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Buku pegangan.

HARRISON : INTERNAL MEDICINE

SUPARTONDO : ILMU OENYAKIT DALAM

NORMAN KAPLAN : CLINICAL

HYPERTENSION


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Section 1: Definition and Classification

of Hypertension


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Definition and classification ofhypertension: ESH/ESC 2003

Hypertension is defined as blood pressure 140/90 mmHg

Category Systolic

(mmHg)

Diastolic

(mmHg)

Optimal


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Definition and classification ofhypertension: JNC VII


Category Systolic

(mmHg)

Diastolic

(mmHg)

Normal


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Definition and classification ofhypertension: WHO/ISH 1999/2003


Category Systolic

(mmHg)

Diastolic

(mmHg)

Optimal


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Section 2: Prevalence of Hypertension


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Prevalence of hypertension*:North America and Europe

0

10

20

3040

50

60

70

80

Prevalence(%)

Men

Women

Total

Wolf-Maier K, et al. JAMA 2003;289:2363-2369* BP 140/90 mmHg or treatment with antihypertensive medication


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Prevalence of hypertension: Asia

0

10

2030

40

50

60

7080

Prev

alence(%)

Men

Women

Total

Gu DF, et al. Hypertension2002;40:920-927; Singh RB, et al. J Hum Hyper tens2000;14:749-763; Janus ED. Cl in Exp Pharmacol Physiol1997;24:987-988; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al.

Singapor e Med J2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol1998;27:405-409; Muhilal H. Asia Pacif ic J Cl in Nutr1996;5:132-134;Gupta R. J Hum Hyper tens2004;18:73-78; Asai Y, et al. Nippon Ko shu Eisei Zasshi2001;48:827-836 [in Japanese]


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Prevalence of hypertension:Other countries

0

10

20

30

40

50

60

70

80

Prevalence(%)

MenWomen

Total

Ordunez P, et al. Pan Am J Pub l ic Health2001;10:226-231;Cubillos-Garzon LA, et al. Am Heart J2004;147:412-417; Amad S, et al. J Hum Hyper tens1996;10:S31-S33


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TABEL 4 Prevalensi Hipertensi Pada Populasi,Obese, TGT dan DM di SumBar 2005

NO

KOTA POPULASI(%)

OBESE

(%)

TGT

(%)

DM

(%)

1

2

34

5

6

78

P.Panjang

Bt.Sangkar

SolokPariaman

Payakumbuh

Painan

BukittinggiPadang

22.3

23.4

26.122.9

19.1

16.0

26.611.8

22.4

23.4

24.622.2

17.6

17.7

37.612.0

26.3

32.5

33.335.6

326.6

36.4

38.225.3

33.3

42.2

41.240.0

18.4

29.4

28.623.1

RERATA 21.1 22.2 30.4 30.0


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Section 3 : Classification of

hypertension


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CLASSIFICATION

PRIMARY ( 90 % )

SECUNDARY ( 10 % )

renovascular hypertension

renal parenchymal hypertension

hypertension with pregnancy

pheochromocytoma

primary aldosteronemia

drug induced or related causes

JNC 7 2003, Caplan, clinical hypertension 2002


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Section 4 : Risk factors of

Hypertension


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Table Cardiovaskuler risk factors

Major Risk Factors

Hypertension*

Cigarette* (body mass index 30 kg/m2)Physical inactivity

Dislipidemia*

Diabetes mellitus*

Microalbuminuria or estimated GFR < 60 mL/min

Age (older than 55 for men, 65 for women)

Family history of premature cardiovascular disease (men under age 55 or women under age 65)

Target Organ Damage

Heart

Left ventricular hypertrophy

Angina or prior myocardial infarction

Prior coronary revascularization Heart failure

Brain

Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease

Retinopathy

GFR, glomerular filtration rate* Components of the metabolic syndrome JNC VII 2003


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Risk factors

Gender

Race Age Family history

Cigarette smoking Obesity ( BMI 30 Kg/m2 )* Physical activity Dyslipidemia*

Diabetes Mellitus* Microalbuminuria

* componen of metabolic syndrome

JNC 7 2003


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Bahaya HIPERTENSI(bi la tdk dikendal ikan)

Kerusakan pada Organ Target

Stroke

Retinopati

(buta)

LVH

GagalJantung

PJK

Penyakit Ginjalkhronik

Gagal Ginjal

Terminal


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PATHOPHYSIOLOGY OF HYPERTENSION

Several hypothesis exists of the originalpathogenesis of hypertension

- Excess Na intake

- Renal Na retention- RAS

- Stress & sympathetic activity

- Peripheral resistance

- Endothelial dysfunction- Obesity

- Insulin resistance


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Pathogenesis hipertensi( Kaplan N, 2002 )


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Angiotensinogen

Angiotensin I

Angiotensin II

Ellis ML, et al. Pharmacotherapy1996;16:849-860;Carey RM, et al. Hyper tension2000;35:155-163

AT1 AT2

Vasoconstriction

Aldosterone secretion

Catecholamine release

Proliferation

Hypertrophy

Vasodilation

Inhibition of cell growth

Cell differentiation

Injury response

Apoptosis

BP

(-)

Renin-angiotensin-aldosterone system

Renin

Angiotensin-converting

enzyme

Bradykinin

Inactive kinins

BP, blood pressure


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Section 6 : Diagnosis of Hypertension


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SYMPTOMS

HeadacheNocturia

PalpitationDizzinessTinitusEpistaxis

Kaplan N , 2002


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PHYSICAL EXAMINATION


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25


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TABLE. IMPORTANT ASPECTS OF THE PHYSICALEXAMINATION

ACCURATE MEASUREMENT OF BLOOD PRESSURE

GENERAL APPEARANCE : DISTRIBUTION OF BODY FAT,SKIN LESSION,MUSCLESTRENGTH.

FUNDUSCOPY.

NECK : PALPATION AND AUSCULTATION OF CAROTIDS,THYROID.

HEART : SOUND, RHYTHM, SIZE.

LUNG : RALES.

ABDOMEN : RENAL MASSES, BRUIT OVER AORTA OR RENALARTERIES, FEMORAL PULSES, WAIST CIRCUMFERENCE.

EXTREMITIES : PERIPHERAL PULSES, EDEMA.

NEUROLOGIC ASSESSMENT, INCLUDING COCNITIVEFUNCTION.


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LABORATORY TEST

ROUTINE LAB WORK UP

RISK FACTORS: BLOOD SUGAR, LIPID

PROFILE, ELECTROLYTES. LAB OF TARGET ORGAN DEMAGE

PLASMA INSULIN, PLASMA RENINACTIVITY


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FUNDUSCOPY EXAMINATION :

RETINOPATHY

CARDIAC ASSESSMENT: LVH, ARYTHMIA

CEREBRAL ASSESSMENT:ENCEPHALOPATHY

RENAL ASSESSMENT


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Section 7 : Treatment Guidelines


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Table Lifestyle modifications to manage hypertension *

DASH, Dietary Approaches to Stop Hypertension.

* For overall cardiovascular risk reduction, stop smoking.

The effects of implementing these modifications are dose and time dependent, and could be greater for some

individualsJNC VII 2003

Modification Recommendation Approximate SBP

Reduction (range)

Weight reduction Maintain normal body weight (body massindex 18.5-24.9 kg/m2)

5-20 mmHg/10 kg weightloss23-24

Adopt DASH eating plan Consume a diet rich in fruits, vegetables,and lowfat dairy products with a reducedcontent of saturated and total fat

8-14 mmHg25-26

Dietary sodium reduction Reduce dietary sodium intake to no morethan 100 mmol per day (2.4 g sodium or6 g sodium chloride)

2-8 mmHg25-27

Physical activity Engage in regular aerobic physicalactivity such as brisk walking (at least 30min per day, most days of the week0

4-9 mmHg26-27

Moderation of alcoholconsumption

Limit consumption to no more than 2drinks ( 1 oz or 30 mL ethanol; e.g., 24

oz beer, 10 oz wine, or 3 oz 80-proofwhiskey) per day in most men and to nomore than 1 drink per day in women andlighter weight persons

2-4 mmHg30


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THE IDEAL ANTIHYPERTENSIVE AGENT

- Effectively reduces BP

- Maintains BP control over 24 hours with

once-a-day dosing- Effective in all hypertensive patients

- No adverse effects

- No negative metabolic side effects


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History of antihypertensive drugs

Directvasodilators

Alpha-blockers

Peripheralsympatholytics

Ganglion

blockers

Veratrumalkaloids

Central 2agonists

Calciumantagonists-non-DHPs

Beta-blockers

Thiazidediuretics

Calciumantagonists-

DHPs

ARBs

1940s 1950 1957 1960s 1970s 1980s 1990s 2000

ACEinhibitors

DHP, dihydropyridine;ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker

Effectiveness and general tolerability


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AASK MAP


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Main classes of antihypertensive drugs

Diuretics Inhibit the re absorption of salts and water from kidney

tubules into the bloodstream

Calcium-channel antagonists

Inhibit influx of calcium into cardiac and smooth muscle Beta-blockers

Inhibit stimulation of beta-adrenergic receptors

Angiotensin-converting enzyme (ACE) inhibitors

Inhibit formation of angiotensin II Angiotensin II receptor blockers (ARBs)

Inhibit binding of angiotensin II to type 1 angiotensin IIreceptors


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Clinical trial and guideline basis for compelling indications for individual drugclasses

RECOMMENDED DRUGS+COMPELLING INDICATION CLINICAL TRIAL BASIS+

DIURETIC BB ACEI ARB CCB ALDO ANT

Heart failure ACC/AHA Heart Failure Guide-line,40MERIT-HF, 41 COPERNI-CUS,42CIBIS,43SOLVD,44AIRE,45TRACE,44ValHEFT,47RALES48

Postmyocardial infarction ACC/AHA post-MI Guideline,49BHAT,50SAVE,51Capricorn,52

EPHESUS,53

High coronary disease risk ALLHAT,33HOPE,34ANBP2,36

LIFE,32 CONVINCE31

Diabetes NKF-ADA Guideline,31,32UKPDS,34

ALLHAT33

Chronic Kidney disease NKF Guideline,22captopril Trial,55RENALL,56IDNT,57REIN,58 AASK59

Recurrent stroke prevention PROGRESS35

JNC VII , 2003

Compeling indications for antihypertensive drugs are based on benefits from outcome studies or existing

clinical guidelines; the compelling indications is managed in parallel with the BP

+ Drug abbreviations; ACEI, angiotensin converting enzyme inhibitor; ARB,angiotensin receptor blicker;

Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker

Conditions for which trials demonstrate benefit of specific classes of antihypertensive drugs.


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Treatment initiation: JNC VII

Normal Pre-hypertension

Stage 1hypertension

Stage 2hypertension

Lifestylemodification

Encourage Yes Yes Yes

Initial drug therapy

Withoutcompellingindication

No antihypertensive drugindicated Thiazide-typediuretics for most;may consider

ACE-I, ARB, BB,CCB, or

combination

Two-drugcombination formost (usuallythiazide-typediuretic and

ACE-I or ARB

or BB or CCB)With

compellingindications

Drug(s) for compellingindications

Drug(s) for compelling indications;other antihypertensive drugs

(diuretics, ACE-I, ARB, BB, CCB)as needed

ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II

receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker JNC VII. JAMA 2003;289:2560-2572


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Goals of treatment: JNC VII

The SBP and DBP targets are


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Diuretik: Hati hati pada :

- gangguan elektrolit

- dislipidemia

Beta blokerhati hati pada :

- Asma bronkhial / spasme bronkhus

- Diabetes melitus


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