farkin hipertensi

8/13/2019 FARKIN HIPERTENSI

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FARMAKOTERAPIHIPERTENSI


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HIPERTENSI :

Adalah kenaikan TD arteri yg tetap

(JNC-7 = Joint National Committee)


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KLASIFIKASI TEK DARAHJNC-7

KLASIFIKASI SISTOL(mmHg) DIASTOL (mmHg)

Normal 100


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Bila TDD < 90 mmHg &TDS 140 mmHg

= isolated systole HTBila TDD/TDS >

180/120 mmHgCrisis Hypertenson


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Definitions HPT emergency(crisis): Is characterized

by a severe elevation in BP, complicated byevidence of impending or progressivetarget/end organ dysfunction

VS

HPT urgency: is a severe elevation in BP

without progressive target organdysfunction

NB these definitions do not specifyabsolute BP levels


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PATOFISIOLOGI HT

A.Hipertensi esensial (HT primer)= HTIdiopatik, yg blm jelas penyebabnya.Dipenga-ruhi usia, kelamin, merokok, kholesterol, BB

B.Hipertensi sekunder. Dipengaruhi oleh obat,penyakit ginjal, penyakit endokrin (DM, tiroid, Cushing)


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Hypertension


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Hypertension Tingkat tekanan darah adalah fungsi

dari cardiac output dikalikan dengan

resistensi perifer (perlawanan dalampembuluh darah ke aliran darah) Dasar hemodinamik hipertensi

MAP = CO x TPRMAP=mean arteria pressure; CO=cardiac output; TPR=totalresistence perifer


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Prevalence of

Hypertension by Age Age 18-29

30-39

40-49

50-59

60-69

70-79 80+

% Hypertensive 4

11

21

44

54

64 65


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MANFAATMENURUNKAN TD

Stroke incidence 3540%

Myocardial infarction 2025%

Heart failure 50%


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Tanda-Tanda Klinik HT1.Pusing paroksismal

2.Berkeringat3.Takikardia

4.Palpitasi


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Organ yg terkena HT :

HeartLeft ventricular hypertrophyAngina or prior myocardial infarctionPrior coronary revascularizationHeart failure

Brain

Stroke or transient ischemic attackChronic kidney diseasePeripheral arterial diseaseRetinopathy


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Untreated hypertension can result in:Arteriosclerosis --Kidney damage

Heart Attack --StrokeEnlarged heart --Blindness


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FAKTOR RESIKO HTFaktor resiko mayorHipertensiMerokokObesitas (BMI 30)ImmobilitasDislipidemiaDiabetes mellitusMikroalbuminuria atau perkiraan GFR55 tahun untuk laki-laki, >65 tahun untukperempuan)Riwayat keluarga untuk penyakit kardiovaskularprematur (laki-laki < 55tahun atau perempuan < 65 tahun)


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TERAPI :NON FARMAKOLOGI

FARMAKOLOGI


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TUJUAN TERAPI HT :

1.Reduce CVD and renalmorbidity and mortality.2.Treat to BP


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Tx NON-FARMAKOLOGI

PENCEGAHAN & TERAPI1.Bagi yg obese, turunkan BB2.Diet garam ( 2.4g/hr)3.Kurangi konsumsi lemak

4.Tidak merokok, kurangi kopi &alkohol

5.Istirahat cukup

6.Olahraga teratur.


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Tx FARMAKOLOGI

A B C DA.ACE-1 / ACE-2 (ARB) / ALFA1-

BLOCKERB.BETA-BLOCKERS

C.CA-ANTAGONISTSD.DIURETICS


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T i K bi i


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Terapi Kombinasi

Rasional kombinasi obatantihipertensi:

Ada 6 alasan mengapa pengobatankombinasi pada hipertensi

dianjurkan: 1. Mempunyai efek aditif 2. Mempunyai efek sinergisme 3. Mempunyai sifat saling mengisi 4. Penurunan efek samping masing-masing obat

5. Mempunyai cara kerja yang saling mengisi pada organ target tertentu 6. Adanya fixed dose combination akan meningkatkan kepatuhan pasien (adherence)


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ANTIHIPERTENSI DI

PUSKESMAS 1.Propanolol / Bisoprolol 2.Nifedipin / Adalat OROS /

Amlodipin 3.Captopril / Lisinopril

4.HCT / Spironolakton

5.Reserpin


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Fixed-dose combinationyang paling efektif adalah

sebagai berikut:

1. Penghambat enzim konversi angiotensin (ACEI)

dengan diuretik 2. Penyekat reseptor angiotensin II (ARB) dengan diuretik 3. Penyekat beta dengan diuretik

4. Diuretik dengan agen penahan kalium 5. Penghambat enzim konversi angiotensin (ACEI) dengan antagonis kalsium 6. Agonis -2 dengan diuretik

7. Penyekat -1 dengan diuretic


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ALGORITMA Tx HT

Lifestyle Modifications

Not at Goal Blood Pressure (100 mmHg)

2-drug combination for most (usuallythiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140159 or DBP 9099 mmHg)

Thiazide-type diuretics for most.May consider ACEI, ARB, BB, CCB,

or combination.

Without Compelling

Indications

Drug(s) for the compelling

indications

Other antihypertensive drugs(diuretics, ACEI, ARB, BB, CCB)

as needed.

With Compelling

Indications

Not at Goal

Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.Consider consultation with hypertension specialist.


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JNC 7 (cont)

Diuretics first Addition of a second drug from a

different class > 2 drugs (combo good) >160/100-start with 2 drugs (diuretic/BB,

diuretic/ACEI, diuretic/ARB,diuretic/CCB)

Multiple drugs if CAD, DM, Renal disease Monotherapy response rate 40-50% Multiple meds response rate 75-80% Racial differences in response disappear

with multiple drugs


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Kieran McGlade Nov Department of General Practice QUB

Logical Combinations

Diuretic b-blocker CCB ACE inhibitor a-blocker

Diuretic - -

b-blocker - * -

CCB - * -

ACE inhibitor - -

a-blocker -

* Verapamil + beta-blocker = absolute contra-indication


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Kieran McGlade Nov 2001

Department of General Practice QUB

British Hypertension Society Guidelines 2000Compelling and possible indications and contrindications for the major classes of

antihypertensive drugs

INDICATIONS CONTRAINDICATIONSCLASSS OF DRUG POSSIBLE COMPELLING POSSIBLE COMPELLING

a-blockers Prostatism Dyslipidaemia Postural Hypotension Unrinary incontinence

Angiotensin converting enzyme (ACE) inhibitors Heart failureLeft ventricular dysfunction

Chronic renal disease *Type II diabetic nephropathy

Renal impairment *Peripheral vascular disease

PregnancyRenovascular disease

Angiotensin II receptor antagonists Cough induced by ACE inhibitor Heart failureIntolerance of other antihypertensive drugs

Peripheral vascular disease PregnancyRenovascular disease

b-blockersMyocardial infarction

Angina

Heart failure

Heart failureDyslipidaemia

Peripheral vascular disease

Asthma or COPDHeart block

Calcium antagonists (dihydropyridine) Isolated systolic hypertension (ISH) in elderly patients AnginaElderly patients

_ _

Calcium antagonists (rate limiting) Angina Myocardial infarction Combination with b-blockade Heart blockHeart failure

Thiazides Elderly patients including ISH _ Dyslipidaemia Gout

* ACE inhibitors may be beneficial in chronic renal failure but should be used with caution. Close supervision andBritish Hypertension Society Guidelines 2000

specialist advice are needed when there is established and significant renal impairment Caution with ACE inhibitors and angiotensin II receptor antagonists in peripheral vascular disease because of association with renovascular disease.

If ACE inhibitor indicatedf b-blockers may worsen heart failure, but in specialist hands may be used to treat heart failure

KLASIFIKASI & MANAGEMEN HT PADA DEWASA


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BPclassification

SBP*mmHg

DBP*mmHg

Lifestylemodificati

on

Initial drug therapy

Without compelling

indication

With compellin

indicationsNormal 100

Yes Two-drug combinationfor most(usuallythiazide-type diureticand ACEI or ARB or

BB or CCB).

KLASIFIKASI & MANAGEMEN HT PADA DEWASA


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HATI HATI MENGGUNAKAN


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HATI-HATI MENGGUNAKAN: Presription Drugs:

NSAIDs, including Coxibs

Corticosteroids and anabolic steroids Oral contraceptive and sex hormones Vasoconstricting/sympathomimetic decongestants

(ephedrin, PPA, Pseudoefedrin) Calcineurin inhibitors (cyclosporin, tacrolimus)

Erythropoietin and analogues Monoamine oxidase inhibitors (MAOIs)

Other: Licorice root Stimulants including cocaine, amfetamin (Ecstasy, Sabu2) Garam Excessive alcohol use


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CONTOH KASUS RESEP Dr.Jantung R/.Tanapres 10 mg XXX

S.1-0-0

R/.Bisoprolol 5 mg XXX S.0-0-1

R/.Letonal 25 mg XXX

S.1-0-0

R/.Analsik XV

S.3dd 1

Pro : Tn. LK

Dr.Jantung R/.Cedocard 5 mg 90

S. 3 dd 1R/.Concor 2.5 mg 30

S. 1-0-0R/.Rhinofed XV

S. 1-1-0R/.OBH Combi 1 fl

S. 3 dd CR/.Xanax 0.5 mg 30S.0-0-1

Pro : Ny.Zakky


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