | RTD Master Slide 2 nd Semester

Atherosclerosis
 Hyperlipemia

• Cholesterol
• LDL-Cholesterol
• HDL-Cholesterol
• Triglyceride
 Arterial wall:
structure and function
Vascular endothelium modification
in atherosclerosis
Plaque formation 1 — Fatty streak
Plaque formation 2- Fibrous cap
Plaque formation 3 – Lipid core
 Characteristics of the
stable atherosclerotic
plaque
Fibrous
Fibrous cap
cap
(VSMCsand
(VSMCs andmatrix)
matrix) IntimalVSMCs
Intimal VSMCs
Endothelial
Endothelial (repair
(repair
cells
cells phenotype)
phenotype)
Lipid core

Adventitia

MedialVSMCs
Medial VSMCs
(contractile
(contractile
phenotype)
phenotype)
.
.
The vulnerable atherosclerotic
plaque

Lipid core

Adventitia
 Plaque rupture
The main releasing factors
 Atherosclerosis Timeline
Foam Fatty Intermediate Fibrous Complicated
Cells Streak Lesion Atheroma Plaque Lesion/Rupture

Endothelial Dysfunction
From first decade From third decade From fourth decade
Smooth muscle Thrombosis,
Growth mainly by lipid accumulation and collagen hematoma

Stary HC, et al. Circulation. 1995;92:1355-74. Artery wall often gets

larger with increasing plaque-Glagov NEJM 1987
 Severity of Coronary Artery Stenosis
Prior to Acute MI
68%
60

MI
Patients 40
(%)
20 18%
14%

0
<50% 50%–70% >70%
% Stenosis
Data constructed from 4 individual trials in approximately 200 MI patients
Falk E et al. Circulation. 1995;92:657-671. 10
The Grip of Angina
 Medical Management
• Antiplatelet

• ACE inhibitor

• Statin

• Kontrol faktor risiko

 EKG KEGAWATAN
PADA AKUT MIOKARD INFARK:
VES LEBIH DARI 5/MENIT
VES BERPASANGAN
VES TIPE R ON T
VES MULTIVOKAL
RUN OF VENTRIKEL TAKHIKARDI
VENTRIKEL FLUTTER & FIBRILLASI

SUPRAVENTRIKULER TAKHIKARDI
 APLIKASI EKG SECARA KLINIS

RBBB INKOMPLIT = NORMAL

RBBB KOMPLET BIASANYA JUGA NORMAL
SERING TERDAPAT PADA ASD
IRAMA SINUS ATAU JUNCTIONAL BIASANYA
NORMAL
ATRIAL TAKHIKARDI, FLUTTER & FIBRILASI
PERLU PENGOBATAN
TAK ADA ARTI KLINIS PADA : LAHB, LPHB,
CCWR/CWR, AV BLOK I
 ARITMIA SUPRAVENTRIKULER

SVT SECEPATNYA DIATASI : MASSAGE

KAROTIS, VALSALVA, ATP, AMIODARON,
INFUS DELTIAZEM, DC SHOK

ATRIAL FLUTTER & FIBRILLASI : ASPIRIN

AMIODARON ATAU DIGITALIS PADA YANG
RAPID VENTRIKEL RESPONS

VENTRIKEL FLUTTER & FIBRILLASI DC SHOK

 EKG YANG ADA HUBUNGANNYA DNG
PENYAKIT JANTUNG KORONER
• OVER-DRIVE VENTRIKULER

• ATRIAL FIBRILLASI, ATRIAL FLUTTER, SA ARREST

• LVH, LBBB, RBBB, AV BLOK I, II, III

• ISKEMIA, INJURY, INFARK

 Antihypertensive therapy
• Antihypertensive therapy should
– Lower blood pressure effectively
– Have a favourable safety profile
– Reduce cardiovascular morbidity and mortality
•
• Five drug categories
– Diuretics
– Beta-blockers
– ACE inhibitors
– Calcium channel blockers
– Angiotensin-receptor blockers

Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice.
Eur Heart J 2003; 24: 1601-10.
 SUBCLINICAL ORGAN DAMAGE

 ECG LVH
 ECHOCSRDIOGRSPHY LVH
 IMT >0.9 mm OR PLAQUE
 SERUM CREATININE
 MALE 1.3 – 1.5 mg/dl
 FEMALE 1.2 – 1.4 mg/dl
 eGFR <60 ml/min/1.73 m2
 MICROALBUMINURIA 30-300 mg/24h

Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
 BP Reductions as Small as 2 mmHg Reduce the Risk
of CV Events by up to 10%

 Meta-analysis of 61 prospective, observational studies

 1 million adults

 12.7 million person-years

7% reduction in
risk of IHD
2 mmHg mortality
decrease in 10% reduction in
mean SBP risk of stroke
mortality

Prospective Studies Collaboration. Lancet 2002;360:1903-1913.

 Benefit of Treating Hypertension
• Antihypertensive therapy has been associated
with 40 percent reduction in stroke; 25 percent in
myocardial infarction; and more than 50 percent
in heart failure

• It is estimated that control of hypertension to

below 140/90 mmHg could, in men and women,
prevent 19 and 31 percent of coronary heart
disease events
 NON DRUGS TREATMENT
• WEIGHT REDUCTION [ > 10% ]

• INCREASED PHYSICAL EXERCISE

• DIET: SODIUM [<6GM/DAY] INCREASED

FRUIT, VEGETABLES, KALIUM
HYPERTENSION & PREGNANCY
• DIET NORMAL AND LIMIT ACTIVITY
• METILDOPA, LABETALOL, CCB
• ACE-I & ARB CONTRA-INDICATION
• CA SUPPL & OMEGA 3 NO EFFICIENT
• ASPIRIN FOR HISTORY PRE-ECLAMPSIA
• SBP >170 OR DBP >110 HOSPITALIZED
• ALL DRUGS EXCRETED IN BREAST MILK,
EXCEPTION OF PROPRANOLOL & NIFEDIPIN
IN BREAST MILK IS VERY LOW
 ESH 2003 & JNC VII

ESH-ESC BP BP JNC VII

BP Classification Bp Classification
Optimal <120 / <80 <120/<80 Normal

Normal 120-129 / 80-84 120-129 /80-84 Prehypertension

High normal 130-139 / 85-89 130-139 / 85-89 Prehypertension

Grade 1 Hypertension 140-159 / 90-99 140-159 / 90-99 Stage 1

(mild) Hypertension
Grade 2 Hypertension 160-179 /100-109 Stage 2
(moderate) >160 / >100 Hypertension
Grade 3 Hypertension > 180 / >110
(severe)
Isolated Systolic Isolated Systolic
Hypertension > 140 < 90 Hypertension
 CARDIOVASCULAR RISK STRATIFICATION
Blood pressure (mm Hg)

Other risk factor, organ

Normal High normal Grade 1 HT Grade 2 HT Grade 3 HT
damage, or disease

Low added Moderate High added

No other risk factors Average risk Average risk
risk added risk risk

Low added Low added Moderate Hgh added Very high

1-2 risk factors
risk risk added risk risk added risk

≥ 3 risk factors, mets,

Moderate High added High added High added Very high
organ damage, or
added risk risk risk risk added risk
diabetes

Established CV or renal Very high Very high Very high Very high Very high
disease added risk added risk added risk added risk added risk

HT: hypertension; mets: metabolic syndrome; CV: cardiovascular

Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
 TO START DRUG TREATMENT DEPEND ON

THE LEVEL OF BLOOD PRESSURE AND OTHER

RISK FACTOR
 Initiation of Antihypertensive Treatment
Other risk
factor, OD, Normal High normal Grade I HT Grade II HT Grade III HT
or disease

Lifestyle changes for Lifestyle changes for Lifestyle changes

No other risk No BP several months than several weeks than and immediate
No BP intervention
factors intervention drug treatment if BP drug treatment if BP drug
uncontrolled uncontrolled treatment

Lifestyle changes for Lifestyle changes for Lifestyle changes

1-2 risk several weeks than several weeks than and immediate
Lifestyle changes Lifestyle changes
factors drug treatment if BP drug treatment if BP drug
uncontrolled uncontrolled treatment

≥ 3 risk Lifestyle changes

factors, MS, Lifestyle changes and consider
Lifestyle changes
or OD drug treatment Lifestyle changes and Lifestyle changes and
and immediate
drug drug
drug
treatment treatment
Lifestyle changes treatment
Diabetes Lifestyle changes and drug
treatment

Lifestyle changes Lifestyle changes Lifestyle changes

Established Lifestyle changes and Lifestyle changes and
and immediate and immediate and immediate
CV or renal immediate immediate
drug drug drug
disease drug treatment drug treatment
treatment treatment treatment

HT: hypertension; MS: metabolic syndrome; CV: cardiovascular; OD: organ damage
Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
 ESH/ESC: Antihypertensive Treatment Preferred Drug

Compelling - ACE Aldo-

Diuretic ARB CCB
blocker inhibitor antagonist
indication

Heart failure • • • • •
Post-MI
• • •
Angina
pectoris • • • •
Diabetes • •
Renal
dysfunction • •
Previous
Any blood pressure lowering agent
stroke
Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
 WHEN BLOOD PRESSURE IS 20 mm Hg

ABOVE SYSTOLIC GOAL OR 10 mm Hg ABOVE

DIASTOLIC GOAL, CONSIDERATION SHOULD BE

GIVEN TO INITIATE THERAPY WITH 2 DRUGS,

EITHER AS SEPARATE PRESCRIPTION OR IN

FIXED-DOSE COMBINATION

The JNC VII Report. JAMA 2003;289:2560-2572

Possible combinations of antihypertensive agents

Diuretics

-blockers ARBs

-blockers CCBs

ACE inhibitors

2007 ESH/ESC guidelines for the management of arterial hypertension

 Non – Pharmacologic Treatment

• Stopping smoking

• Losing Excess Weight

• Reducing Alcohol Intake

• Eating less Salt

• Low level exercise

 Total risk management

Lifestyle and risk factor goals

• Healthy food choices
• Be physically active
• Achieve ideal weight
• Reduce blood pressure to < 140/90 mmHg
• Reduce total cholesterol to < 5.0 mmol/l (190 mg/dl)
• Reduce LDL cholesterol to <3.0 mmol/l (115 mg/dl)
• Achieve optimal glycaemic and blood pressure
control in patients with diabetes mellitus (HbA level
between 6.2 and 7.5%) and a blood pressure
<130/85 mmHg
 EKG PADA HIPERTENSI
• LVH LBBB LAH

• SINUS TAKHIKARDI, OVER-DRIVE, SINUS

BRADIKARDI

• ISKEMIA, OLD MIOKARD INFARK

• ATRIAL TAKHIKARDI, FLUTTER & FIBRILLASI

~10% Weight loss = ~30% Visceral
adipose tissue loss