hipertensi.pptx

HIPERTENSI

Pentingnya akurasi pengukuran TD :

• Ketidakakuratan pengukuran TD dapat menimbulkan masalah perbedaan 5 mmHg membawa akibat yang besar

• Overestimasi orang dengan prehipertensi hipertensi

• Underestimasi orang dengan hipertensi normotensi/ klasifikasi HTN yang berbeda

BLOOD PRESSURE MEASUREMENT

Perlu diketahui faktor-faktor yang mempengaruhi akurasi pengukuran TD

AMERICAN HEART ASSOCIATION GUIDELINES FOR IN-CLINIC BLOOD PRESSURE MEASUREMENT

Recommendation Comments

Patient should be seated comfortably, with back supported, legs uncrossed, and upper arm bared.

Diastolic pressure is higher in the seated position, whereas systolic pressure is higher in the supine position.An unsupported back may increase diastolic pressure; crossing the legs may increase systolic pressure.

Patient’s arm should be supported at heart level.

If the upper arm is below the level of the right atrium, the readings will be too high; if the upper arm is above heart level, the readings will be too low.If the arm is unsupported and held up by the patient, pressure will be higher.

Cuff bladder should encircle 80 percent or more of the patient’s arm circumference.

An undersized cuff increases errors in measurement.

Information from Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al.; Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Recommendations for blood pressure measurement in humans and experimental animals. Part 1: blood pressure measurement in humans. Hypertension 2005;45:142–61.

Recommendation Comments

Mercury column should be deflated at 2 to3 mm per second.

Deflation rates greater than 2 mm per second can cause the systolic pressure to appear lower and the diastolic pressure to appear higher.

The first and last audible sounds should be recorded as systolic and diastolic pressure, respectively. Measurements should be given to the nearest 2 mm Hg.

Neither the patient nor the person taking the measurement should talk during the procedure.

Talking during the procedure may cause deviations in the measurement.

RECOMMENDED CUFF SIZES FOR ACCURATE MEASUREMENT OF BLOOD PRESSURE

*—A standard adult cuff, large adult cuff, and thigh cuff should be available for use in measuring a child’s leg blood pressure and for children with larger arms

Patient Recommended cuff size

Adults (by arm circumference)

22 to 26 cm 12 x 22 cm (small adult)

27 to 34 cm 16 x 30 cm (adult)

35 to 44 cm 16 x 36 cm (large adult)

45 to 52 cm 16 x 42 cm (adult thigh)

Children (by age)*

Newborns and premature infants 4 x 8 cm

Infants 6 x 12 cm

Older children 9 x 18 cm

Category Systolic Diastolic

120 and 80

120-129 and/or 80-84

High Normal 130-139 and/or 85-89

Grade 1 Hypertension 140-159 and/or 90-99

Grade 2 Hypertension 160-179 and/or 100-109

Grade 3 Hypertension ≥ 180 and/or ≥110

Isolated Systolic Hypertension ≥ 140 and 90

ESH/ESC Definition and Classification of Blood Pressure Levels (mm Hg)

Mancia G, et al. J Hypertens 2007;25:1105-1187

Optimal

Normal

Slide SourceHypertension Online

www.hypertensiononline.org

Blood Pressure (mm Hg) Category

Systolic Diastolic

<120 and <80 Normal

120-139 or 80-89 Prehypertension

140-159 or 90-99 Stage 1 hypertension

≥160 or ≥100 Stage 2 hypertension

KLASIFIKASI HIPERTENSI JNC 7 – 2003Dewasa usia > 18 tahun

Chobanian AV, et al. Hypertension 2003;42:1206-52

Isolated hypertension : usia >55 tahun TDS ≥ 140 dan TDD < 90 mmHg

Tekanan darah : refleksi kardiovaskular

Tekanan darah sistolik : nilai curah jantung

dpt berubah dalam waktu singkat (aktifitas fisik ringan, emosi)

Tekanan darah diastolik : refleksi resistensi perifer

sukar dipengaruhi faktor emosi, aktifitas fisik ringan

HIPERTENSI : kondisi abnormal hemodinamik (fungsi pengaturan / kontrol)

batasan hipertensi dipakai kriteria tek. drh sistolik dan/atau tek.drh diastolik

DEFINISI

Tekanan nadi (pulse pressure/PP) = TD sistolik – TD diastolik

Tekanan arteri rata-rata (mean arterial pressure/MAP) =

(TD sistolik + 2xTD diastolik) / 3

DEFINISI

HIPERTENSI

• ESSENSIAL (PRIMER ) : 90-95%

• SECONDARY : 5-10%

DEFINISI

• HIPERTENSI ESENSIAL (HIPERTENSI PRIMER) :

hipertensi yang tidak diketahui penyebabnya

• HIPERTENSI SEKUNDER :

hipertensi yang diketahui penyebabnya (hipertensi karena sebab-sebab yang diketahui)

DEFINISI

HIPERTENSI :The Disease Continuum

HIPERTENSI :The Disease Continuum

Early Paradigm

Elevated BP Target Organ Damage

Natural History of CVD Progression

More Recent Paradigm

Vascular Dysfunction Elevated BP Target Organ Damage

A Proposed Future Paradigm

EndothelialDysfunction

LVHRenal

DamageMI Stroke

AnginaPectoris

VascularDysfunction

Elevated BP Target OrganDamage

?

PATOGENESIS

HIPERTENSI DAN KERUSAKAN ORGAN TARGET

*preclinical data

LV = left ventricular; MI = myocardial infarction; GFR = glomerular filtration rate

Adapted from Willenheimer R et al Eur Heart J 1999;20(14):997-1008; Dahlöf B J Hum Hypertens 1995;9(suppl 5):S37-S44; Daugherty A et al J Clin Invest 2000;105(11):1605-1612; Fyhrquist F et al J Hum Hypertens 1995;9(suppl 5):S19-S24;

Booz GW, Baker KM Heart Fail Rev 1998;3:125-130; Beers MH, Berkow R, eds. The Merck Manual. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories, 1999:1682-1704; Anderson S Exp Nephrol 1996;4(suppl 1):34-40;

Fogo AB Am J Kidney Dis 2000;35(2):179-188.

HTN

Atherosclerosis*Vasoconstriction

Vascular hypertrophy

LV hypertrophyFibrosis

RemodelingApoptosis

GFRProteinuria

Aldosterone releaseGlomerular sclerosis

Stroke

Hypertension

Heart failureMI

Renal failure

DEATH

Komplikasi HipertensiKomplikasi Hipertensi

Kerusakan yang disebabkan oleh hipertensi tergantung :

• Besarnya peningkatan tekanan darah

• Lamanya kondisi tekanan darah yang tidak terdiagnosis dan tidak diobati

Kerusakan Target Organ!!Eyesretinopathy

Kidneysrenal failure

Brainstroke

Heartischemic heart disease

left ventricular hypertrophyheart failure

Peripheral arterial disease

MENGAPA TEKANAN DARAH HARUS DITURUNKAN ?

Lewington S, et al. Lancet. 2002;360:1903-1913;Chobanian AV, et al. JAMA. 2003;289:2560-2572.

CARDIOVASCULAR MORTALITY RISKINCREASES AS BLOOD PRESSURE RISES*

Card

iovascu

lar

Mort

ality

Ris

k

Systolic/Diastolic Blood Pressure (mm Hg)

0

1

2

3

4

5

6

7

8

115/75 135/85 155/95 175/105

2x

4x

8x

*Measurements taken in individuals aged 40–69 years, beginning with a blood pressure of 115/75 mm Hg.



Very high added risk

High added

risk

High added

risk

High added

risk

Moderate added

risk

≥ 3 risk factors, mets, organ damage, or diabetes


Very high

added risk

Very high

added risk

Very high

added risk

Very high

added risk

Established CV or renal disease


Moderate added

risk

Moderate added

risk

Low added

risk

Low added

risk1-2 risk factors

High added risk

Moderate added

risk

Low added

risk

Average risk

Average risk

No other risk factors

Grade 3 HT

Grade 2 HT

Grade 1 HT

High normal

NormalOther risk factor, organ damage, or disease

Blood pressure (mm Hg)

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

Cardiovascular Risk Stratification

•A gradual reduction in blood pressure is desirable in hypertensive patients in general, particularly in elderly patients,

•Target control level should be achieved within a few weeks in high-risk patients, such as those with grade III hypertension and multiple risk factors.

Japan Society of Hypertension 2009

Target Pengobatan

Series1

mm Hg

UncomplicatedHypertension

Chronic Kidney DiseaseCoronary Artery Disease

Diabetes

≤140

≤90

≤130

≤80

Systolic Blood Pressure

Diastolic Blood Pressure

CURRENT BLOOD PRESSURE TARGETS FOR VARIOUS CHRONIC CONDITIONS

American Diabetes Association. Diabetes Care. 2003;26:S80-S82; Hansson L, et al. Lancet. 1998;351:1755-1762; National Kidney Foundation. Am J Kidney Dis. 2002;39(2 Suppl 1):S1-S266;Rosendorff C, et al. Circulation. 2007;115:2761-2788.



TERAPI HIPERTENSI

• Non-farmakologik

• Farmakologik

• JNC VII 2004: berjenjang dan compelling indications

• BHS-NICE 2006 : terapi sekuensial

• Pengobatan awal dan kombinasi :

ESH-ESC 2009, CHEP 2009, JHS 2009

MODIFIKASI GAYA HIDUP UNTUK PENGENDALIAN HIPERTENSI

Modifikasi Rekomendasi Penurunan Tekanan Darah Sistolik kurang

lebih

Menurunkan berat badan

Pelihara berat badan normal (BMI 18.5-24.9)

5-20 mm Hg utk setiap penurunan 10 kg BB

Menu Konsumsi makanan kaya buah, sayur, susu rendah lemak dan rendah lemak jenuh

8-14 mm Hg

Mengurangi asupan garam/sodium

Kurangi natrium sampai tidak lebih dari 2.4 g/hari atau NaCl 6 g/hari

2-8 mm Hg

Meningkatkan aktifitas fisik

Berolahraga erobik teratur seperti misalnya berjalan kaki (30 men/hari 4-5 hari seminggu)

4-9 mm Hg

Kurangi konsumsi alkohol

Batasi konsumsi alkohol,jangan lebih dari 2 /hari utk pria dan 1 /hari utk perempuan.

2-4 mm HgSource: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

<55 years aaaaaaaaaa

55 years or black patients at any age

Step 1

Step 2

Step 3

Step 4 Add: further diuretic therapy or alpha-blocker or beta-blocker

Consider seeking specialist advice

A: ACE inhibitor or ARB, if ACE inhibitor intolerant C: Calcium-channel blocker D: Diuretic (thiazide)

A

A C or D

or

+C D

National Collaborating Centre for Chronic Conditions. Hypertension: management in adults in primary care: partial update. London: Royal College of Physicians, 2006

THE BHS RECOMMENDATIONS FOR COMBINING BLOOD PRESSURE-LOWERING DRUGS

+

BHS, British Hypertension Society; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker

2006 update

A C+ A D+

Choose between:

Single agent at low dose

Two-drug combination at low dose

If goal BP not achieved

Previous agent at full dose

Switch to differentagent at low dose

Previous combination at full dose

Add a third drug at low dose

Two-three-drug combination at effective doses

Two- to three-drug combination

Full-dosemonotherapy

If goal BP not achieved

BP, blood pressure

Mild BP elevationLow/moderate CV risk

Conventional BP target

Marked BP elevationHigh/very high CV risk

Lower BP target

ESH/ESC Guidelines 2007 European Heart Journal. 2007;28:1462-1536

HYPERTENSION TREATMENT STRATEGY: ESH/ESC 2007

1-blockers

2007 ESH/ESC Guidelines

CCBs

Diuretics

ACE inhibitors

AT1-receptor blockersß-blockers

WHAT’S NEW FOR 2009

The combination of an ACE inhibitor with an ARB is not recommended in

patients with

• Hypertension without compelling indications,

• Coronary artery disease who do not have heart failure,

• Prior stroke,

• Non proteinuric chronic kidney disease or

• Diabetes mellitus without micro albuminuria

N Engl J Med 2008;358:1547-59Lancet 2008; 372: 547–53

FOLLOW-UP OF BLOOD PRESSURE ABOVE TARGETS

• Patients with blood pressure above target are recommended to

be followed at least every 2nd month

• Follow-up visits are used to increase the intensity of lifestyle

and drug therapy, monitor the response to therapy and assess

adherence

MAIN CLASSES OF ANTIHYPERTENSIVE DRUGS

• Diuretics• Inhibit the reabsorption 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 II • Receptors

• Vasodilators• Direct renin inhibitors

JAPAN HYPERTENSION SOCIETY 2009TREATMENTS OF HYPERTENSION

1. The antihypertensive drug to be first administered alone or

concomitantly with other drugs should be selected from Ca channel blockers,

angiotensin-receptor blockers (ARBs),angiotensin-converting enzyme

(ACE) inhibitors, diuretics and b-blockers.

2. Appropriate antihypertensive drugs should be selected considering

positive indications, contraindications, conditions that require the

careful use of drugs and the presence or absence of complications.

3. Administered once a day, but as it is more important to control the

BP over 24 h, splitting the dose into twice a day is desirable

in some situations.

TREATMENT OF HYPERTENSION

• Each drug class has contraindications as well favorable effects in specific clinical settings. The choice of drug(s) should be made according to this evidence.

• The traditional ranking of drugs into first, second, third, and subsequent choice, with an average patient as reference, has now little scientific and practical justification and should be avoided

Mancia et al. Reappraisal of ESH-ESC Guidelines 2009

THIAZIDE DIURETICS

• Mechanism: inhibit Na/K pumps in the distal tubule

• Examples:• Hydrocholorthiazide 12.5-25 mg daily

• Chlorthalidone 12.5-50 mg daily

• Effective first line agent and provides synergistic benefit

• As single agent more effective if CrCl >30 ml/min

• Compelling indications: HF, High CAD risk, Diabetes, Stroke, ISH

• Mechanism: Inhibit Na/K/Cl ATPase in ascending loop of henle

• Examples:• Furosemide 20 mg BID

• Typically only beneficial in patients with resistant HTN and evidence of fluid; effective if CrCl <30 ml/min

• MUST be dosed at least twice daily (Lasix = Lasts six hours)

• Administer AM and lunch time to avoid nocturia

LOOP DIURETICS

• Mechanism: inhibit aldosterone’s effect at the receptor, reducing Na and water retention

• Examples:• Spironolactone 25 mg daily

• Can provide as much as 25 mmHg BP reduction on top of 4 drug regimen in resistant hypertension

• Monitor SCr and K

• Compelling indications: HF

Am J Hypertension. 2003; 16:925-930.

ALDOSTERONE RECEPTOR ANTAGONISTS

• Mechanism: Competitively inhibit the binding of catecholamines to beta-adrenergic receptors

• Examples:• Atenolol 25-100 mg QD, Metoprolol 25 -100 mg BID, Bisoprolol 2.5 –

10 mg QD

• Carvedilol 6.25-50 mg (alfa+Beta)BID

• Monitor: HR, Blood Glucose in DM

• Not contraindicated in asthma or COPD but use caution

• Compelling indications: HF, post-MI, High CAD risk, Diabetes

BETA BLOCKERS

• Mechanism: Decrease calcium influx into cells of vascular smooth muscle and myocardium

• Examples:• Diltiazem Long acting; CD 100 -400 mg

• Verapamil 60-480 mg, long acting SR

• Monitor: HR

• Verapamil causes constipation

• Relatively contraindicated in heart failure

• Compelling indications: Diabetes, High CAD risk

CALCIUM CHANNEL BLOCKERS NON-DIHYDROPYRIDINE:

• Mechanism: Decrease calcium influx into cells of vascular smooth muscle

• Examples:• Amlodipine 2.5-10 mg PO daily

• Felodipine 2.5-10 mg PO daily

• OROS/GITS. Do not use immediate release nifedipine

• Monitor: Peripheral edema, HR (can cause reflex tachycardia)

• Good add on agent if cost is not an issue

CALCIUM CHANNEL BLOCKERS: DIHYDROPYRIDINE

• Mechanism: Inhibit vasoconstriction by inhibiting synthesis of angiotensin II; provides balanced vasodilation

• Examples:• ACEI: Captopril 12.5 -50 BID, Enalapril 2.5-40 mg daily –BID, Lisinopril

5 – 40 mg daily, Imidapril 5-10 QD, Perindopril 4-8 mg QD, Ramipril 2.5-20 mg

• Monitor: S Cr, K

• Compelling indications: HF, post-MI, High CAD risk, Diabetes, CKD, Stroke

ACE - INHIBITORS

• Mechanism: Inhibit vasoconstriction by blocking action of angiotensin II; provides balanced vasodilation

• Examples:• ARB: Irbesartan 150-300 mg QD, Losartan 25-100 mg BID,

Olmesartan 20-40 mg, Telmisartan 20-80 mg, Valsartan 90-160 mgQD

• Monitor: S Cr, K

• Compelling indications: HF, post-MI, High CAD risk, Diabetes, CKD, Stroke

ARB’S

• Mechanism: Inhibit peripheral post-synaptic alpha1 receptors causing vasodilation

• Examples:• Terazosin 1 – 20 mg daily

• Doxazosin 1 – 16 mg daily

• Cause marked orthostatic hypotension, give dose at bedtime

• Consider only as add on therapy

• Can be beneficial in patients with BPH

ALPHA1 BLOCKERS

• Mechanism: false neurotransmitters reduce sympathetic outflow reducing sympathetic tone

• Examples:• Clonidine 0.75-0.6 mg bid, Methyldopa 250 mg-1000 mg BID

(Pregnancy), Reserpin 0,1 -0,25 mg QD

• Monitor: HR (bradicardia)

• Side effects often limiting: Dry mouth, orthostasis, sedation

• Withdrawal/Rebound effect

BETA BLOCKERS

• Mechanism: Direct vasodilation of arterioles via increased intracellular cAMP

• Examples:• Hydralazine 20-400 mg BID-QID

• Minoxidil 2.5-40 mg PO daily-BID

• Monitor: HR (can cause reflex tachycardia), Na/Water retention

• Hydralazine is an alternative in HF if ACEI contraindicated

• Consider minoxidil in refractory patients on multi-drug regimens

VASODILATORS

hipertensi.pptx

Documents