Hipertensi Finish Part 2
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HYPERTENSION
Taufan Adi Nugroho
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Batasan Hipertensi1. 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.
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Blood Pressure Classification
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 Hypertension
140–159 or 90–99
Stage 2 Hypertension
>160 or >100
BP Classification
SBP mmHg
DBP mmHg
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WHO/ISH 2003.
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ESC/ESH 2003 .
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Classification of blood pressure levels of the British Hypertension Society
Brit Med J 2004 328:634-40.
Category Systolic blood pressure Diastolic blood pressure (mmHg) (mmHg) Optimal <120 <80Normal <130 <85High-normal 130–139 85–89
HypertensionGrade 1 (mild) 140–159 90–99Grade 2 (moderate) 160–179 100–109Grade 3 (severe) 180 110
Isolated Systolic Hypertension Grade 1 140 - 159 <90Grade 2 >160 <90
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AUSTRALIA 2003
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BP Measurement TechniquesMethod 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 “white-coat” 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
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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
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……… 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, …………………..
How to measure blood pressure accurately
Australia, 2004
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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.
ESC/ESH 2003
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HIPERTENSIHIPERTENSI
Tekanan Darah :Tekanan Darah :
• Rata-rata dari 2 kali pemeriksaan• Pengukuran pada waktu yang berbeda• Pengukuran pada waktu duduk
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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
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Prevalensi Hipertensi USA 50 Juta dari total
Penduduk ( 1 dari 4 orang
dewasa) Indonesia Baliem 0,65% Sukabumi 28,6%
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Etiology
Primary hypertension 95% of all cases
Secondary hypertension 5% of all cases Chronic renal disease – most common
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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.
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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
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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
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Origin Origin CategoryCategory
Large arteries Large arteries Loss of complianceLoss of compliance(Dissecting) aneurysm(Dissecting) aneurysmPeripheral occlusive arterial disease Peripheral occlusive arterial disease
KidneyKidney NephrosclerosisNephrosclerosis
Categories of hypertensive end-organ damage
Birkenhäger and de Leeuw (1992)Birkenhäger and de Leeuw (1992)
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Hipertensi & Kerusakan Organ Target
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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
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TreatmentOverview
Goals of therapy
Lifestyle modification
Pharmacologic treatment• Algorithm for treatment of hypertension
Classification and management of BP for adults
Followup and monitoring
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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.
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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)
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Symptomatic associated with malignant HTN Headache Blurred vision Chest pain Breathlessness Nausea, vomiting Anxiety, confusion, coma Seizures
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Consequences of Malignant HTN
End Organ ComplicationsAorta Aortic disectionBrain Hipertensive encepahlopathy Cerebral Infarction or HaemmorhargeHeart Cardiac failure Myocardial ischemic or infarctionKidney Renal failure HaematuriaGastrointestinal Anorexia,nausea,vomiting,abdominal painPlacenta EclampsiaOther Micro-angiopathic haemolytic anemia
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Consequences of hypertension Cardiac disease Left ventricular failure Angina Myocardial infarction
Cerebrovascular disease Transient ischemic attacks Stroke Multi-infarct dementia Hypertensive encephalopathy
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Consequences of hypertension
Vascular disease Aortic aneurysm Occlusive peripheral vascular disease Arterial dissection
Others Progressive renal failure Hypertensive retinopathy
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Risk of Hypertension
Advancing age Positive family history of premature
cardiovascular disease Smoking Hypercholesterolemia
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Hypertension is thought to account for :- One–half of all deaths due to stroke- Up to one quarter of coronary heart
disease deaths
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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%
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Aetiology of hypertension Essential hypertension (primer/idiopathic hypertension remain uncertain (genetic and environmental factors contribute to development of
hypertension)
Secondary hypertension
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Secondary hypertension
Renal parenchymal disease, causes : - the glomerulonephritides - diabetic nephropathy - analgesic nephropathy - adult polycystic kidney disease Renal artery stenosis Primary hyperaldosteronism Phaeochromocytoma
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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
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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
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Grades of hypertension retinopathyGrade Features
I Mild narrowing or sclerosis of the retinal arteriole, no symptoms, Good general health
II Venous compression at artriovenous crossing (A-V nipping) no symptoms, good general health
III Retinal oedema, cotton wool spots, hemmorhages, often symptoms
IV All abovePapiloedema,SymptomaticCardiac and renal function often impaired, reduced survival
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Treatment Non Pharmacotherapy (lifestyle modification) Pharmacotherapy
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Tujuan:
ANGKA KESAKITAN KERUSAKAN ORGAN TARGET ANGKA KEMATIAN
Pengobatan
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Sasaran PengelolaanSasaran 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
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Strategi Penatalaksanaan HipertensiJNC: Preventif Deteksi Evaluasi Pengobatan
JNC VI, 1997
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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
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Preventif
Upaya preventif primer: Terhadap individu yang potensial
hipertensi:TD normal tinggi
Riwayat keluarga hipertensiObesitas
Konsumsi tinggi garamKurang aktifitas
Konsumsi tinggi alkohol
Diharapkan prevalensi Hipertensi turun
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Intervensi Preventif PrimerTerbukti Efektif
Turunkan BB Kurangi Garam Kurangi Alkohol Olah Raga
Efektif terbatas
Manajemen Stres Kalium Minyak Ikan (Fish oil) Kalsium Magnesium Serat Cegak makronutrien
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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
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Evaluasi Mencari penyebab hipertensi
(sekunder)
Memeriksa adanya kerusakan organ target dan penyakit lain
Mencari faktor risiko
Mengetahui respon pengobatan, efek samping dan kepatuhan pasien
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WHO-ISH Guidelines for Management of Hypertension: Stratification of Cardiovascular Risk
Blood Pressure (mm Hg)
Grade 1 Grade 2 Grade 3
Mildhypertension
Moderatehypertension
Severehypertension
Other risk factors anddisease history
SBP 140–159or DBP 90–99
SBP 160–179or DBP 100–109
SBP 180or 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
IV ACC Very high risk Very high risk Very high risk
TOD = Target-organ damageACC = Associated clinical conditions
Guidelines subcommittee. WHO-ISH Guidelines. J Hypertens 1999;17:151-183.
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BP TARGETS:
WITHOUT COMPLICATION : <140/80 mmHg
DIABETES : < 130/80 mmHg
CKD : < 130/80 mmHg
PROTEINURIA > 1 g/d : <125/75 mmHg
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Lifestyle ModificationModification Approximate SBP
reduction(range)
Weight reduction 5–20 mmHg/10 kg weight lossAdopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity 4–9 mmHgModeration of alcoholconsumption
2–4 mmHg
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For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy
Lifestyle Recommendations for Hypertension: Physical Activity
Should be prescribed to reduce blood pressure
Type Dynamic exercise- Walking- Cycling- Non-competitive swimming
Time - 45-60 minutes
Intensity - Moderate
Frequency - Four or five times per weekFI
T
T
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Treatment of Hypertension Diuretic ACE-Inh ARB Beta blocker Alpha blocker Direct renin inhibitor
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Treatment Algorithm for Adults with Systolic-Diastolic Hypertension without another compelling indication
TARGET <140/90 mmHg
Beta-blocker
Long-actingDHP-CCBARBThiazide
Lifestyle modificationtherapy
ACE-I
INITIAL TREATMENT AND MONOTHERAPY
Alpha-blockeras initial
monotherapy
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Indications for PharmacotherapyStrongly consider prescription if:
Average DBP equal or over 90 mmHg and:Hypertensive Target-organ damage (or CVD) orIndependant 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
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Diuretics
-blockers AT1 receptor blockers
Ca Antagonistα-blockers
ACE Inhibitors
2003 Guidelines for Management of Hypertension, J of Hypertension 2003
C.I. : Verapamil + ßBlocker ESH-ESC 2003
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JNC 7: Management of Hypertension by Blood Pressure Classification
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker; CCB = calcium channel blocker.Chobanian AV et al. Chobanian AV et al. JAMA. JAMA. 2003;289:2560-2572.2003;289:2560-2572.
Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed
Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed
BP ClassificationLifestyle Modification
Initial Drug TherapyWithout Compelling
IndicationWith Compelling
Indication
Normal<120/80 mm Hg
Prehypertension120-139/80-89 mm Hg
Stage 1 hypertension140-159/90-99 mm Hg
Stage 2 hypertension≥160/100 mm Hg
Encourage
Yes
Yes
Yes
No drug indicated Drug(s) for the compelling indications
Thiazide-type diuretics for most; may consider ACE-I, ARB, BB, CCB, or combination
2-drug combination for most (usually thiazide-type diuretic and ACE-I, ARB, BB, or CCB)
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Diabetes
Chronic kidney disease
Recurrent stroke prevention
Compelling Indications for Individual Drug Classes
Compelling Indication
Initial Therapy Options
Clinical Trial Basis
NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK
PROGRESS
THIAZ, BB, ACE, ARB, CCB
ACEI, ARB
THIAZ, ACEI
JNC 7 2003
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