Departemen Ilmu Penyakit DalamDepartemen Ilmu Penyakit Dalam

FKFK UKIUKI

Jakarta, 6 Oktober 201Jakarta, 6 Oktober 20155

HIPERTENSI

Sahala Panggabean

PATOFISIOLOGI HIPERTENSI Autoregulation

BLOOD PRESSURE = CARDIAC OUTPUT x PERIPHERAL RESISTANCE Hypertension = Increased CO and/or Increaced PR Preload Contractility Functional Structural

Constriction hypertrophy Fluid Volume Volume Redistribution Sympathetic Renin- Cell Hyper nervous over- Angiostensin Membran Insulinemia Renal Decreased activity Excess Alteration Sodium filtration Retension surface Stress Obesity Excess Genetic Genetic Endothelium

Sodium Alteration Alteration derived

Intake factors

Goodman and Gilman: The Goodman and Gilman: The Pharmacological Basis of TherapeuticsPharmacological Basis of Therapeutics

Classification and Management of Classification and Management of Blood Pressure for Adults (JNC VII)Blood Pressure for Adults (JNC VII)

BPClassification

SBp*mmHg

DBp*mmHg

LifestyleMODIFICATION

INITIAL GRUG THERAPY

Without CompellingIndication

With Compelling indication

Normal <120 And <80 Encourage No AntihypertensionDrug indicated

Drug(s) for comppellingindicationPrehypertension 120-139 Or 80-89 Yes

Stage 1hypertension

140-159 Or 90-99 Yes Thiazide-type diuretics for most. May consider ACEI,ARB,BB, CCB or combination

Drug(s) for the compelling indications Other antihypertensive drugs (diuratics, ACEI, ARB, BB, CCB) as neededStage 2

hypertension<160 Or <210 Yes Two drug combination

for most (usually Thiazide-type diuretics an ACEI or ARB or BB or CCB)

DBP* diagnostic blood pressure, SBP, systotic blood pressureDBP* diagnostic blood pressure, SBP, systotic blood pressureDrug abbreviations :ACEL, angiotension converting enxyme inhibitor. ARBN, Angiotension receptor blocker. BB beta-blocker. Drug abbreviations :ACEL, angiotension converting enxyme inhibitor. ARBN, Angiotension receptor blocker. BB beta-blocker. CCB, calcium chanel blocker.CCB, calcium chanel blocker.* * ……..……..

Evaluation ObjectivesEvaluation Objectives

To identify know causes To assess presence or absence of target

organ damage and cardiovascular disease To identify other risk factors or disorders

that might guide treatment

Evaluation ComponentsEvaluation Components

  Medical history  Physical examination  Routine laboratory tests  Optional tests

MEDICAL HISTORYMEDICAL HISTORY

  Duration and classification of hypertension  Patient history of cardiovascular disease  Family history  Symptoms suggesting causes of

hypertension  Lifestyle factors   Current and previous medications

Physical ExaminationPhysical Examination

 Blood pressure readings (two or more) Verification in contralateral arm. Height, weight, and waist circumference Funduscopic examination Examination of the neck, heart, lungs,

abdomen, and extremities Neurological assessment

Laboratory Tests RecommendedLaboratory Tests RecommendedBefore Initiating TherapyBefore Initiating Therapy

 Urinalysis Complete blood count Blood chemistry (potassium, sodium,

creatinine, and fasting glucose) Lipid profile (total cholesterol and HDL

cholesterol) 12-lead electrocardiogram

OOpptional Tests and Procedurestional Tests and Procedures

  Creatinine clearance  Microalbuminuria  24-hour urinary protein  Serum calcium  Serum uric acid  Fasting triglycerides  LDL cholesterol  Glycosolated

hemoglobin

 Thyroid-Stimulating hormone

 Plasma renin activity/urinary sodium determination

 Limited echocardiography Ultrasonography Measurement of ankle/arm

index

Examples of IdentifiableExamples of IdentifiableCauses of HypertensionCauses of Hypertension

 Renovascular disease Renal parenchymal disease Polycystic kidneys Aortic coarction Pheochromocytoma

 Primary aldosteronism Cushing syndrome Hyperparathyroidism Exogenous causes

Clinical Cardiovascular Risk Factors in Clinical Cardiovascular Risk Factors in Patients with HypertensionPatients with Hypertension

Major Risk Factors : Smoking Dyslipidemia Diabetes mellitus Age older than 60 years Sex (men or postmenopausal women) Family history of cardiovascular disease

Risk Factors of Patients With Risk Factors of Patients With HypertensionHypertension

  Heart diseases  Stroke or transient ischemic attack  Nephropathy  Peripheral arterial disease  Retinopathy

Types of Hypertension Types of Hypertension

Primary HTN: also known as essential HTN. accounts for 95% cases of HTN. no universally established cause known.

Secondary HTN: less common cause of HTN ( 5%). secondary to other potentially rectifiable causes

Causes of Secondary HTNCauses of Secondary HTN Common

Intrinsic renal diseaseRenovascular diseaseMineralocorticoid excess Sleep Breathing disorder

Risk Stratification of Risk Stratification of HypertensionHypertension

Risk Group A No risk factorsNo target organ disease/clinical cardiovascular disease

 Risk Group B At least one risk factor, not including diabetes

No target organ disease/clinical cardiovascular disease Risk Group C Target organ disease /clinical cardiovascular disease and/or diabetes.

With or without other risk factors

Treatment Strategies andTreatment Strategies andRisk StratificationRisk Stratification

High-normal(130-139/85-89) Stage 1(140-159/90-99) Stages 2 and 3(≥160/ ≥ 100)

Lifestyle modification   Lifestyle modification(up to 12 months)  Drug therapyLifestyle modification

Lifestyle modification  Lifestyle modification(up to 6 months)** Drug therapyLifestyle modification

Drug therapyLifestyle modification Drug therapyLifestyle modification Drug therapyLifestyle modification

Or those with heart failure, renal insufficiency, or diabetesOr those with heart failure, renal insufficiency, or diabetesFor those with multiple risk factors, clinicians should consider drugs as initial Therapy plus lifestyle For those with multiple risk factors, clinicians should consider drugs as initial Therapy plus lifestyle modification modification

Blood PressureBlood PressureStages (mmHg)Stages (mmHg) Risk Group ARisk Group A Risk Group B Risk Group C Risk Group B Risk Group C

Goal of HypertensionGoal of HypertensionPrevention and ManagementPrevention and Management

  To reduce morbidity and mortality by the least intrusive means possible. This may be accomplished by-   Achieving and maintaining SBP < 140 Hg and DBP < 90 mm Hg.- Controlling other cardiovascular risk factors.

Lifestyle Modifications( Non-Lifestyle Modifications( Non-Pharmocologic Treatment of Pharmocologic Treatment of

Hypertension)Hypertension)For Prevention and For Overall andManagement Cardiovascular Health  Lose weight if overweight  Limit alcohol intake  Increase aerobic physical activity  Reduce sodium intake  Maintain adequate intake of

Potassium

  Maintain adequate intake of calcium and magnesium

  Stop Smoking  Reduce dietary saturated fat and

cholesterol

Pharmacologic TreatmentPharmacologic Treatment

  Decreases cardiovascular morbidity and mortality based on randomised controlled trials

  Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality

Special ConsiderationsSpecial ConsiderationsIn Selecting Drug TherapyIn Selecting Drug Therapy

   DemographicsCoexisting diseases and Therapies   Quality of life   Physiological and biochemical measurements   Drug interactions   Economic considerations

Drug TherapyDrug Therapy

  A low dose of initial drug should be used slowly titrating upward.

  Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours

  Combination therapies may provide additional efficacy with fewer adverse effects

Classes ofClasses ofAntihypertensive DrugsAntihypertensive Drugs

  ACE inhibitors  Adrenergic inhibitors  Angiotensin II receptor blockers  Calcium antagonists  Direct vasodilators  Diuretics

Combination TherapiesCombination Therapies

β – adrenergic blockers and diuretics  ACE inhibitors and diuretics  Angiotensin II receptor antagonists and diuiretics   Calcium antagonists and ACE inhibitors   Other combinations

FolFolllowupowup

   Follow up within 1 to 2 months after initiating therapy   Recognize that high-risk patients often require high

dose or combination therapies and shorter intervals between changes in medications

   Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose

   Consider reducing dose and number of agents after 1 year at or below goal.

Causes for inadequateCauses for inadequateResponse to drug TherapyResponse to drug Therapy

  Pseudo resistance  Non adherence to therapy  Volume overload  Drug-related causes  Associated conditions  Identifiable cause of hypertension

Hypertensive Hypertensive EmergenciesEmergenciesAnd And UrgenciesUrgencies Emergencies require immediate blood

pressure reduction to prevent or limit target organ damage

Urgencies benefit from reducing blood pressure within a few hours

Elevated blood pressure alone rarely requires emergency therapy

Fast-acting drugs are available.

Drugs Available forDrugs Available forHypertensive EmergenciesHypertensive Emergencies Vasodilators Adrenergic Inhibitors Nitroprusside Labetalol Nicardipine Esmolol Fenoldopam Phentolamine Nitroglycerin Enalaprilat Hydralazine

Lifestyle Modifications Lifestyle Modifications (JNC VII)(JNC VII)

Not at Goal Blood Pressure (<140/90 mmHg)Not at Goal Blood Pressure (<140/90 mmHg)(<130/80 mmHg for patiens with diabetes or chronic kidney disease(<130/80 mmHg for patiens with diabetes or chronic kidney disease

Initial Drug ChoicesInitial Drug Choices

Without Compelling Without Compelling IndicationIndication

With Compelling IndicationWith Compelling Indication

Stage 1Stage 1HypertensionHypertension(SBP 140-159 or DBP (SBP 140-159 or DBP 90-99 mmHg90-99 mmHg

Thiazide -type diuretc Thiazide -type diuretc for most. May consider for most. May consider ACEI, ARB, BB, CCB, ACEI, ARB, BB, CCB, or combinationor combination

Stage 2Stage 2HypertensionHypertension(SBP >=160 or DBP (SBP >=160 or DBP >=100 mmHg>=100 mmHg

To-drug combination for To-drug combination for most (usually thiazide - most (usually thiazide - type diuretic and ACEI type diuretic and ACEI or ARB or BB or CCB)or ARB or BB or CCB)

Drug(S) for the Drug(S) for the compelling indications compelling indications (se table *(se table *

Other antihypertensive Other antihypertensive drugs ( diuretics, ACEI, drugs ( diuretics, ACEI, ARB, BB, CCB) as ARB, BB, CCB) as neededneeded

NOT AT GOAL BLOOD PRESSURENOT AT GOAL BLOOD PRESSURE

Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialistconsultation with hypertension specialist

DBP, diastolic blood pressure, SBP, systolic blood pressureDBP, diastolic blood pressure, SBP, systolic blood pressureDrug abbreviations: ACEI= angiotensin converting enzyme inhibitor; ARB=,angiotensin Drug abbreviations: ACEI= angiotensin converting enzyme inhibitor; ARB=,angiotensin

receptor blocker; BB= beta-blocker; CCB= calcium channel blocker. receptor blocker; BB= beta-blocker; CCB= calcium channel blocker.

Lifestyle Modifications

Lose weight Maintain potassium Limit alcohol Maintain calsium and

magnesium Increase physical activity Stop Smoking Reduce sodium Reduce saturated fat

cholesterol

Not at Goal Blood PressureNot at Goal Blood Pressure

ReferenceReferenceGoodman and Gilman. Medical Diagnosis and Treatment. 2015. Mc Goodman and Gilman. Medical Diagnosis and Treatment. 2015. Mc graw Hill Education; Edition 54graw Hill Education; Edition 54thth. Chapter 11: . Chapter 11: Systemic Hypertension. Systemic Hypertension. Page: 432-462.Page: 432-462.

Buku Ajar Ilmu Penyakit Dalam. Interna Publishing: jilid 2. Edisi VI Buku Ajar Ilmu Penyakit Dalam. Interna Publishing: jilid 2. Edisi VI hal. 2259-2305: Pendekatan Klinis Hipertensi.hal. 2259-2305: Pendekatan Klinis Hipertensi.

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