hipertensi utk awam

66

Click here to load reader

Upload: januarw

Post on 30-Oct-2014

271 views

Category:

Documents


30 download

Tags:

TRANSCRIPT

Page 1: Hipertensi Utk Awam

Hipertensi dan Masalah disekitarnya

Lukman Muliadi

Page 2: Hipertensi Utk Awam

Apakah itu Hipertensi?

• Hipertensi atau Tekanan Darah Tinggi adalah suatu keadaan dimana tekanan darah di atas normal (>140 mmHg untuk sistolik dan >90 mmHg untuk diastolik)

• Hipertensi bisa menyerang anak-anak atau orang dewasa, namun umumnya pada orang dewasa di atas 35 tahun

Page 3: Hipertensi Utk Awam

BP CLASSIFICATIONESH-ESC & WHO-ISH 2003 BP Classification

Systolic BP Diastolic BP JNC VII

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

Grade 1 Hypertension (mild)

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

Grade 2 Hypertension (moderate)

160-179 /100-109 >160 / >100 Stage 2 Hypertension

Grade 3 Hypertension (severe)

> 180 / >110

Isolated Systolic Hypertension

Isolated Systolic Hypertension> 140 < 90

Page 4: Hipertensi Utk Awam

Hypertension SyndromeHypertension SyndromeIt’s More Than Just Blood PressureIt’s More Than Just Blood Pressure(Tidak hanya tekanan darah yang meningkat)(Tidak hanya tekanan darah yang meningkat)

DecreasedArterial

Compliance Endothelial Dysfunction

Abnormal Glucose

Metabolism

Neurohormonal Dysfunction

Renal-Function Changes

Blood-Clotting Mechanism

Changes

Obesity

Abnormal Insulin

Metabolism

LV Hypertrophyand Dysfunction

Accelerated Atherogenesis

Abnormal Lipid Metabolism

Hypertension

Kannel WB. JAMA. 1996;275:1571-1576. Weber MA et al. J Hum Hypertens. 1991;5:417-423. Dzau VJ et al. J Cardiovasc Pharmacol. 1993;21(suppl 1):S1-S5.

Page 5: Hipertensi Utk Awam

The Metabolic Syndrome :

The Iceberg Concept

Page 6: Hipertensi Utk Awam

Hypertension Linked To Chronic Renal Disease Among 332,544 Men Screened

for MRFIT

0

50

100

150

200

250

<8080-84

85-8990-99

100-109110

180 160-179 140-159 130-139 120-129 <120

Systolic BP (mm Hg) Diastolic BP (m

m Hg)

Adapted from Klag MJ, et al. N Engl J Med. 1996;334(1):13-18.© Massachusetts Medical Society

250

200

150

100

50

0Age

-Ad

jus t

ed R

ate

of E

SR

DP

er 1

00.0

00 P

erso

n- Y

ears

Page 7: Hipertensi Utk Awam

Apa Penyebab Hipertensi ?

• 90-95% hipertensi tidak diketahui penyebabnya

• 5-10% disebabkan penyakit lain :– Gangguan ginjal– Gangguan pembuluh darah– Ganguan hormonal: hypertiroidi

• - obat obatan : NSAID,Steroid, kontrasepsi hormonal

Page 8: Hipertensi Utk Awam

hipertensi(patogenesis)

TEKANAN DARAH = CURAH JANTUNG x RESAISTENSI PERIFERA

Hipertensi Peningkatan CJ Peningkatan RP

Preload Kontraktilitas Konstriksi Fungsional Hipertrofi struktural

Volume Redistribusi

Cairan Cairan

Retensi Luas hiperaktif RAS Gangguan Hiper

Na Ginjal Filtrasi S.Simpatis membran sel insulinemi

Asupan Na Gg Stress Gg

ekses genetik Genetik Obesitas EDF

Page 9: Hipertensi Utk Awam

HEREDITER - LINGKUNGANUmur

0 – 30 tahunPRE-HIPERTENSI

Normotensi HIPERTENSI DINI 20 – 40 tahun

HIPERTENSI (KLINIS) 30 –50 tahun

TANPA KOMPLIKASI DENGAN KOMPLIKASI

Hipertensi Jantung P.Darah Besar Otak GinjalMaligne Hipertrofi Aneurisma Iskemia Sklerosis

Gagal Diseksi Trombosis Gagal GinjalInfark Perdarahan

Gambar 1. Perkembangan alamiah hipertensi esential tanpa terapi

Perkembangan alamiah hipertensi esential tanpa terapi

Page 10: Hipertensi Utk Awam

Blood Pressure rises with age

0

10

20

30

40

50

60

70

%

18-29 30-39 40-49 50-59 60-69 70-79 80+

0

10

20

30

40

50

60

70

%

18-29 30-39 40-49 50-59 60-69 70-79 80+

Kannel-W. Cardioprotection and Antihypertensive Therapy, Am. J. Cardiol 1996 ; 77

In the elderly, one out of two is hypertension

Prevalence of Hypertension by age in USA

Age Group

Page 11: Hipertensi Utk Awam

Levels of Risk Associated with Smoking, Hypertension and Hypercholesterolaemia

Levels of Risk Associated with Smoking, Hypertension and Hypercholesterolaemia

.x1,6 x4

x3

x6

x16

x4.5 x9

Hypertension(SBP 195 mmHg)

Serum cholesterol level(8.5 mmol/L, 330 mg/dL)

Smoking

Poulter N et al., 1993

Page 12: Hipertensi Utk Awam
Page 13: Hipertensi Utk Awam

Systolic BP is a better indicator of CAD Systolic BP is a better indicator of CAD risk than diastolic blood pressure (DBP)risk than diastolic blood pressure (DBP)

0

10

20

30

40

50

60

70

80

90

100

MRFIT*: CAD death and BPMRFIT*: CAD death and BP

BP 130 150 170 190 210 DBP 80 90 100 110 120

DBP

Systolic BP

Ag

e-a

dju

ste

d C

AD

dea

th r

ate

per

10

,00

0 p

erso

n-y

ear

s

*Multiple Risk Factor Intervention Trial.

Adapted from Neaton et al, Arch Intern Med, 1992.

Systolic

mm Hg

Page 14: Hipertensi Utk Awam

BP directly correlates with risk of strokeBP directly correlates with risk of stroke

Adapted from He and Whelton, J Hypertens, 1999.

<112 112- 118- 121- 125- 129- 132- 137- 142- ≥151<71 71- 76- 79- 81- 84- 86- 89- 92- ≥98

Rel

ati

ve

risk

of

stro

ke

MRFIT: elevated systolic BP MRFIT: elevated systolic BP confers increased risk of strokeconfers increased risk of stroke

mm Hg

0

1

2

3

4

5

6

7

8

9

Systolic BPDBP

Systolic BP

DBP

Page 15: Hipertensi Utk Awam

Elevated systolic BP interacts with diabetesElevated systolic BP interacts with diabetesto increase CVD riskto increase CVD risk

MRFIT: men with diabetes and elevated systolic BP MRFIT: men with diabetes and elevated systolic BP are at greater risk of CVD than those without diabetesare at greater risk of CVD than those without diabetes

0

50

100

150

200

250

300

<120 120-139 140-159 160-179 180-199 ≥200

CV

D d

ea

ths

pe

r 1

0,0

00

pe

rso

n-y

ea

rs

Systolic BP (mm Hg)

Patients with diabetes

Patients without diabetes

Stamler et al, Diabetes Care, 1993.

Page 16: Hipertensi Utk Awam
Page 17: Hipertensi Utk Awam

Importance of blood pressure control

“It is estimated that in patients with

stage 1 hypertension and additional

cardiovascular risk factors,

achieving a sustained 12-mmHg reduction

in SBP over 10 years will prevent 1 death

for every 11 patients treated.”

JNC VII 2003

Page 18: Hipertensi Utk Awam

Millimetres matter …

“For individuals 40-70 years of age, each

increment of 20 mmHg in systolic BP or

10 mmHg in diastolic BP doubles the risk

of CVD across the entire BP range from

115/75 to 185/115 mmHg”

JNC VII. JAMA 2003;289:2560-2572BP, blood pressure; CVD, cardiovascular diseaseBP, blood pressure; CVD, cardiovascular disease

Page 19: Hipertensi Utk Awam

Millimetres matter …

“A 2-mmHg reduction in DBP would

result in … a 6% reduction in the risk

of

CHD and a 15% reduction in the risk of

stroke and TIAs”Cook NR, et al. Arch Intern Med 1995;155:701-709

DBP, diastolic blood pressure; CHD, coronary heart DBP, diastolic blood pressure; CHD, coronary heart disease; disease; TIA, transient ischaemic attackTIA, transient ischaemic attack

Page 20: Hipertensi Utk Awam

Relative importance of SBP and DBP as predictors of CHD risk as a function of age

* The difference between SBP and DBP proportional hazard regression coefficients, ie, (SBP) - (DBP), was estimated for each age group

SBP, systolic blood pressure; DBP, diastolic blood pressure;CHD, coronary heart disease

25 6545 5535 75

(SBP) -

(DBP)*

Age (years)

Favours DBP

Favours SBP

-1.0

-0.5

0.0

0.5

1.0

-1.5

p=0.008

Franklin SS, et al. Circulation 2001;103:1245-1249

Page 21: Hipertensi Utk Awam

Natural history of coronary heart disease

Atherosclerosis

Risk factor :• Hypertension• Hyperlipidemia• Diabetes• Insulin resistance

LV Hypertrophy

Coronary Artery Disease

Myocardial Ischemia

MyocardialInfarction

Remodelling

VentricularDilatation

Heart Failure

Death

Arrhythmia

SuddenDeath

Dzau & Braunwald, 1991

Page 22: Hipertensi Utk Awam

Vessel

Kidney

Hypertension

Left Ventricular Hypertrophy

Chronic Heart Failure

Myocardial Infarction

Congestive Heart Disease

ArrhythmiaArteriosclerosis

Peripheral Vascular Disease

Coronary Heart Disease

Renal Insufficiency

ESRD / Gagal Gnjal

Heart Brain

Stroke

Page 23: Hipertensi Utk Awam

The pioneersThe pioneersVasodilation treatment with fever-Vasodilation treatment with fever-

producing or antimalarial agents :producing or antimalarial agents :►Fries 1940s:Fries 1940s:

This was the first time we had seen reversal This was the first time we had seen reversal of the signs of malignant hypertension of the signs of malignant hypertension following an anti-hypertensive drug. It was following an anti-hypertensive drug. It was an exciting experiencean exciting experience

► Page 1949 :Page 1949 : I need hardly say this an unpleasant I need hardly say this an unpleasant

treatment butconsidering the danger of the treatment butconsidering the danger of the diseaseto the life of the patient it is a small diseaseto the life of the patient it is a small price to pay for the benefits price to pay for the benefits

Page 24: Hipertensi Utk Awam

A case of untreated A case of untreated hypertensionhypertension

YearYear Blood Blood pressurepressure

ComplicationComplicationss

TreatmentTreatment

19351935 136/78 (age 53)136/78 (age 53)

19371937 162/98162/98 PhenobarbitalPhenobarbital

1937-1937-19411941

170-180/90-100170-180/90-100 Low salt and low fat Low salt and low fat diet/massages/digitalidiet/massages/digitaliss

19411941 188/105188/105 Cardiac Cardiac enlargement enlargement Probable lacunnar Probable lacunnar infarctsinfarcts

19441944

1944-1944-19451945

186/108186/108

180-230/110-126180-230/110-126CHFCHF

Renal failureRenal failure

April12, April12, 19451945

Cerebral Cerebral haemorrhage-haemorrhage-death, age 63death, age 63

Page 25: Hipertensi Utk Awam

Pengukuran Tekanan Darah Contoh tekanan darah Normal : 120/80 mmHg

Tinggi : >140/>90 mmHg

Page 26: Hipertensi Utk Awam

Pengukuran Tekanan Darah

• Ada 2 angka yang terukur dalam pengukurang tekanan darah :– Sistolik (tekanan ketika jantung memompa)– Diastolik (tekanan ketika jantung menerima

darah kembali)

Sistolik (tekanan yang lebih tinggi) saat ini dianggap LEBIH BERPERAN dalam menyebabkan komplikasi: PJK, stroke dan gagal ginjal

Page 27: Hipertensi Utk Awam

Tehnik Pengukuran Tekanan Darah

1. Pasien harus tenang / relaks, tangan ditopang, lengan baju longgar

2. Sebaiknya ½ jam setelah makan / merokok3. “Cuff” sesuai lingkar lengan4. Manometer harus tegak lurus. Air raksa

dipompa sampai denjut hilang, diturunkan pelahan : 2-3 mm/detik.

5. Bunyi pertama = TDS, bunyi hilang = TDD 6. Hipertensi ringan diulang setelah 1 minggu

Page 28: Hipertensi Utk Awam

Perubahan Tekanan Darah Terkait Aktivitas

Aktivitas TDS(mmHg) TDD(mmHg)Rapat

Bekerja

Jalan

Berpakaian

Telepon

Makan

Kerja tulis menulis

Membaca

Nonton TV

Relaks

Tidur

+20.2

+16.0

+12.0

+11.5

+9.5

+8.8

+5.9

+1.9

+0.3

0.0

-10.0

+15.0

+13.0

+9.2

+5.5

+7.2+9.6

+5.3

+2.2

+1.1

0.0

-7.6

Page 29: Hipertensi Utk Awam

Faktor Risiko Hipertensi

• Tidak dapat dimodifikasi– Usia lanjut– Keturunan

• Dapat dimodifikasi– Kegemukan– Asupan garam berlebih– Kurang bergerak/beraktivitas– Stress– Merokok

Page 30: Hipertensi Utk Awam

Proof of BenefitProof of Benefit► 1960s to 1980s several major clinical trials establish the facts 1960s to 1980s several major clinical trials establish the facts

that early treatment of hypertension would prevent that early treatment of hypertension would prevent complication and prolong lifecomplication and prolong life VAS, USPHS, HDFPVAS, USPHS, HDFP

► Benefits of therapy :Benefits of therapy :ComplicationsComplications ControlControl

No. No. %%

TreatedTreated

No. No. %%

% Improvement% Improvement

Total morbid eventsTotal morbid events 563 563 9.09.0

417 417 6.66.6

2727

Total mortalityTotal mortality 342 342 5.45.4

252 252 4.14.1

2424

Cerebrovascular events ; Cerebrovascular events ; fatal & nonfatal fatal & nonfatal

140 140 2.22.2

76 76 1.21.2

5050

Fatal coronary eventsFatal coronary events 79 79 1.21.2

46 46 0.70.7

4242

Data from a subset of patients in VACS, USPHCS, HDFP, AustS, Oslo Study

Page 31: Hipertensi Utk Awam

Relative risk reduction of fatal events and combined fatal and non-fatal events in patients on active treatment versus placebo or no

treatment

S-D hypertension

Risk reduction

P

SIS-hypertension

Risk reduction

P Mortality

all cause

cardiovascular

noncardiovascular

-14% <0.01

-21% <0.001

-1% ns

-13% <0.02

-18% <0.01

-1% ns

Fatal and non fatal events

stroke

coronary

- 42% <0.001

- 14% <0.01

- 30% <0.001

- 23% <0.001

ESH-ESC 2003

Page 32: Hipertensi Utk Awam

BP Control RatesTrends in awareness, treatment, and control of high

blood pressure in adults ages 18–74

National Health and Nutrition Examination Survey, Percent

II1976–80

II(Phase 1)1988–91

II(Phase 2)1991–94 1999–2000

Awareness 51 73 68 70

Treatment 31 55 54 59

Control 10 29 27 34

Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC6.

Page 33: Hipertensi Utk Awam

27 % 22% 20,5% 20% 19%

6 % 24% 22,5% 17,5% 9%

< 140 / 90 mmHg < 160 / 95 mmHg USA Canada Finland Spain Australia

England France Germany Scotland India

> 65 yr only

European heart journal suppl B vol 2 ,March 2000

% Patients with controlled BP world-wide% Patients with controlled BP world-wide

Page 34: Hipertensi Utk Awam

Goals of treatment

JNC VII ( 2003 ) : @ < 140 / 90 mmHg or < 130 / 80 mmHg for those with Diabetes or Chronic Kidney disease. @ Achieve SBP goal especially in persons >50 years of age.

ESH ( 2003 ) : @ At least below 140 / 90 mmHg ( lower values if tolerated )@ Below 130 / 80 mmHg in Diabetics.@ Keeping in mind, however, that systolic below 140 mmHg

may be difficult to achieved in elderly( more flexible )

Page 35: Hipertensi Utk Awam

BP Threshold & Target BP (mmHg)

Low and medium risk >140/90 <140/90

High risk <160/90 <140/90

DM <130/<80

Goals BP

JNC 7 - WHO/ISH –ESH-ESC, 2003

Page 36: Hipertensi Utk Awam

AASK MAP <92

Target BP (mmHg)

Multiple antihypertensive agents are needed to achieve target BP

Number of antihypertensive agents1

UKPDS DBP <85

ABCD DBP <75

MDRD MAP <92

HOT DBP <80

Trial 2 3 4

DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure

IDNT SBP <135/DBP <85

ALLHAT SBP <140/DBP <90

Bakris GL, et al. Am J Kidney Dis 2000;36:646-661;Lewis EJ, et al. N Engl J Med 2001;345:851-860;

Cushman WC, et al. J Clin Hypertens 2002;4:393-404

Page 37: Hipertensi Utk Awam

Choose between

Low-dose 2-drug combinationLow-dose single agent

Not at BP goal

Full dose ofsingle agent

Switch todifferent agent

at low dose

Full dose of2-drug

combination

Add athird drugat low dose

Not at BP goal

2–3 drugcombinationat full dose

Full doses of 2–3-drugcombination

ESH–ESC: Algorithm for ESH–ESC: Algorithm for Treatment of HypertensionTreatment of Hypertension

Full-dosesingle agent

TOD = target organ damage

Marked BP elevation

High/very high CV risk

Lower BP target

Mild BP elevation

Low/moderate CV risk

Conventional BP target

Task Force for ESH–ESC. J Hypertens 2007;25:1105–87

Page 38: Hipertensi Utk Awam

Updated UK NICE Guidelines for the Treatment of Newly Updated UK NICE Guidelines for the Treatment of Newly Diagnosed HypertensionDiagnosed Hypertension

ACEI (or ARB*) + CCB orACEI (or ARB*) + thiazide diuretic

<55 years

ACEI (or ARB*) + CCB + diuretic

CCB or thiazide-type diuretic

ACEI (or ARB*)

55 years or black patients at any age

Add further diuretic therapy, α-blocker, or β-blocker.Consider seeking specialist advice

Step 1

Step 2

Step 3

Step 4

Page 39: Hipertensi Utk Awam

Management of Hypertension (JNC VII)

BP Classification

Lifestyle modification

Initial Drug

(-) compelling Indication

Therapy

(+) compelling indication

Normal Encourage

Pre-

Hypertension

Yes No AHD indicated AHD (s) for the compel- ling indications

Stage 1

Hypertension

Yes Thiazide-type D for most, may consider other AHD.

AHD(s) for the compel- ling indications.

Other AHD as needed.

Stage 2

Hypertenssion

Yes 2-AHDs combination for most (usually thiazide-type D and ACEI or ARB or BB or CCB

AHD(s) for the compel- ling indications.

Other AHDs (D.ACEI,ARB,BB.CCB)

Modified from JNC VII

Page 40: Hipertensi Utk Awam

Treatment initiation: ESH/ESC 2003Blood pressure

Other risk factors and disease history

Normal High normal Grade 1 Grade 2 Grade 3

No other risk factors

No BP intervention

No BP intervention

Lifestyle changes for several months, then drug treatment if preferred by the patient and resources available

Lifestyle changes for several months, then drug treatment

Immediate drug treatment and lifestyle changes

1-2 risk factors Lifestyle changes

Lifestyle changes

Lifestyle changes for several months, then drug treatment

Lifestyle changes for several months, then drug treatment

Immediate drug treatment and lifestyle changes

3 or more risk factors, target organ damage, or diabetes

Lifestyle changes

Drug treatment and lifestyle changes

Drug treatment and lifestyle changes

Drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

Associated clinical conditions

Drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

Immediate drug treatment and lifestyle changes

ESH/ESC Guidelines 2003. J Hypertens 2003;21:1011-1053

Page 41: Hipertensi Utk Awam

Diuretics

Angiotensinreceptor blockers

(ARBs)

Calcium channelblockers (CCBs)

Angiotensin-converting enzyme (ACE) inhibitors

-blockers

-blockers

Available as a single-pill combination

Less frequently used/combination used as necessary

Task Force for ESH–ESC. J Hypertens 2007;25:1105–87

ESHESC Recommendations for Combining BP-loweringDrugs and Availability as Single-pill Combinations

Page 42: Hipertensi Utk Awam

Mitos-mitos di seputar Hipertensi

• Tekanan darah diastolik (angka yang lebih rendah) lebih penting dari sistolik– FAKTA:

• Tekanan darah sistolik dan diastolik sama-sama penting, bahkan pada usia lanjut, tekanan darah sistolik lebih harus dikontrol

Page 43: Hipertensi Utk Awam

Mitos-mitos di seputar Hipertensi

• Pada orang tua, sudah biasa tekanan darahnya tinggi, sehingga tidak perlu diobati (100 + umur mmHg adalah wajar)– FAKTA:

• Baik orang muda maupun orang tua, tekanan darah HARUS di bawah 140/90 mmHg untuk mencegah komplikasi

Page 44: Hipertensi Utk Awam

Mitos-mitos di seputar Hipertensi

• Jika saya minum obat hipertensi dan tekanan darah saya terkontrol baik, obat tersebut tidak perlu diminum lagi– FAKTA:

• Tekanan darah terkontrol tsb. karena disebabkan oleh obat. Jika obat dihentikan maka tensi akan meningkat kembali. Hipertensi tidak dapat disembuhkan, hanya dapat dikendalikan. Jadi obat hipertensi harus terus diminum sesuai instruksi dokter

Page 45: Hipertensi Utk Awam

Mitos-mitos di seputar Hipertensi

• Jika kita pusing-pusing dan leher terasa kaku, itu berarti tensi kita sedang naik. Jika tidak terasa apa-apa, tensi kita normal– FAKTA:

• Hipertensi itu penyakit yang umumnya tidak bergejala. Untuk mengetahui apakah tensi kita naik atau tidak hanyalah mengukur dengan tensi meter. Periksalah tekanan darah secara teratur untuk mengetahui berapa tekanan darah kita.

Page 46: Hipertensi Utk Awam

• Sebagian besar hipertensi TIDAK bergejala• Tekanan darah tinggi bisa merusak organ-

organ tubuh yang berhubungan erat dengan pembuluh darah

• Hipertensi adalah penyebab utama STROKE, SERANGAN JANTUNG DAN GAGAL GINJAL

• Hipertensi dapat dikontrol untuk mencegah komplikasi tersebut

Hipertensi = “Silent Killer”

Page 47: Hipertensi Utk Awam

Don’t wait to treat hypertensionDon’t wait to treat hypertension““Awaiting overt signs and symptoms of Awaiting overt signs and symptoms of

coronary disease before treatment is coronary disease before treatment is no longer justified.”no longer justified.”

““In some respects, the occurrence of In some respects, the occurrence of symptoms may be regarded more symptoms may be regarded more properly as a medical failure than as properly as a medical failure than as the initial indication for treatment.”the initial indication for treatment.”

William B. Kannel, MDWilliam B. Kannel, MD

Department of MedicineDepartment of Medicine

Boston University Medical Boston University Medical CenterCenter

Kannel, Atherosclerosis and Coronary Artery Disease, 1996.

““Menunnggu sampai gejala dan tanda Menunnggu sampai gejala dan tanda penyakit jantung koroner timbul baru penyakit jantung koroner timbul baru diberi terapi sudah tidak benar .”diberi terapi sudah tidak benar .”

““Pada beberapa keadaan, timbulnya atau Pada beberapa keadaan, timbulnya atau telah adanya gejala justru telah adanya gejala justru menggambarkan kegagalan tindakan menggambarkan kegagalan tindakan medis, bukan saat baru mulai terapi.”medis, bukan saat baru mulai terapi.”

——William B. Kannel, MDWilliam B. Kannel, MD

Department of Medicine Department of Medicine

Boston University Medical Center Boston University Medical Center

Page 48: Hipertensi Utk Awam

10 kewajiban penderita hipertensi

1. Mengukur tekanan darah secara teratur

2. Jangan lupa mengkonsumsi obat sesuai aturan dokter

3. Mengontrol berat badan

4. Tidak mengkonsumsi garam berlebih (menghindari makanan bergaram tinggi)

5. Makan makanan rendah lemak

6. Berhenti merokok

7. Berkonsultasi dengan dokter secara teratur

8. Latihan fisik sesuai anjuran dokter

9. Menjalani kehidupan secara normal dan sehat

10. Menganjurkan keluarga (orang tua, kakak, adik, paman, anak dll) untuk memeriksakan tekanan darah secara teratur (risiko keturunan)

Page 49: Hipertensi Utk Awam

Obat-obat yang ideal

• Efektif menurunkan tekanan darah• Efek samping minimal• Diminum sekali sehari• Efek penurunan tekanan gradual• Memiliki “drug holiday protection” (melindungi

pasien yang lupa minum obat)• Tidak perlu memilih obat yang penurunan

tekanan darahnya cepat (kecuali kasus emergency)

Page 50: Hipertensi Utk Awam

Tips untuk mengurangi berat badan

• Kurangi makanan yang digoreng• Kurangi mentega, minyak dan lemak• Kurangi porsi makanan• Kurangi daging dan pilihlah ayam atau ikan

(kulit ayam disingkirkan)• Konsumsi buah dan sayuran lebih banyak• Konsumsi susu yang rendah lemak• Aktivitas fisik 30-60 menit 3-6 kali seminggu

Page 51: Hipertensi Utk Awam

Tips untuk mengurangi asupan garam

• Kurangi jumlah garam dalam masakan• Tambahkan bumbu dan penyedap untuk mengimbangi

rasa masakan• Kurangi kripik kentang dan jagung asin, hot dogs,

ikan asin, burger yang banyak mengandung garam• Tambahkan konsumsi buah dan sayur segar dan

bukan kalengan• Perhatikan LABEL kandungan garam dalam makanan

Page 52: Hipertensi Utk Awam

Obat-obat anti-hipertensi

• Bersikap sabar dalam menjalani pengobatan, tidak mengharapkan terapi yang “ajaib” yang cepat menurunkan tekanan darah

• Memberi kesempatan pada tubuh untuk menyesuaikan dengan obat yang mungkin memerlukan waktu untuk mengendalikan tekanan darah

• Obat diminum sesuai dengan anjuran dokter. Tidak menghentikan pengobatan sendiri atau merubah dosis dan segera mengunjungi dokter jika ditemukan adanya efek samping

Page 53: Hipertensi Utk Awam

Obat-obat anti-hipertensi

• Diuretik

• Beta bloker

• Antagonis kalsium

• ACE inhibitor

• Alfa bloker

• Angiotensin II antagonis

• Central agonist dan vasodilator

• Anti Renin

Page 54: Hipertensi Utk Awam

Development of Antihypertensive Development of Antihypertensive TherapiesTherapies

Directvasodilators

Alphablockers

Renin Inh

Peripheralsympatholytics

Ganglion blockers

Veratrumalkaloids

Central alpha2 agonists

Non-DHPCCBs

Beta blockers

Thiazidediuretics

DHP CCBs

ARBsACEinhibitors

Effectiveness

Tolerability

1940s 1950 1957 1960s 1970s 1980s 1990s 2005+

DHP, dihydropyridine; CCB, calcium channel blocker; ARB, angiotensin II receptor blocker.

The primary goal of treatment is to achieve maximum reduction in total

CV risk, through treatment of elevated BP and all associated

reversible risk factors ESH/ESC 2007

Page 55: Hipertensi Utk Awam

AMLODIPINE

• Obat yang mempunyai masa kerja panjang dari generasi kedua antagonis kalsium

• Mempunyai waktu paruh 35-48 jam

• T/P Ratio >50%

• Dosis sekali sehari

• Menurunkan tekanan darah secara gradual

Page 56: Hipertensi Utk Awam

• Olmesartan medoxomil is a prodrug, which is hydrolyzed to its active metabolite, olmesartan

• Absolute bioavailability 25.6%

• Time to Cmax ~2 hours

• t1/2 ~10-15 hours

• Dual elimination: – 40% renal

– 60% hepatobiliary

Schwocho LR, et al. J Clin Pharmacol 2001;41:515-527;Laeis P, et al. J Hypertens 2001;19(Suppl 1):S21-S32

Pharmacokinetics: Olmesartan

Page 57: Hipertensi Utk Awam

• Not metabolized by cytochrome P450 system; interactions with drugs metabolized by CYP450 unlikely

• Can be administered with or without food

• No dosage adjustment necessary for the elderly or in patients with renal or hepatic impairment

– BUT not recommended for patients with severe renal or hepatic impairment

Schwocho LR, et al. J Clin Pharmacol 2001;41:515-527;Laeis P, et al. J Hypertens 2001;19(Suppl 1):S21-S32;

von Bergmann K, et al. J Hypertens 2001;19(Suppl 1):S33-S40

Pharmacokinetics: Summary (cont.)

Page 58: Hipertensi Utk Awam

Olmesartan may give more prolonged AT1 blockade than

irbesartan or valsartan

0

3.16

1.78

1.19

1.84

0

1

2

3

4

5

Placebo Olmesartan 40mg

Irbesartan 300mg

Valsartan 160mg

Valsartan 320mg

Chan

ge fr

om p

redo

se to

24

hour

s in

mea

n PRA

(ng/

mL/

h)

p vs placebo <0.0001 0.005 0.058 (NS) 0.004

p vs olmesartan 0.028 0.002 0.036

n=20

PRA, plasma renin activity

Jones M, et al. Presented at ASH 2006; Abstract P-195

Page 59: Hipertensi Utk Awam

-13.0

-8.9 -9.2

-10.8

-14

-12

-10

-8

-6

-4

-2

0

Ch

ange

in B

P (

mm

Hg)

Olmesartan 20 mg/d

Losartan50 mg/d

Valsartan 80 mg/d

Irbesartan150 mg/d

Oparil S, et al. J Clin Hypertens 2001;3:283-291

** **

*

n=588* p0.05** p0.005

Results at Week 2 (cont.) Change in SeSBP

SeSBP, seated systolic blood pressure;BP, blood pressure

Page 60: Hipertensi Utk Awam

-11.5

-8.2 -7.9

-9.9

-12

-8

-4

0

Ch

ange

in B

P (

mm

Hg)

Olmesartan 20 mg/d

Losartan50 mg/d

Valsartan 80 mg/d

Irbesartan150 mg/d

Oparil S, et al. J Clin Hypertens 2001;3:283-291;Brunner HR. J Hypertens 2003;21(Suppl 2):S43-S46

* p<0.05 ** p<0.0005

** **

*

n=588

Results at Week 8 Change in SeDBP

40% 46% 16%

SeDBP, seated diastolic blood pressure; BP, blood pressure

Page 61: Hipertensi Utk Awam

Compliance at 1 year withantihypertensive treatment

Bloom BS, et al. Bloom BS, et al. Clin TherClin Ther 1998;20:671-681 1998;20:671-681

3843

50

5864

0

10

20

30

40

50

60

70

Diuretics Beta- blockers CCBs ACE inhibitors ARBs

Com

plia

nce

at 1

ye

ar (

%)

** p<0.007 vs ACE inhibitors p<0.007 vs ACE inhibitors

**

ACE, angiotensin-converting enzyme; ACE, angiotensin-converting enzyme; CCB, calcium-channel blocker; ARB, angiotensin II receptor CCB, calcium-channel blocker; ARB, angiotensin II receptor blockerblocker

Page 62: Hipertensi Utk Awam

ACEI + CCB• Less peripheral oedema• Less cough• Potentiation of the BP lowering effect• Greater reduction of CV events• Greater organ protection• Antiinflamatory vasc effect• Anti atherogenic properties• Anti diabetogeniceffects• Neutral effects on lipid profile and uric acid

Page 63: Hipertensi Utk Awam

Take home messages

• Kenalilah tekanan darah anda

• Kendalikanlah dengan :– Mengkonsumsi obat sesuai anjuran dokter– Rajin berkonsultasi pada dokter– Mengurangi asupan garam– Mengendalikan berat badan– Berhenti merokok

- Olah raga teratur

Page 64: Hipertensi Utk Awam

Summary

• Regardless of the blood pressure level, all patients should adopt appropriate lifestyle modifications

• A low dose of a diuretic should be considered as the first choice of therapy for the majority of patients without a compelling indication for another class of drug

2003 WHO/ISH Statement on Hypertension. J Hypertens 2003;21:1983-1992

Page 65: Hipertensi Utk Awam

Summary• Specific drug classes may differ in their effects• Main benefits are due to BP lowering• Drugs are not equal in adverse-event profiles• Major drug classes are suitable for initiation and

maintenance of therapy• Choice of drug will be influenced by patient

experience and preference, and cost and risk profile

• Long-acting drugs that provide once-daily, 24-hour efficacy are preferable

ESH/ESC Guidelines 2003. J Hypertens 2003;21:1011-1053BP, blood pressure

Page 66: Hipertensi Utk Awam

Thank You