Download penatalaksanaan hipertensi terkini fokus pada jnc 8

PENATALAKSANAAN HIPERTENSI
TERKINI :
FOKUS PADA JNC 8
WACHID PUTRANTO
Divisi Ginjal Hipertensi
Fakultas Kedokteran UNS/RS.Dr. Moewardi
Surakarta
Suatu keadaan klinis dimana tekanan darah
seseorang lebih tinggi daripada tekanan
darah normal
• Epidemiologi :
• Jumlah penderita hipertensi di seluruh dunia :
1 milyar
• USA : 65 juta
• Indonesia ? : belum ada data resmi
Conlin PR, Int J Clin Pract 2005; 59(2):214-24
Prevalensi Hipertensi
prevalence of hypertension (%)
70
60
SBP > 140 mm Hg
DBP > 90 mm Hg
64
65
70-79
80+
54
50
44
40
30
20
21
4
11
18-29
30-39
10
0
age (yrs)
40-49
50-59
60-69
Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36
Hypertension complication
Eyes
retinopathy
Brain
stroke
Target Organ damage!!
Damages depend on:
Kidneys
renal failure
Heart
ischaemic heart disease
left ventricular hypertrophy
heart failure
Peripheral arterial disease
• How high of the blood
pressures
• How long the
uncontrolled and
untreated high blood
presure
Blood Pressure Reduction Of 2 mmHg
Reduces The Risk Of CV Events by 7–10%
• Meta-analysis of 61 prospective, observational studies
• 1 million adults
• 12.7 million person-years
2 mmHg
decrease in
mean SBP
7% reduction in risk
of ischaemic heart
disease mortality
10% reduction in risk
of stroke mortality
Lewington et al. Lancet 2002;360:1903–13
ASH/ISH
HYPERTENSION
GUIDELINES
CLASSIFICATION
HYPERTENSION
BP
BP
SBP
Optimal
<120
DBP
and
<80
SBP
DBP
Normal
<120 and
<80
High Normal
130-139
85-89
80-89
HT stg 1
140-159
90-99
Stg 1
120-139 or
140-159 or
90-99
HT stg 2
160-179
100-109
Stg 2
≥160 or
≥100
HT stg 3
≥180
≥110
ISH
≥140
<90
Normal
Pre HT
BP
SBP
Optimal
<120
and
<80
Normal
<130
and
<85
High Nml
130-139
or
85-89
HT stg 1
140-159 or
90-99
HT stg 2
160-179 or
100-109
HT stg 3
≥180
120-129and./or 80-84
and
DBP
or
≥110
JNC 8
No definition of HT
Topic
Methodology
JNC 7
Non systematic literature review by
expert committee including a range
of study design
Recommendation based on consensus
2014 Hypertension Guidelin
Critical questions and review criteria defined by expert
panel with input from methodology team
Initial systematic review by methodologist restricted to
RCT evidence
Subsequent review of RCT evidence and recommendations
by the panel according to a standardized protocol
Definitions
Defined hypertension and prehypertension Definision of hypertension and prehypertension not
addressed, but tresholds for pharmacologic treatment
were defined
Treatments
Separate treatmen goals defined for
Similar treatment goals defined for all hypertensive
Goals
“uncomplicated” hypertension and for
populations except when evidence review supports
subsets with various comorbid condition
different goals for a particular subpopulation
Lifestyle
Recommended lifestyle modifications
Lifestyle recommendations recommended by endorsing
Recommendation based on literature review and expert
the evidence based recommendations of the Lyfestyle
opinion
Work Group
Drug therapy
Recommended 5 classes to be considered
Recommended selection among 4 specific medications
as initial therapy for most patients without
classes ( ACEI or ARB, CCB or Diuretics) and doses based
compelling indication for another class
on RCT evidence
Specified particular antihypertensive
Recommended specific medication classes based on
medication classes for patients with
evidence review for racial, CKD, and diuretics sub group
compelling indication,ie,diabetes,CKD,heart Panel created a table of drugs and doses used in the
failure,myocardial infarction,stroke,high
outcome trials
CVD risk
Scope of topics
Review process
Prior to
Publication
Included a comprehensive table oral
Antihypertensive drugs including names
and usual dose ranges
Addressed multiple issues ( blood pressure
Evidence review of RCT’S addressed a limited
measurements methods,patients evaluation
number of questions,those judge by the panel
components,secondary hypertension,
to be of highest priority
adherence to regimens,resistant hypertension,
and hypertension in special populations) based
on literature review and expert opinion
Reviewed by the National High Blood pressure
Reviewed by experts including those affiliated
Education Program Coordinating Committee,
with professional and public organizations and
a coalition of 39 major professional,public, and federal agencies; no official sponsorship by any
voluntary organizations and 7 federal agencies
organization should be inferred
The Process
Literature review 1/1/1966 – 12/31/2009
Inclusion Criteria
(1) HTN
(2) 2000 participants
(3) multisenter
(4) Kriteria inklusi/eksklusi.
9 Recommendations
A
B
C
D
E
N
Recommendation
Strength of
Recommendation
Recommendation 1
Populasi berusia
≥60 yrs,mulai
terapi
farmakologi SBP≥150 mmHg, DBP≥90 mmHg
Grade A
HYVET, Sys-Eur, SHEP, JATOS, VALISH,
CARDIO-SIS
Corollary Recommendation
Populasi usia ≥60 yrs, jika terapi farmakologi
mengakibatkan penurunan TD lebih rendah
(<140/90) dan pengobatan ditoleransi dengan
baik tanpa efek samping, teruskan pengobatan.
Usia ini TD <140 tidak lebih baik disbanding
140-160
Grade E
Recommendation 2
Populasi usia <60 yrs, terapi farmacologi bila
DBP≥90 mmHg . Target DBP<90 mmHg
Grade A (30-59 yrs)
Grade E (18-29 yrs)
HDFP, HT-Stroke Cooperative, MRC,
ANBP, VA cooperative
Recommendation
Strength of
Recommendation
Recommendation 3
Populasi usia <60 yrs, terapi farmacologi bila
SBP ≥140 mmHg.Target SBP<140 mmHg
Grade E
Recommendation 4
Populasi usia ≥18 yrs dengan CKD, terapi
farmacologi bila SBP ≥140 mmHg or DBP ≥90
mmHg . Target SBP <140 mmHg dan DBP <90
mmHg
Grade E
AASK, MDRD, REIN-2
Recommendation 5
Populasi usia ≥18 dengan DM, terapi
Grade E
farmacologi bila SBP ≥140 mmHg atau DBP ≥ 90
mmHg. Target SBP<140 and DBP <90
SHEP, Syst-Eur, UKPDS, ACCORD,
ADVANCE, HOT
Recommendation
Strength of
Recommendation
Recommendation 6
Pada populasi non black , termasuk dg DM,
initial anti HTN treatment : a thiazide type
diuretic, CCB, ACEI or ARB
Grade B
VA-cooperative, HDFP, SHEP
Recommendation 7
Populasi kulit hitam, termasuk dg DM, initial
anti HT: thiazide-type diuretic or CCB
Grade B ( No DM)
Grade C ( DM)
ALLHAT
Recommendation 8
Populasi usia ≥18 dg CKD dan HTN, initial (or
add on) anti HTN : ACEI or ARB utk
memperbaiki kidney outcomes. Tanpa melihat
ras atau status DM
Grade B
IDNT, AASK
Recommendation
Strength of
Recommendation
Recommendation 9
• Tujuan treatment HTN adalah untik mencapai dan
mempertahankan target BP
• Jika target BP tidak tercapai dlm 1 bl, naikkan dosis
atau tambahkan 2nd 1 obat dr rekomendasi 6
(thiazide-type diuretic, CCB, ACEI, or ARB)
• Jika target BP tidak tercapai dg 2 obat, tambah dan
titrasi obat 3rd . Do not use an ACEI and an ARB
together
• Jika target BP tidak dapat tercapai dg obat-obat pada
recommendasi 6 krn kontraindikasi atau butuh >3
obat, obat antiHT dari kelas lain bias digunakan.
• Referral kepada hypertension specialist jika BP tidak
tercapai atau untuk management komplikasi.
Grade E
Strategies to Dose Antihypertensive Drugs
Strategies
Description
Details
A
Mulai 1 obat naikan sp
dosis
maksimum,kemudian
tambahkan obat ke-2
Jika target BP blm tercapai naikkan dosis
obat 1 sp dosis maksimum sblm
menambahkan obat ke-2 dan ke-3.
B
Mulai 1 obat kemudian
tambahkan obat ke-2
sblm dosis maksimum
Tambahkan obat ke-2 sblm obat 1
mencapai dosis maks.Jk Target BP blm
tercapai,tambahkan obat ke-3 dan
titrasi sp dosis maks.
C
Mulai dengan 2 obat
(separate or single
combination)
• Mulai dg 2 obat
• Bbrp committee merekomendasi:
 ≥2 obat SBP >160 dan/atau DBP
>100, atau SBP >20 mmHg diatas
target dan/atau DBP >10 mmHg
 Jika target BP tdk tercapai (2 drugs),
tambahkan obat ke-3 dan titrasi.
Lifestyle Modification
JNC 8
JNC 7
G
U
I
D
E
L
I
N
E
C
0
M
P
A
R
I
S
O
N
GOAL BP
INITIAL TX
Guideline
2014 HT
Guideline
ESH/ESC
Population
Goal BP
Initial drugs
General ≥60 y
<150/90
General <60 y
DM
<140/90
<140/90
CKD
<140/90
Non Black: thiazide type diuretic, ACEI,
ARB or ARB
Black: thiazide type-diuretic or CCB
Thiazide type diuretic, ACEI, ARB or
CCB
ACEI or ARB
•
•
•
•
•
•
CHEP
General (non
elderly)
General elderly
<80 y
General ≥ 80 y
DM
CKD (no
proteinemia)
CKD +
proteinemia
<140/90
βBocker, diuretic, CCB, ACEI, ARB
<150/90
<150/90
<140/85
<140/90
ACEI or ARB
ACEI or ARB
<130/90
General <80 y
<140/90
General >80 y
DM
<150/90
<130/80
CKD
<140/90
Thiazide, βBlocker (<60y), ACEI (nonblack) or
ARB
Add CVD risk: ACEI or ARB
No CVD risk: ACEI/ARB/Thiazide/DHPCCB
ACEI or ARB
Guideline
Population
Goal BP
Initial drugs
ADA
DM
<140/80
ACEI or ARB
KDIGO
• DM and CKD
alb exc <30
mg/d
• DM and CKD
alb exc >30
mg/d
≤140/90
ACEI or ARB
NICE
General <80 y
General ≥80 y
<140/90
<150/90
<55 y; ACEI or ARB
≥55 y or black; CCB
ISHIB
Black, lower risk
TOD or CVD risk
<135/85
<130/80
Diuretic or CCB
JNC 7
General
CKD
DM
<140/90
<130/80
<130/80
≤130/80
ACEI or ARB
Important Variables For HTN Recommendations
BP
NICE
ESC/ESH
ASH/ISH AHA/AC
C/CDC
Definition
HTN
≥140/90
and
daytime
ABPM
≥135/85
≥140/90
≥140/90
Drug th/ in
low risk
pts after
non pharm
th/
βBlocker
as 1st line
≥160/100 ≥140/90
or daytime
ABPM
≥150/95
No
Yes
≥140/90
No
≥140/90
≥140/90
No
JNC 7
JNC 8
Pre HT 120-139
or 80-89
Stg 1 HT
140-159 or 9099
Stg 2 HT
≥160 or ≥100
Not
addressed
≥140/90
• <60 y,
≥140/90
• ≥60 y,
≥150/90
No
No
NICE
ESH/ESC
ASH/ISH
AHA/ACC
/CDC
JNC 7
JNC 8
Diuretic
Chorthalidone
(CTD)
Indapamide (IND)
Thiazides
(THZ),
CTD
ND
THZ
CTD
IND
THZ
THZ
THZ
CTD
IDP
Initiate
th/ with
2 drugs
Not
mentioned
Pts w/
markedly
elevated BP
≥160/90
≥160/100
≥160/100
Not
mentioned
<140/90
<160/90
(<60 y)
BP
target
<140/90
≥80 y,
<150/90
<140/90
<140/90
• Elderly <80 ≥80 y,
SBP 140<150/90
150, in fit
pts SBP
<140
• Elderly ≥80
y SBP 140150
<140/90
≥60 y,
<150/90
Under JNC 8, in all cases, targets BP should be reached within
a month of starting treatment either by increasing the dose or
by using a combination drugs
In patients ≥60 yrs who do not have DM or CKD, the goal BP
level is <150/90 mm Hg
In pts 18 - 59 yrs without major comorbidities target BP
<140/90, and in patient ≥ 60 yrs without DM, CKD, or both, the
new goal BP is <150/90 mm Hg
JNC 8 panel recommended thiazide-type diuretics as initial
therapy for most patients (include newly diagnosed HTN)
JNC 8 also recommend lifestyle interventions include use of the
DASH eating plan, weight loss, reduction in sodium intake to
<2.4 gr/day, and at least 30 minutes of aerobic activity most
days of the week
Under the JNC 8 guidelines, patients would receive a dosage
adjustment and combinations of the 4 first-line & later line
therapies ACEI/ARB, CCB, and thiazide-type diuretic
The JNC 8 does not recommend β-blockers and α-blockers as 1st
therapy due to 1 trial that showed a higher rate of CV events
with use of βB compared with use of an ARB, and another trial
in which αB resulted in inferior CV outcomes compared with use
of a diuretic
When initiating therapy, patients of African descent
without CKD should use CCBs and thiazides instead of ACE
inhibitors
ACE inhibitors and ARBs should not be used in the same
patient simultaneously