02. hypertension syakib bakri - bpjs 2015 final

8/19/2019 02. Hypertension Syakib Bakri - BPJS 2015 FINAL

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Hypertension

Syakib Bakri


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The classification of blood pressure and hypertension

Shin et al. Clinical Hypertension (2015)


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Hypertension as a Risk Factor

Hypertension is a significant risk factor for: – cerebrovascular disease

– coronary artery disease

– congestive heart failure

– renal failure – peripheral vascular disease

– dementia

– atrial fibrillation

– erectile dysfunction


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Blood Pressure andRisk of Stroke Mortality

Lancet 2002;360:190313


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Blood Pressure and Risk of !s"#e$i"Heart %isease &!H%' Mortality

Lancet 2002;360:190313


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CA eath Rate per !"#""" $erson%years

100( 9099 )0)9 *+*9 *0*, -*0

-120120139

1,01+9

160(

iastolic B$ &mmHg'

Systolic B$

&mmHg'

(")*

!")+ !!), ,), ,)- .)(

!!),!()*!(),!+).

(/)* (-)+ (-)( (/).

!*).

(+),

+!)"(-),

+/)0

/+),

+,)!

,")*

+0)/

/,)+

.eaton et al/ Arch Intern Med 1992; 1+2:+66,

ffe"t of SBP and %BP on edusted 4% Mortality: MR5!


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!$pa"t of Hi#.or$al Blood Pressure on t#e Riskof 4ardio7as"ular %isease

N Engl J Med 2001;3,+:1291*

Cumulative incidence of cv events in men without hypertensionaccording to baseline blood pressure

(130-139) mmHg

(121-129) mmHg

(< 120) mmHg


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Benefits of reatin Hypertension

8 ouner t#an 60 &redu"in BP 10+6 $$H' – redu"es t#e risk of stroke y /(1

– redu"es t#e risk of "oronary e7ent y !/1

8


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Benefits of reatin Hypertension

8 redu"tion in t#e risk of "oronary e7ents

Lancet 199*;3+0:*+*6,


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Blood pressure $easure$ent usin aus"ultation $et#od&1'

8 fter restin for + or $ore $inutes in a ?uiet@ appropriateen7iron$ent

8 7oidin s$okin@ al"o#ol@ or "affeine efore$easure$ent

8 Measurin 2 or $ore ti$es at 1 to 2$in inter7als in one7isit

8 "uff =it# a ladder at least ,0> of ar$ "ir"u$feren"e=ide; )0> to 10> of ar$ "ir"u$feren"e lon &a standard

ladder for adults: 13 "$ =ide; 22 to 2, "$ lon'


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8 Maintainin t#e upper ar$ "uff at t#e #eart le7el8 !nflatin t#e "uff rapidly and deflatin slo=ly at a speed

of 2 $$ H per #eart eat

8 !dentifyin t#e lood pressure as t#e systoli" lood

pressure at t#e first Aorotkoff sound; t#e lood pressureas t#e diastoli" lood pressure at t#e fift# Aorotkoffsound

8 Reardin t#e lood pressure as t#e diastoli" lood

pressure at t#e fourt# Aorotkoff sound in prenan"y@arterio7enous s#unt@ and "#roni" aorti" insuffi"ien"y



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8 akin lood pressure in ot# ar$s on t#e initial 7isit;suse?uently usin t#e ar$ of #i#er pressure for$easurin lood pressure

8 akin lood pressure in les to e"lude perip#eral

arterial disease@ =#en pulses in t#e lo=er etre$ities are=eak

8 Repeatin t#e $easure$ent t#ree or $ore ti$es toesti$ate t#e a7erae systoli" and diastoli" pressure in

"ase of arr#yt#$ia8 Measurin BP after 1 and 3$in standin in elderly

persons and persons =it# diaetes and suspe"tedort#ostati" #ypotension



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Blood Pressure ssess$ent:Patient position

X


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Re"o$$ended e"#ni?ue for Measurin BP:Standin BP

8 Perfor$ in patients – o7er ae 6+

– =it# diaetes

– if t#ere are sy$pto$s of postural #ypotension

8 4#e"k after 1 to + $inutes in t#e standin position and ift#e patient "o$plains of sy$pto$s suesti7e of#ypotension


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4riteria for %ianosis

8 5irst Cisit – SBP D1,0 andor %BP D90 $$H &at least t=o $ore

readins@ t#e first readin s#ould e dis"arded andt#e latter t=o a7eraed'/

– SBP D1)0 andor %BP D110 $$H s#ould edianosed as #ypertensi7e

8 re?uire i$$ediate $anae$ent/

– SBP 160–1*9 andor %BP 100–109 $$H se"ond

7isit =it#in one =eek for "onfir$ation of H./ – !f a7erae BP le7els is =it#in stae 1 rane se"ond

7isit =it#in 2 =eeks for t#e assess$ent of H./


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4riteria for %ianosis

8 Se"ond Cisit – Patients =it# $a"ro7as"ular &4%@ stroke@ or P%'@


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4riteria for %ianosis of Hypertension

8


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Benefits of


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.ot all patients are suited to #o$e $easure$ent

8 Jndue aniety in response to #i# lood pressurereadins

8 P#ysi"al or $ental disaility pre7ents a""uratete"#ni?ue or re"ordin

8 r$ not suited to lood pressure "uff &e// "oni"als#aped ar$'

8 !rreular pulse or arr#yt#$ias pre7ent a""uratereadins

8 Ka"k of interest

The vast ma4ority of patients can be trained to measure

blood pressure


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!nitial 7aluation

8


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!nitial 7aluation

8


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!nitial 7aluation

8 History – "o$pre#ensi7e fa$ily #istory s#ould e otained

=it# parti"ular attention to H.@ %M@ dyslipide$ia@pre$ature 4%@ stroke@ P% or renal disease/


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!nitial 7aluation &4lini"al History'

– %uration and pre7ious le7els of #i# BP

– Leneral sy$pto$atoloy &usualy asy$pto$ati"'

– Sy$pto$s and indi"ators of oran da$ae

– Sy$pto$s suesti7e of se"ondary "auses

– !ntake of drus or sustan"es t#at "an raise BP – Kifestyle fa"tors dietary intake of fat@ salt and al"o#ol@ s$okin

and p#ysi"al a"ti7ity@ =ei#t ain sin"e early adult life

– Sleep #istory Sleep apnea

–Past #istory or "urrent sy$pto$s of "oronary artey disease@ #eartfailure@ "erero7as"ular or perip#eral 7as"ular disease@ renaldisease@ %M@ out@ dyslipide$ia@ ast#$a or any ot#er sinifi"antillnesses@ and drus used to treat t#ose "onditions

– Pre7ious anti#ypertensi7e t#erapy


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P#ysi"al a$ination

8 =ei#t8 #ei#t

8 ody $ass inde/

8 =aist "ir"u$feren"e:

– $etaoli" syndro$e

– risk for type 2 diaetes/ Hi# risk 102 "$ in $enor )) "$ in =o$en/


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P#ysi"al a$ination &4ardia"'

8 Heart rate r#yt#$ – "topi" eats

– atrial firillation

8 Sins of "ardio$ealy

– for"eful@ laterally displa"ed api"al i$pulse KCH/8 n a""entuated aorti" se"ond sound

– espe"ially =it# %BP 7alues 100 $$ H/

8 fourt# #eart sound

– atrial enlare$ent

– in"reased 7entri"ular stiffness

8 a t#ird #eart sound

– dilated "ardio$yopat#y

– redu"ed KC fun"tion/


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P#ysi"al a$ination &do$en'

8 Periu$ili"al or flank ruits

– renal artery stenosis@ espe"ially if t#ere is a diastoli""o$ponent/

8 "ti7e@ for"eful pulsations alon t#e aorta

– nor$al findin in youn@ – ado$inal aorti" aneurys$ in older/

8 Palpation of t#e ado$en &laterally'

– trier a BP sure in indi7iduals =it#p#eo"#ro$o"yto$as

8 Poly"ysti" kidneys palpale in t#e flanks

– related renal insuffi"ien"y

– $ay e t#e etioloy of t#e patientIs #ypertension/


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P#ysi"al a$ination &.euroloi"'

8 ea$ination for – $otor ner7e fun"tion

– "ranial ner7e fun"tion@

– ait@

– stan"e@

– "oordination

8 i$portant to estalis# a aseline for t#erapeuti" follo=up/


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P#ysi"al a$ination &Perip#eral Pulses'

8 #e "arotid arteries presen"e of ruits/8 Perip#eral arteries:

– asen"e@

– redu"tion@

– asy$$etry of pulses@

– "old etre$ities@

– is"#e$i" skin lesions


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Shin et al. Clinical Hypertension

Cardiovascular Risk Factors and Subclinical 5rgan amages


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Cardiovascular Risk Factors and Subclinical 5rgan amages



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6aboratory 78aminations



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Se"ondary H.

8 Leneral 4lini"al 4lues – Se7ere or resistant H./

– n a"ute rise in BP o7er a pre7iously stale 7alue/

– Pro7en ae of onset efore puerty/

– e less t#an 30 years =it# no fa$ily #istory of H.and no oesity/


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Se"ondary H.


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%rus and sustan"es t#at "an indu"eara7ate H.

a) Cogh an! col! me!icines" eye an! nasal preparations (most o#them are o$er-the-conter) may contain sympathomimeticagents (!econgestants) that can in!ce or aggra$ate H%& schas

8 'henylephrine hy!rochlori!e" !ipi$alyl a!renaline hy!rochlori!e"tetrahy!rooline hy!rochlori!e" naphaoline hy!rochlori!e.

8 phe!rine" pse!oephe!rine hy!rochlori!e.*) Corticosteroi!s an! +na*olic Steroi!sc) &S+,s" incl!ing coi*s!) Se Hormones : strogen / progesterone (Contraception"

replacement therapy)" an!rogens" !anaol (semisynthetic

an!rogen)e) +nti!epressi$e +gents: %ricyclic anti!epressants" *spirone"

oetine" thiori!aine hy!rochlori!e#) ,mmnosppressants: cyclosporine" tacrolims" rapamycin"

paclitael

g) ietary Spplements: ginseng" natral licorice" yohim*ineh) Her*al 'ro!cts: mainly relate to !ietary spplements that


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3

,t is not st 4.'.

Paradi$ S#ift in H #erapy

1. +lter the mo!i6a*le ris #actors2. 7eep the S' < 180 an! ' < 90

3. 're$ent or halt or re!ce %

; =H" CH" CH>" C=+" C?>" '= @?etino.

8. 're$ent or control A (as H% B A ishaar!os)

5. 're$ent or control yslipi!emia. 're$ent or control n!othelial

ys#.nction

D. ?e!ce mor*i!ity an! mortality

. ,mpro$e EF+G Eality +!ste! i#e

%+G e mst

stri$e to


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Treatment Approaches:

– Kifestyle

– P#ar$a"oloi"al


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Kifestyle $anae$ent


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K!5SK M


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5b4ective of lifestyle changes in

hypertension

Ko=er lood pressure Mini$iNe dru use Redu"e o7erall "ardio7as"ular risk !$pro7e out"o$e

Maintain or i$pro7e ?uality of life


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Kife style $odifi"ation for $anain #ypertension

Chiang et al. Iornal o# the Chinese Ae!ical +ssociation D (2015)1e8D


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Potential Benefits of a Fide Spread Redu"tion in%ietary Sodiu$

8 1 $illion fe=er #ypertensi7es

8 + $illion fe=er p#ysi"ians 7isits a year for #ypertension

8 Healt# "are "ost sa7ins of O,30 to +,0 $illion per year relatedto fe=er offi"e 7isits@ drus and laoratory "osts for#ypertension

8 !$pro7e$ent of t#e #ypertension treat$ent and "ontrol rate

8 13> redu"tion in 4C%

8 otal #ealt# "are "ost sa7ins of o7er O1/3 illionyear

1/ PenN %/ Cdn J Cardiol 200)2/ offres MR/ Cdn J Cardiol 200*:23&6'

Redu"tion in a7erae dietary sodiu$ fro$ aout3+00 $ to 1*00 $1@2


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Re"o$$endations for ade?uate daily sodiu$ intake

2@300 $ sodiu$ &.a'

E 100 $$ol sodiu$ &.a'

E +/) of salt &.a4l'

E 1 le7el teaspoon oftale salt

8 ,"1 of average sodium intake is in processed foods

8 5nly !"1 is added at the table or in cooking

Age Ade2uate9ntake

&mg'

pper6imit

&mg'

!.%-" !-"" (+""

-!%0" !+"" (+""

0! andover

!("" (+""

!nstitute of Medi"ine@ 2003


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Sodiu$: Metaanalyses

#e 4o"#rane Kirary 2006;3:1,1

7erae Redu"tion of sodiu$in $day

1)00 $day

2300 $day

HypertensivesRedu"tion of BP

+/1 2/* $$H

*/23/) $$H

7erae Redu"tion of sodiu$in $day

1*00 $day

2300 $day

;ormotensives Redu"tion of BP

2/0 1/0 $$H

3/61/* $$H


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Salt $e"#anis$s leadin to #ypertension:

8 By epandin t#e etra"ellular 7olu$e

8 Hi# salt intake in"reases t#e a"tion of aldosterone

8 Hi# salt intake is a per$issi7e fa"tor for t#e #ypertensinoeni"

effe"t of aldosterone8 !n"rease in t#e sodiu$ "on"entration proressi7ely in"reases

endot#elial "ell stiffness@ "auses in#iition of endot#elial .<synt#ase and de"reases release of nitri" oide

8 4#anes in plas$a sodiu$ "on"entration are trans$itted into t#e

"ererospinal fluid trierin t#e release of "ardiotoni" steroids@na$ely@ analoues of diitalis su"# as ouaain and$arinoufaenin =#i"# "ause 7aso"onstri"tion


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;5;%B655 $R7SSR7%R76AT7 7FF7CTS 5F 97TAR< SA6T

8 t#eros"lerosis

8 Stroke

8 Keft 7entri"le #ypertrop#y

8 Proteinuri" kidney disease8 Heart failure

$ t ti h i f th d l t i di l


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$utative mechanisms of the deleterious cardiovascular

effects of e8cessive dietary sodium through blood pressure

increase independent of blood pressure


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ll "ases of #ypertension s#ould restri"t sodiu$ intake toapproi$ately 6 sodiu$ "#loride salt or 2/, sodiu$ perday y adopted t#e follo=in $easures:

8Redu"e salt for "ookin y +0>8Sustitute natural foods for pro"essed foods/

8.o sprinklin of salt on dinin tale

87oid salty sna"ks su"# as pi"kles@ "#utneys@ papad@ salted nuts

8Jse salt sustitutes "ontainin potassiu$

8 7oid $edi"ations su"# as anta"ids as t#ese are ri"# in salt

Kif t l R d ti f H t i


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ietary Sodium

Kess t#an 2300$ day

&=ost of the salt in food is >hidden? and comesfrom processed food'

ietary Potassium%aily dietary intake )0 $$ol

Calcium supplementation

;o conclusive studies for hypertension

=agnesium supplementation

;o conclusive studies for hypertension

Kifestyle Re"o$$endations for Hypertension:%ietary

High in:8 5res# fruits8 5res# 7eetales8 Ko= fat dairy produ"ts

8 %ietary and solule fire8 Plant protein

6o@ in:8 Saturated fat and "#olesterol

8 Sodiu$

===/#"s"/"/"afnanfooduideali$entindeen/p#p/



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78ercise should be prescribed as an ad4unctive to pharmacological therapy

Kifestyle Re"o$$endations for Hypertension:P#ysi"al "ti7ity

Should be prescribed to reduce blood pressure

5re?uen"y 5our to se7en days per =eekF

!ntensity ModerateI

i$e 3060 $inutesType 4ardiorespiratory "ti7ity

Falkin@ oin

4y"lin

.on"o$petiti7e s=i$$in

T



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Kifestyle Re"o$$endations for Hypertension:Fei#t Koss

Height# @eight# and @aist circumference &C' should be measuredand body mass inde8 &B=9' calculated for all adults)

Hypertensive and all patients

B=9 over (- n"ourae =ei#t redu"tion Healt#y BM!: 1)/+2,/9 k$2

aist Circumference=en -102 "$ omen -)) "$

For patients prescribed pharmacological therapy: =ei#t loss #asadditional anti#ypertensi7e effe"ts/ Fei#t loss strateies s#ould e$ploy a$ultidis"iplinary approa"# and in"lude dietary edu"ation@ in"reased p#ysi"ala"ti7ity and e#a7iour $odifi"ation

CMAJ 200*;1*6:11036



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Kifestyle Re"o$$endations for Hypertension: l"o#ol

6o@ risk alcohol consumption

; Jomen: maimm o# 9 stan!ar! !rinsKee

; Aen: maimm o# 18 stan!ar! !rinsKee

; 0-2 stan!ar! !rinsK!ay

A standard drink is about !/( ml or - o of @ine &!(1 alcohol') +/! m6 or

!( o of beer &-1 alcohol' /+ m6 or !)- o of spirits &/"1 alcohol')

Kifest le Re"o$$endations for H pertension


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Kifestyle Re"o$$endations for Hypertension:Stress Manae$ent

Hypertensive patientsin =#o$ stress appears to e an i$portant issue

!ndi7idualiNed "oniti7e e#a7ioural inter7entions are$ore likely to e effe"ti7e =#en relaation te"#ni?ues

are e$ployed/

Stress management

Be#a7iour Modifi"ation

; h l i l T t t; h l i l T t t


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;on%pharmacological Treatment;on%pharmacological Treatment

9ntervention Recommendation 78pected systolic blood

$ressure reduction &range

eight Reduction =aintain ideal body mass inde8&("%(+ kg3m('

-%!" mmHg per !" kg

@eight loss

ASH eating plan Consume diet rich in fruit# vegetables# lo@%

fat dairy products @ith reduced content ofsaturated and total fat

,%!/ mmHg

ietary sodium

restrictionReduce dietary sodium intake to !""

mmol3day &()/ g sodium or * g

sodium chloride'

(%, mmHg

$hysical Activity 7ngage in regular aerobic physicalactivity# for e8ample# brisk @alking

for at least +" min most days

/%. mmHg

Alcohol

moderation

=en (! units per @eek

omen !/ units per @eek (%/ mmHg

All put together reduce SB$ by

(" to -- mmHg


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reat$ent for #ypertension a""ordin to t#e risk

Shin et al. Clinical Hypertension (2015)21:2

t t l it#


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reat$ent alorit#$

Chiang et al. I Chinese Ae! +ss D (2015) 1-8D

reat$ent of dults =it# Systoli"%iastoli"


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reat$ent of dults =it# Systoli"%iastoli"Hypertension =it#out


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4onsiderations Reardin t#e 4#oi"e of5irstKine #erapy

8 Jse "aution in initiatin t#erapy =it# 2 drus in =#o$ ad7erse e7entsare $ore likely &e// frail elderly@ t#ose =it# postural #ypotension or=#o are de#ydrated'/

8 4 in#iitors@ renin in#iitors and RBs are "ontraindi"ated inprenan"y and "aution is re?uired in pres"riin to =o$en of "#ildearin potential/

8 Beta lo"kers are not re"o$$ended as first line t#erapy for patientsae 60 and o7er =it#out anot#er "o$pellin indi"ation/

8 %iureti"indu"ed #ypokale$ia s#ould e a7oided t#rou# t#e use ofpotassiu$ sparin aents if re?uired/

8 #e use of dual t#erapy =it# an 4 in#iitor and an RB s#ould only

e "onsidered in sele"ted and "losely $onitored people =it#ad7an"ed #eart failure or proteinuri" nep#ropat#y/

8 4in#iitorsRBsRenin in#iitors are not re"o$$ended &as$onot#erapy' for la"k patients =it#out anot#er "o$pellin indi"ation/


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BP lo=erin effe"ts fro$ anti#ypertensi7e drus

8 %ose response "ur7es for effi"a"y are relati7ely flat8 )0> of t#e BP lo=erin effi"a"y is a"#ie7ed at #alf

standard dose

8 4o$inations of standard doses #a7e additi7e loodpressure lo=erin effe"ts

Ka=/ BMJ 2003

reat$ent of Systoli" %iastoli" Hypertension


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reat$ent of Systoli"%iastoli" Hypertension=it#out


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Ratio of !n"re$ental SBP lo=erin effe"t atQstandard dose– 4o$ine or %ouleG

9 n

c r e m e n a l S B $ r e

d u c t i o n r a t i o

5

b s e r v e d 3 7 8 p e c t e

d & a d d i t i v e '

Fald et al/ 4o$ination Cersus Monot#erapy for Blood Pressure Redu"tion@The American Journal of Medicine@ Col 122@ .o 3@ Mar"# 2009


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%ru 4o$inations "ontId

8 4aution s#ould e eer"ised in "o$inin a nondi#ydropyridine 44B and a eta lo"ker to redu"e t#erisk of rady"ardia or #eart lo"k/

8 Monitor seru$ "reatinine and potassiu$ =#en"o$inin A sparin diureti"s &su"# as aldosteroneantaonists'@ 4 in#iitors andor aniotensin re"eptorlo"kers/

8 !f a diureti" is not used as first or se"ond line t#erapy@triple t#erapy s#ould in"lude a diureti"@ =#en not

"ontraindi"ated/


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rug combination in hypertension :

PreferredACE inhibitor/diuretic

ARB/diureticACE inhibitor/CCBARB/CCB

Hopkins A Bakris LK/ Curr Opin Nephrol Hyperten/2010;19:,+0,++


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Acceptable!bloc"er/diureticCCB #dihydropyridine$/!bloc"erCCB/diureticRenin inhibitor/diureticRenin inhibitor / ARBThia%ide diuretics/& '!sparingdiuretics




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(ess e)ectiveACE inhibitor/ARBACE inhibitor/!bloc"er

ARB/!bloc"erCCB #nondihydropyridine$/!bloc"erCentrally acting agent/!

bloc"er



reat$ent of !solated Systoli" Hypertension


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reat$ent of !solated Systoli" Hypertension=it#out


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4#oi"e of P#ar$a"oloi"al reat$entfor Hypertension

9ndividualied treatment8 4o$pellin indi"ations: – !s"#e$i" Heart %isease – Re"ent S Se$ent le7ationM! or nonS Se$ent le7ationM! – Keft Centri"ular Systoli" %ysfun"tion – 4erero7as"ular %isease –

Keft Centri"ular Hypertrop#y – .on %iaeti" 4#roni" Aidney %isease – Reno7as"ular %isease – S$okin

8 %iaetes Mellitus – Fit# .ep#ropat#y – Fit#out .ep#ropat#y

8 Lloal Cas"ular Prote"tion for Hypertensi7e Patients – Statins if 3 or $ore additional "ardio7as"ular risks – spirin on"e lood pressure is "ontrolled


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9ndications and contraindications of antihypertensive drugs


Choice of single drug or combination drugs according to the level of blood


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Choice of single drug or combination drugs according to the level of blood

pressure and the global cardiovascular risk


Cas"ular Prote"tion for Hypertensi7e


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Cas"ular Prote"tion for Hypertensi7ePatients: Statins

Recommendations on management of dyslipidemia# statins arerecommended in high%risk hypertensive patients @ith

established atherosclerotic disease or @ith at least + of the

follo@ing criteria:

8 Male8 e ++ or older

8 S$okin

8 otal4H%K4 ratio of 6$$olK or #i#er

8 5a$ily History of Pre$ature4C disease

8 KCH

8 4L anor$alities

8 Mi"roalu$inuria or Proteinuria

S4


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Cas"ular Prote"tion for Hypertensi7ePatients: S

Consider lo@ dose ASA

Caution should be exercised if BP is not controlled .

=onitoring and Adverse 7ffects @ith


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=onitoring and Adverse 7ffects @ith

Antihypertensive rug Therapy

d#eren"e to anti#ypertensi7e $anae$ent "an


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e i$pro7ed y a $ultiproned approa"#

8 ssess ad#eren"e to p#ar$a"oloi"al and nonp#ar$a"oloi"al t#erapy at e7ery 7isit

8 ea"# patients to take t#eir pills on a reular s"#eduleasso"iated =it# a routine daily a"ti7ity e// rus#inteet#/

8 Si$plify $edi"ation rei$ens usin lona"tin on"edaily dosin

8 JtiliNe fieddose "o$ination pills

8 JtiliNe unitofuse pa"kain e// lister pa"kain

8 Repla"in $ultiple pill anti#ypertensi7e "o$inations=it# sinle pill "o$inationsT

d#eren"e to anti#ypertensi7e $anae$ent "an


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e i$pro7ed y a $ultiproned approa"#

8 n"ourae reater patient responsiilityautono$y inreular $onitorin of t#eir lood pressure

8 du"ate patients and patientsU fa$ilies aout t#eirdiseasetreat$ent rei$ens 7erally and in =ritin

8 Jse an interdis"iplinary "are approa"# "oordinatin =it#=orksite #ealt# "are i7ers and p#ar$a"ists if a7ailale


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8 Blood pressure that remains above goal &!/"3."mmHg in non%complicated patients !+"3," mmHg inhigh risk patients' in spite of the concurrent use of of

three antihypertensive agent of different classes

8 9deally# one of the three agents should be diuretic andall agents should be prescribed at optimal doseamounts

8 9ncludes patient @hose blood pressure is controlled

@ith use of more than three medications8 In a compliant patient

esistant Hypertension


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9FF7R7;T9A6 9AD;5S9S 5F ;C5;TR5667 H


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9FF7R7;T9A6 9AD;5S9S 5F ;C5;TR5667 H


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Uncontrolled blood pressure

on 3 or more antihypertensivesConsider ambulatory blood

pressure monitoring if

available to rule out “white-

coat” phenomenon

Correct identifiable causes if

present; consider work-up ofsecondary conditions

Insure therapy meets !C-" criteria for compelling indications

#hia$ide-type#hia$ide-type

diuretic present%diuretic present%

'dd low-dose diuretic

(chlorthalidone )*+, mg

preferred; titrate to *,mgd.

/e-evaluate0ptimi$e combination as follows1

' or 2 4 C 4 5

' spironolactone #*+,- mg/d to+- mg/d$

If blood pressure

remains uncontrolled

* if not already part of

regimen, consider B for

addition if pulse >84

'6 'C7I or '/2

2 6 2eta 2lockerC6 CC2 (long-acting.

56 5iuretic

If blood pressure remains uncontrolled, adjust regimen to include:

If blood pressure

remains uncontrolled

NO

Y!

Tre!et CLB" et al# $outh Med# %&&'()&)*%+,)--.)/0

&&uggested algorithm for the treatment of resistant hypertensionuggested algorithm for the treatment of resistant hypertension


82/116

If blood pressure remains uncontrolled, adjust regimen to include:

'C7I

4 '/2

* CC2s

(different types.

alpha-blocker or

combined

alphabeta blocker

Centrally-acting

(e+g+ Clonidine.or or or

" #asodilator $e%g%

&ydrala'ine(

Trewet CLB, et al. South Med. 2!"##$2%''(#)*

Aey Messaes for t#e


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Manae$ent of Hypertension

1/ ll adults s#ould #a7e t#eir lood pressure assessed at allappropriate "lini"al 7isits/

2/


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hat?s still importantI8


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T.A&

012 A((For Your Kind Attention


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ssess$ent for Reno7as"ular Hypertension


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Patients presentin =it# t=o or $ore of t#e follo=in "lini"al "lueslisted elo= suestin reno7as"ular #ypertension s#ould ein7estiated/

!/ Sudden onset or =orsenin of #ypertension and ae ++ or -30 years

!!/ #e presen"e of an ado$inal ruit

!!!/ Hypertension resistant to 3 or $ore drus!C/ rise in "reatinine of 30> or $ore asso"iated =it# use of an

aniotensin "on7ertin enNy$e in#iitor or aniotensin !! re"eptorlo"ker

C/


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#e follo=in tests are re"o$$ended@ =#en a7ailale@ tos"reen for renal 7as"ular disease:

8 "aptoprilen#an"ed radioisotope renal s"anE

8 doppler sonorap#y

8 $aneti" resonan"e aniorap#y8 4aniorap#y &for t#ose =it# nor$al renal fun"tion'

E captopril%enhanced radioisotope renal scan is not recommended for

those @ith glomerular filtration rates *" m63min'

S"reenin for Hyperaldosteronis$


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S#ould e "onsidered for patients =it# t#e follo=in"#ara"teristi"s: – Spontaneous #ypokale$ia &-3/+ $$olK'/

– Profound diureti"indu"ed #ypokale$ia &-3/0 $$olK'/

– Hypertension refra"tory to treat$ent =it# 3 or $ore drus/

– !n"idental adrenal adeno$as/



90/116


Screening for hyperaldosteronism should includeplasma aldosterone and renin activity &or renin

concentration'

– $easured in $ornin sa$ples/

– taken fro$ patients in a sittin position after restin at least 1+

$inutes/

8 ldosterone antaonists@ RBs@ etalo"kers and"lonidine s#ould e dis"ontinued prior to testin/

8 positi7e s"reenin test s#ould lead to referral orfurt#er testin/

S"reenin for P#eo"#ro$o"yto$a


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8 Should be considered for patients @ith the follo@ingcharacteristics: – Paroys$al andor se7ere sustained #ypertension refra"tory to

usual anti#ypertensi7e t#erapy;

– Hypertension and sy$pto$s suesti7e of "ate"#ola$inee"ess &t=o or $ore of #eada"#es@ palpitations@ s=eatin@ et"';

– Hypertension triered y etalo"kers@ $onoa$ine oidasein#iitors@ $i"turition@ or "#anes in ado$inal pressure;

– !n"identally dis"o7ered adrenal $ass;

– Multiple endo"rine neoplasia &M.' 2 or 2B; 7onRe"klin#ausenIs neurofiro$atosis@ or 7on HippelKindaudisease/



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8 S"reenin for p#eo"#ro$o"yto$a s#ould in"lude a 2,#our urine for $etanep#rines and "reatinine/

8 ssess$ent of urinary CM is inade2uate/

8 nor$al plas$a $etanep#rine le7el "an e used toe"lude p#eo"#ro$o"yto$a in lo= risk patients ut t#etest is perfor$ed y fe= laoratories/

Kaoratory ests


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Kaoratory ests

$reliminary 9nvestigations of patients @ith hypertension

1/ Jrinalysis

2/ Blood "#e$istry &potassiu$@ sodiu$ and "reatinine'

3/ 5astin lu"ose

,/ 5astin total "#olesterol and #i# density lipoprotein "#olesterol&H%K'@ lo= density lipoprotein "#olesterol &K%K'@ trily"erides

+/ Standard 12leads 4L

4urrently t#ere is insuffi"ient e7iden"e to re"o$$end routine

testin of $i"roalu$inuria in people =it# #ypertension =#o donot #a7e diaetes

Kaoratory ests


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Kaoratory ests

Follo@%up investigations of patients @ith hypertension

8 %urin t#e $aintenan"e p#ase of #ypertension$anae$ent@ tests &in"ludin ele"trolytes@ "reatinine@lu"ose@ and fastin lipids' s#ould e repeated =it# a

fre?uen"y refle"tin t#e "lini"al situation/8 %iaetes de7elops in 13>year of t#ose =it# dru

treated #ypertension/ #e risk is #i#er in t#ose treated=it# a diureti" or eta lo"ker@ in t#e oese@ sedentary@

=it# #i#er fastin lu"ose and =#o #a7e un#ealt#yeatin patterns/ ssess for diaetes $ore fre?uently int#ese patients/


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#e Role of "#o"ardiorap#y

8 "#o"ardiorap#y is useful for: – ssess$ent of left 7entri"ular dysfun"tion and t#e presen"e of

left 7entri"ular #ypertrop#y

8 "#o"ardiorap#y is not useful for routine e7aluation of

#ypertensi7e patients

.4* &$eri"an' 4lassifi"ationof Blood Pressure


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of Blood Pressure

Category Systolic iastolic

5ptimal -120 and or -)0

;ormal &PreH stae 1' -130 and or -)+

High%;ormal &PreH stae 2' 130139 and or )+)9

Stage ! &$ild #ypertension ' 1,01+9 and or 9099

Stage ( &$oderate to se7ere#ypertension'

≥160 and or ≥100109

9solated Systolic Hypertension&!SH'

≥1,0 and -90

The category pertains to the highest risk blood pressure

E9SHJ9solated Systolic Hypertension)

JAMA 2003;2)9:2+60*2

ssess$ent of t#e o7erall "ardio7as"ular risk


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8 of #ypertensi7e patients #a7e ot#er"ardio7as"ular risks

8 ssess and $anae #ypertensi7e patients fordyslipide$ia@ dysly"e$ia &e// i$paired fastin lu"ose@diaetes' ado$inal oesity@ un#ealt#y eatin andp#ysi"al ina"ti7ity



99/116


Cardiovascular Risk Factors

8 Presen"e of Risk 5a"tors – !n"reasin ae – Male ender – S$okin – 5a$ily #istory of pre$ature "ardio7as"ular disease &ae- ++ in $en and - 6+ in =o$en' – %yslipide$ia – Sedentary lifestyle – Jn#ealt#y eatin

– do$inal oesity – %ysly"e$ia &diaetes@ i$paired lu"ose toleran"e@ i$paired fastin lu"ose'

8 Presen"e of aret


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Patient preparation and posture

Standardied $reparation:

$atient1/ .o a"ute aniety@ stress or pain/2/ .o "affeine@ s$okin or ni"otine in t#e pre"edin

30 $inutes/3/ .o use of sustan"es "ontainin adreneri"

sti$ulants su"# as p#enylep#rine orpseudoep#edrine &$ay e present in nasalde"onestants or op#t#al$i" drops'/

,/ Bladder and o=el "o$fortale/+/ .o ti#t "lot#in on ar$ or forear$/6/ Vuiet roo$ =it# "o$fortale te$perature

*/ Rest for at least + $inutes efore $easure$ent)/ Patient s#ould stay silent prior and durin t#e

pro"edure/

Blood Pressure ssess$ent:P ti t ti d t


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Patient preparation and posture

Standardied techni2ue:

$osture

8 #e patient s#ould e"al$ly seated =it# #is or#er a"k =ell supportedand ar$ supported at t#ele7el of t#e #eart/

8 His or #er feet s#ould

tou"# t#e floor and less#ould not e "rossed/

Difficult-to-Control


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8 9nade2uately treated hypertension&pseudo%resistance'

Hypertension

nder treatment

Treatment @ith inappropriate agents 9ncorrect blood pressure measurement

hite coat effects

=edications nonadherence $seudo%hypertension

Under Treatment (Suboptimal Medical


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Treatment)

Clinical inertia 3 the provider4s failureto increse therapy 5hen the treatmentgoal is not reached,

(ac" of "no5ledge of treatmentguidelines

2nderestimation of cardiovascular ris"

The use of spurious reason to avoidintensi6cation of therapy,


104/116

Medication Poor Aderence

High cost of treatment Comple8 medical regimen

Adverse effect of medical therapy

$oor relation bet@een doctors

and patients

Clinical clues su!!esti"e of


105/116

pseudoypertension

=arked hypertension in the absence oftarget organ damage

Antihypertensive therapy produces

symptoms consistent @ith hypotension in

the absence of successful reduction of B$ Radiological evidence of pipe stem

calcification in the brachial arteries

Brachial artery pressure higher than lo@ere8tremity pressure

Severe and isolated systolic hypertension

Clinical clues su!!esti"e of #$ite


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coat% effects

Clinic blood pressure measurements areconsistently higher than out%of%office

measurements)

$atients sho@ signs of overtreatment#

particularly orthostatic symptoms)

$atients @ith chronically high office blood

pressures values but an absence of target

organ damage)

Difficult-to-Control


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9nade2uately treated hypertension &pseudo%resistance'

True resistant hypertension

Hypertension

Associated factors:

=edications &;SA9# oral contraceptive#

sympathomimetic# corticosteroid# erythropoetin#

cyclophospamid)

78cessive alcohol consumption

Chronic kidney disease

5besity

5bstructive sleep apnea

9dentifiable causes

$rimary aldosteronism

Renovascular disease

$heocromocytoma

Coarctation of the aorta

9ntracranial tumor

reat$ent of Hypertension in Patients =it#!s"#e$i" Heart %isease


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!s"#e$i" Heart %isease

8 4aution s#ould e eer"ised =#en "o$inin a non %HP44B and a etalo"ker 8 !f anor$al systoli" left 7entri"ular fun"tion: a7oid non %HP44B &Cerapa$il or

%iltiaNe$'

8 %ual t#erapy =it# an 4! and an RB are not re"o$$ended in t#e asen"e ofrefra"tory #eart failure

8 #e "o$ination of an 4i and 44B is preferred

1/ Betalo"ker 2/ Kona"tin 44B

Stable angina

AC79 are recommended for most

patients @ith established CAE

ARBs are not inferior to AC79 in 9H

Short-actingni#e!ipine

EThose at lo@ risk @ith @ell controlled risk factors may not benefit from AC79 therapy

reat$ent of Hypertension in Patients !ith Re"ent S Se$entle7ationM! or nonS Se$ent le7ationM!


109/116

6ong%acting

ihydropyridine

CCBE

Beta%blockerand AC79 or

ARB

Recentmyocardial

infarction

Heart5ailure

G

;5


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Systoli" %ysfun"tion

Beta%blockers used in clinical trials @ere bisoprolol# carvedilol and metoprolol)

!f additional t#erapy is needed:

8 %iureti" &#iaNide for #ypertension; Koop for 7olu$e "ontrol'

8 for CHF class 99%9K or post =9 and selected patients @ith 6K dysfunction &see notes': Aldosterone

Antagonist

Systoliccardiac

dysfunction

L AC79 and Beta blocker L if AC79 intolerant: ARBTitrate doses of AC79 or ARB to those used in clinical trials

!f 4! and RB are "ontraindi"ated: HydralaNine and !sosoridedinitrate in "o$ination

!f additional anti#ypertensi7e t#erapy is needed:

8 4! RB 4o$ination

8 Kona"tin %HP44B &$lodipine'.on

di#ydropyridine44B

reat$ent of Hypertension in sso"iation Fit# Stroke

"ute Stroke:


111/116

Treat e8treme B$ elevation &systolic

((" mmHg# diastolic !(" mmHg'

by !-%(-1 over the first (/ hour

@ith gradual reduction after)89f eligible for thrombolytic therapytreat very high B$ &!,-3!!" mmHg'

Acute

ischemicStroke

Avoid e8cessive lo@ering of B$ @hich can e8acerbate ischemia

reat$ent of Hypertension in Patients =it# KeftCentri"ular Hypertrop#y


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Centri"ular Hypertrop#y

Hypertensive patients @ith left ventricular hypertrophy shouldbe treated @ith antihypertensive therapy to lo@er the rate of

subse2uent cardiovascular events

Kasodilators:

Hydralaine# =ino8idil can increase 6KH

6eft ventricular hypertrophy

AC79 ARB# CCB Thiaide iuretic BB &if age belo@ *"'

reat$ent of Hypertension in Patients =it# .on%iaeti" 4#roni" Aidney %isease


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%iaeti" 4#roni" Aidney %isease

Chronic kidney disease

and proteinuria E

4!RB:Bilateral renalartery stenosis

AC79 or ARB &if AC79 intolerant'

Combination @ith other agents

Additive therapy: #iaNide diureti"/Alternate: !f 7olu$e o7erload: loop diureti"

Target B$: !/"3." mmHg

E albumin:creatinine ratio MACRN +" mg3mmol

or urinary protein -"" mg3(/hr

=onitor serum potassium and creatinine carefully in patients @ith CO prescribed an AC79 or ARB

Combinations of a AC79 and a ARB are specifically not recommended in the absence of proteinuria

reat$ent of Hypertension in Patients =it#Reno7as"ular %isease


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Reno7as"ular %isease

Close follo@%up and intervention &angioplasty and stenting or surgery' should

be considered for patients @ith: uncontrolled hypertension despite therapy@ith three or more drugs# or deteriorating renal function# or bilateralatherosclerotic renal artery lesions &or tight atherosclerotic stenosis in a

single kidney'# or recurrent episodes of flash pulmonary edema)

oes not imply specific

treatment choice

Renovascular

disease

4aution in t#e use of 4! or RB inilateral renal artery stenosis orunilateral disease =it# solitary kidney

reat$ent of Hypertension in asso"iation =it#%iaetes Mellitus


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%iaetes Mellitus

Threshold e2ual or over !+"3," mmHg and Target belo@ !+"3," mmHg

@ith

;ephropathyE

Erinary albumin to creatinine

ratio ()" mg3mmol in men or

(),mg3mmol in @omenE

iabetes

@ithout

;ephropathyEE

9solatedSystolic

Hypertension

Systolic%

diastolic

Hypertension

E based on at least ( of + measurements

"o$ination of 2 first line drus $aye "onsidered as initial t#erapy if t#elood pressure is 20 $$H systoli"or 10 $$H diastoli" ao7e taret

Combinations of an AC79 @ith an ARB are specifically

not recommended in the absence of proteinuria

reat$ent of Hypertension in asso"iation =it#%iaetes Mellitus


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%iaetes Mellitus

=ore than + drugs may be needed to reach target values for diabetic patients

!f 4reatinine o7er 1+0 W$olK or "reatinine "learan"e elo= 30 $l$in & 0/+ $lse"'@ a loop diureti" s#ould e sustituted for a

Threshold e2ual or over !+"3," mmHg and TARD7T belo@ !+"3," mmHg

7iabetes

(%drugcombinations

AC7 9nhibitor or ARB

@ithout

;ephropathy

*, ACEInhibitor orARB

or

+, 7.P!CCB orThia%idediuretic

=onitor serum potassium and creatinine carefully in patients @ith CO prescribed an AC79 or ARB

Combinations of an AC79 @ith an ARB are specifically not recommended in the absence of proteinuria

"o$ination of 2 first linedrus $ay e "onsidered asinitial t#erapy if t#e loodpressure is 20 $$H systoli"or 10 $$H diastoli" ao7etaret/ 4o$inin an 4i and a%HP44B is re"o$$ended/

02. hypertension syakib bakri - bpjs 2015 final

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