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HYPERTENSION
MAIMUN SYUKRI
Batasan Hipertensi
1. Bila tekanan sistolik >= 140 mmHg, dan
atau tekanan diastolik >= 90 mmHg,
atau sedang mendapat obat
antihipertensi.
2. Dilakukan dua kali atau lebih
pengukuran pada dua kali atau lebih
kunjungan.
Blood Pressure Classification
BP
Classification
SBP
mmHg
Normal
<120
DBP
mmHg
and
<80
Prehypertension 120–139
or
80–89
Stage 1
Hypertension
140–159
or
90–99
Stage 2
Hypertension
>160
or
>100
WHO/ISH 2003.
ESC/ESH 2003 .
Classification of blood pressure levels of the
British Hypertension Society
Category
Optimal
Normal
High-normal
Systolic blood pressure
(mmHg)
<120
<130
130–139
Diastolic blood pressure
(mmHg)
<80
<85
85–89
Hypertension
Grade 1 (mild)
140–159
Grade 2 (moderate) 160–179
Grade 3 (severe)
180
90–99
100–109
110
Isolated Systolic Hypertension
Grade 1
140 - 159
Grade 2
>160
<90
<90
Brit Med J 2004 328:634-40.
AUSTRALIA 2003
BP Measurement Techniques
Method
Brief Description
In-office
Two readings, 5 minutes apart,
sitting in chair. Confirm elevated
reading in contralateral arm.
Ambulatory BP
monitoring
Indicated for evaluation of “whitecoat” HTN. Absence of 10–20% BP
decrease during sleep may indicate
increased CVD risk.
Self-measurement
Provides information on response
to therapy. May help improve
adherence to therapy and evaluate
“white-coat” HTN.
JNC 7 2003
Office BP Measurement
 Use auscultatory method with a properly calibrated and validated
instrument.
 Patient should be seated quietly for 5 minutes in a chair
(not on an exam table), feet on the floor, and arm supported at heart
level.
 Appropriate-sized cuff should be used to ensure accuracy.
 At least two measurements should be made.
 Clinicians should provide to patients, verbally and in writing,
specific BP numbers and BP goals.
JNC 7 2003
How to measure blood pressure accurately
 ……… sphygmomanometer
 Patient should be seated and relaxed, preferably for several
minutes prior to the measurement and in a quiet room.
 Appropriate cuff size.
 Average the readings. If the firsty two readings differ by more than 10
mmHg systolic or 6 mmHg diastolic or if the initial readings are high,
take several readings after five minutes of quiet rest, until consecutive
readings do not vary by greater than these amounts.
 Ideally, patients should not take caffeine-containing beverages or
smoke for at least two hours before blood pressure is measured,
…………………..
Australia, 2004
Box 2 Procedures for blood pressure measurement
When measuring blood pressure, care should be taken to
 ……….. to sit for several minutes in a quiet room before
beginning blood pressure measurements.

Take at least two measurements spaced by 1-2 min, ………….

Use a standard bladder ……. but have a larger and a smaller
bladder available for fat and thin arms, respectively.

Have the cuff at the heart level, whatever the position of the
patient.
Use phase I and V …………….


Measure blood pressure in both arms at first visit to detect
possible differences ……………………..

Measure blood pressure 1 and 5 min after assumption of
the standing position in elderly subjects, diabetic
patients,……………..

Measure heart rate by pulse palpation (30 s) after the
second measurement in the sitting position.
HIPERTENSI
Tekanan Darah :
• Rata-rata dari  2 kali pemeriksaan
• Pengukuran pada waktu yang berbeda
• Pengukuran pada waktu duduk
12
 TD  kekuatan darah ketika melewati
dinding arteri
 Jenis Hipertensi
Hipertensi Resisten
Hipertensi Emergensi
Hipertensi Urgensi
 Berdasarkan Penyebab
Hipertensi Primer  idiopatik 90-95%
Hipertensi Skunder  Sistemik
Prevalensi Hipertensi 
USA
Penduduk
dewasa)
Indonesia
50 Juta dari total
( 1 dari 4 orang
Baliem 0,65%
Sukabumi
28,6%
Etiology
 Primary hypertension
 95% of all cases
 Secondary hypertension
 5% of all cases
 Chronic renal disease – most common
CVD Risk Factors
 Hypertension*
 Cigarette smoking
 Obesity* (BMI >30 kg/m2)
 Physical inactivity
 Dyslipidemia*
 Diabetes mellitus*
 Microalbuminuria or estimated GFR <60 ml/min
 Age (older than 55 for men, 65 for women)
 Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.
Identifiable
Causes of Hypertension
 Sleep apnea
 Drug-induced or related causes
 Chronic kidney disease
 Primary aldosteronism
 Renovascular disease
 Chronic steroid therapy and Cushing’s syndrome
 Pheochromocytoma
 Coarctation of the aorta
 Thyroid or parathyroid disease
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
Categories of hypertensive
end-organ damage
Origin
Category
Large arteries
Loss of compliance
(Dissecting) aneurysm
Peripheral occlusive arterial disease
Kidney
Nephrosclerosis
Birkenhäger and de Leeuw (1992)
Hipertensi & Kerusakan Organ Target
20
Laboratory Tests
 Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose, and hematocrit
• Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
 Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine ratio
 More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved
Treatment
Overview
 Goals of therapy
 Lifestyle modification
 Pharmacologic treatment
• Algorithm for treatment of hypertension
 Classification and management of BP for adults
 Followup and monitoring
Goals of Therapy
 Reduce CVD and renal morbidity and mortality.
 Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients
with diabetes or chronic kidney disease.
 Achieve SBP goal especially in persons >50 years of age.
Sign and Symptoms
 Essential HTN is usually
- asymptomatic
- undetected for many years
- headache, BP elevated systolic
beyond 200 mmHg or BP rising
rapidly (can occur in malignant
HTN)
Symptomatic associated with
malignant HTN







Headache
Blurred vision
Chest pain
Breathlessness
Nausea, vomiting
Anxiety, confusion, coma
Seizures
Consequences of Malignant HTN
End Organ
Complications
Aorta
Aortic disection
Brain
Hipertensive encepahlopathy
Cerebral Infarction or Haemmorharge
Heart
Cardiac failure
Myocardial ischemic or infarction
Kidney
Renal failure
Haematuria
Gastrointestinal
Anorexia,nausea,vomiting,abdominal
pain
Placenta
Eclampsia
Other
Micro-angiopathic haemolytic anemia
Consequences of hypertension
 Cardiac disease
Left ventricular failure
Angina
Myocardial infarction
 Cerebrovascular disease
Transient ischemic attacks
Stroke
Multi-infarct dementia
Hypertensive encephalopathy
Consequences of hypertension
 Vascular disease
Aortic aneurysm
Occlusive peripheral vascular disease
Arterial dissection
 Others
Progressive renal failure
Hypertensive retinopathy
Risk of Hypertension
 Advancing age
 Positive family history of premature
cardiovascular disease
 Smoking
 Hypercholesterolemia
Hypertension is thought to account for :
- One–half of all deaths due to stroke
- Up to one quarter of coronary heart
disease deaths
Isolated Systolic hypertension increase
the risk of :
 stroke and coronary heart disease by
about 40%
 cardiovascular death by about 50%
 heart failure by about 50%
Aetiology of hypertension
 Essential hypertension
(primer/idiopathic hypertension
remain uncertain
(genetic and environmental factors
contribute to development of
hypertension)
 Secondary hypertension
Secondary hypertension
 Renal parenchymal disease, causes :
- the glomerulonephritides
- diabetic nephropathy
- analgesic nephropathy
- adult polycystic kidney disease
 Renal artery stenosis
 Primary hyperaldosteronism
 Phaeochromocytoma
Secondary hypertension
 Aortic coarctation
 Cushing’s syndrome
 Drug induced hypertension
- the oral contraception pill
- steroids
- NSAID
- immunosuppressive
- sympathomimetics
- anabolic steroids
- erythropoieti n
- monoamin oxidase inhibitors
 Thyrotoxicosis
 Rare monogenic syndrome
Clinical assesment of hypertension







Sign and symptoms
Pointers to secondary hypertension
Features of malignant hypertension
End organ damage
Hypertensive nephropathy
Left ventricular hypertrophy
Hypertensive retinopathy
Grades of hypertension retinopathy
Grade
I
II
III
IV
Features
Mild narrowing or sclerosis of the retinal
arteriole, no symptoms,
Good general health
Venous compression at artriovenous
crossing (A-V nipping) no symptoms,
good general health
Retinal oedema, cotton wool spots,
hemmorhages, often symptoms
All above
Papiloedema,Symptomatic
Cardiac and renal function often
impaired, reduced survival
Treatment
 Non Pharmacotherapy
(lifestyle modification)
 Pharmacotherapy
Pengobatan
Tujuan:
ANGKA KESAKITAN
KERUSAKAN ORGAN TARGET
ANGKA KEMATIAN
Sasaran Pengelolaan
Menilai gaya hidup dan identifikasi faktor
risiko kardiovaskular lain atau gangguan
yang menyertai yang dapat
mempengaruhi prognosis & pengobatan
Mengetahui penyebab tekanan darah
yang tinggi
Menilai adanya kerusakan organ dan
penyakit kardiovaskular
39
Strategi Penatalaksanaan Hipertensi
JNC:
 Preventif
 Deteksi
 Evaluasi
 Pengobatan
JNC VI, 1997
Preventif
 Untuk mencegah atau memperlambat terjadinya
Hipertensi
 Merupakan solusi jangka panjang masalah hipertensi
 Mencegah terjadi komplikasi
 Dapat menghentikan atau mengurangi biaya
pengobatan dan komplikasi
NHBPEP Working Group Report on Primary Prevention of Hypertension
Preventif
 Upaya preventif primer:
Terhadap individu yang potensial
hipertensi:
TD normal tinggi
Riwayat keluarga hipertensi
Obesitas
Konsumsi tinggi garam
Kurang aktifitas
Konsumsi tinggi alkohol
 Diharapkan prevalensi Hipertensi turun
Intervensi Preventif Primer
Terbukti Efektif




Turunkan BB
Kurangi Garam
Kurangi Alkohol
Olah Raga
Efektif terbatas







Manajemen Stres
Kalium
Minyak Ikan (Fish oil)
Kalsium
Magnesium
Serat
Cegak makronutrien
Deteksi
 Dilakukan di fasilitas kesehatan
dengan alat ukur yang standar dan
cara yang benar
 Pasien diberitahu tentang makna
TDnya
 Pasien dianjurkan melakukan
pemeriksaan periodik sesuai dengan
TD pertama
 Diharapkan ditemukan kasus tahap
awal
Evaluasi
 Mencari penyebab hipertensi
(sekunder)
 Memeriksa adanya kerusakan organ
target dan penyakit lain
 Mencari faktor risiko
 Mengetahui respon pengobatan, efek
samping dan kepatuhan pasien
WHO-ISH Guidelines for Management
of Hypertension: Stratification of
Cardiovascular Risk
Blood Pressure (mm Hg)
Grade 1
Grade 2
Grade 3
Mild
hypertension
Moderate
hypertension
Severe
hypertension
Other risk factors and
disease history
SBP 140–159
or DBP 90–99
SBP 160–179
or DBP 100–109
SBP  180
or DBP  110
I No other risk factors
Low risk
Med risk
High risk
II 1–2 risk factors
Med risk
Med risk
Very high risk
III 3 or more risk factors
or TOD or diabetes
High risk
High risk
Very high risk
Very high risk
Very high risk
Very high risk
IV ACC
TOD = Target-organ damage
ACC = Associated clinical conditions
Guidelines subcommittee. WHO-ISH
Guidelines. J Hypertens 1999;17:151-183.
BP TARGETS:
WITHOUT COMPLICATION : <140/80 mmHg
DIABETES
: < 130/80 mmHg
CKD
: < 130/80 mmHg
PROTEINURIA > 1 g/d
: <125/75 mmHg
Lifestyle Modification
Modification
Weight reduction
Approximate SBP
reduction
(range)
5–20 mmHg/10 kg weight loss
Adopt DASH
eating plan
8–14 mmHg
Dietary sodium
reduction
Physical activity
2–8 mmHg
Moderation of
alcoholconsumption
4–9 mmHg
2–4 mmHg
Lifestyle Recommendations for
Hypertension: Physical Activity
Should be prescribed to reduce blood pressure
F
Frequency
- Four or five times per week
I
Intensity
- Moderate
T
Time
- 45-60 minutes
Type
Dynamic exercise
- Walking
- Cycling
- Non-competitive swimming
T
For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy
Treatment of Hypertension






Diuretic
ACE-Inh
ARB
Beta blocker
Alpha blocker
Direct renin inhibitor
Treatment Algorithm for Adults with SystolicDiastolic Hypertension without another
compelling indication
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
ACE-I
ARB
Long-acting
DHP-CCB
Betablocker
Alpha-blocker
as initial
monotherapy
Indications for
Pharmacotherapy
 Strongly consider prescription if:
 Average DBP equal or over 90 mmHg and:
Hypertensive Target-organ damage (or CVD) or
Independant cardiovascular risk factors
 Elevated systolic BP
 Cigarette smoking
 Abnormal lipid profile
 Strong family history of premature CV disease
 Truncal obesity
 Sedentary Lifestyle
– Average DBP equal or over 80 mmHg and
diabetes
Diuretics
-blockers
AT1 receptor
blockers
α-blockers
Ca Antagonist
ACE Inhibitors
2003 Guidelines for Management of Hypertension, J of Hypertension 2003
C.I. : Verapamil + ßBlocker
ESH-ESC 2003
JNC 7: Management of Hypertension by
Blood Pressure Classification
Initial Drug Therapy
BP Classification
Normal
<120/80 mm Hg
Lifestyle
Modification
Without Compelling
Indication
With Compelling
Indication
Encourage
Prehypertension
120-139/80-89 mm Hg
Yes
Stage 1 hypertension
140-159/90-99 mm Hg
Yes
Thiazide-type diuretics
for most; may consider
ACE-I, ARB, BB, CCB, or
combination
Drug(s) for the compelling
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB, BB,
CCB) as needed
Stage 2 hypertension
≥160/100 mm Hg
Yes
2-drug combination for most
(usually thiazide-type diuretic
and ACE-I, ARB, BB, or
CCB)
Drug(s) for the compelling
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB,
BB, CCB) as needed
No drug indicated
Drug(s) for the compelling
indications
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker;
CCB = calcium channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.
Compelling Indications for
Individual Drug Classes
Compelling
Indication
Initial Therapy
Options
Clinical Trial
Basis
Diabetes
THIAZ, BB, ACE,
ARB, CCB
NKF-ADA
Guideline, UKPDS,
ALLHAT
Chronic kidney
disease
ACEI, ARB
Recurrent stroke THIAZ, ACEI
prevention
NKF Guideline,
Captopril Trial,
RENAAL, IDNT,
REIN, AASK
PROGRESS
JNC 7 2003