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Transcript of hipertensi menurut jnc7.ppt
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TERAPI HIPERTENSIMENURUT JNC 7
ADITIAWARMANSMF PENY DALAM
RS PROF MARGONO SOEKARJOPURWOKERTO
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Why JNC 7? Publication of many new studies.
Need for a new, clear, and concise guideline useful for clinicians.
Need to simplify the classification of BP.
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Pendahuluan
Hipertensi masih jadi masalah: Prevalensi meningkat Banyak yang belum diobati,diobati ttp belum mencapai
target Penyakit penyerta dan komplikasi
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Epidemiologi
> 50 % lansia (>65 tahun) Hipertensi primer merupakan 95% kasus hipertensi Insiden pada dewasa di Amerika: 29-31% Pengendalian hanya tercapai pada 34% dari seluruh
penderita hipertensi
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Patogenesis
Penyakit multifaktorial yang timbul karena interaksi antara faktor-faktor risiko tertentu
Faktor risiko: diet, stres, ras, obesitas, merokok, genetis Sistem saraf simpatis Keseimbangan modulator vasodilatasi dan
vasokonstriksi Pengaruh pada sistem otokrin setempat yang berperan
pada RSAA
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Keuntungan menurunkan tekanan darah
Average Percent Reduction
Insiden Stroke 35–40%
Infark miokard 20–25%
Gagal jantung 50%
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Teknik mengukur tekanan darah
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 “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.
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Cara mengukur tekanan darah
Posisi duduk setelah istirahat 5 menit Kaki di lantai lengan setinggi jantung Ukuran dan letak manset harus benar Stetoskop korotkoff fase 1 dan fase 5 Diukur 2 kali, > kalau perlu Kunjungan pertama ukur juga kontra lateral Hipotensi ortostatik? : sambil berdiri
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Self-Measurement of BP
Provides information on:1. Response to antihypertensive therapy2. Improving adherence with therapy 3. Evaluating white-coat HTN
Home measurement of >135/85 mmHg is generally considered to be hypertensive.
Home measurement devices should be checked regularly.
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JNC VIIClassification of Hypertension
SBP (mmHg) DBP (mmHg)
Normal < 120 and < 80
Pre-hypertension 120-139 or 80-89
Stage 1 140 - 159 or 90-99
Stage 2 > 160 or > 100
SBP = systolic blood pressure
DBP = diastolic blood pressure
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Kerusakan organ target
Jantung - hipertrofi ventrikel kiri - angina atau infark miokardiumm - gagal jantung Otak : stroke atau transient ischemic attack Penyakit ginjal kronis Penyakit arteri perifer retinopati
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Faktor risiko kardiovaskular
Merokok Obesitas Kurang aktivitas fisik Dislipidemia DM Mikroalbuminuria atau LFG < 60 ml/mnt Umur (pria>55 th; wanita>65 th) Riwayat keluarga dg penyakit jantung kardiovaskular prematur
(pria<55 th; wanita<65 th)
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Pemeriksaan laboratorium
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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Lifestyle Modification
Modification Approximate SBP reduction(range)
Weight reduction 5–20 mmHg/10 kg weight loss
Adopt DASH eating plan 8–14 mmHg
Dietary sodium reduction 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg
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Algorithm for Treatment of Hypertension
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)
as needed.
With Compelling Indications
Lifestyle Modifications
Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension(SBP 140–159 or DBP 90–99
mmHg) Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling Indications
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
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Classification and Management of BP for adults
BP classification
SBP* mmHg
DBP* mmHg
Lifestyle modification
Initial drug therapy
Without compelling indication
With compelling indications
Normal <120 and <80 Encourage
Prehypertension 120–139 or 80–89 Yes No antihypertensive drug indicated.
Drug(s) for compelling indications. ‡
Stage 1 Hypertension
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 (diuretics, ACEI, ARB, BB, CCB) as needed.
Stage 2 Hypertension
>160 or >100 Yes Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).
*Treatment determined by highest BP category.†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
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Followup and Monitoring
Patients should return for followup and adjustment of medications until the BP goal is reached.
More frequent visits for stage 2 HTN or with complicating comorbid conditions.
Serum potassium and creatinine monitored 1–2 times per year.
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Followup and Monitoring(continued)
After BP at goal and stable, followup visits at 3- to 6-month intervals.
Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits.
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Compelling Indications for Individual Drug Classes
Compelling Indication Initial Therapy Options Clinical Trial Basis
ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUSALLHAT, HOPE, ANBP2, LIFE, CONVINCE
THIAZ, BB, ACEI, ARB, ALDO ANT
BB, ACEI, ALDO ANT
THIAZ, BB, ACE, CCB
Heart failure
Postmyocardialinfarction
High CAD risk
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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
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BP target of <140/90 mm Hg for patients with uncomplicated hypertension without compelling indications
BP target of <130/80 mm Hg for patients with diabetes
• Combinations of 2 or more drugs are usually needed to achieve target BP goal
BP target of <130/80 mm Hg for patients with chronic renal disease*
• Combinations of 3 or more drugs are often needed to reach target BP goal
*Chronic kidney disease = GFR <60 mL/min per 1.73 m2 or presence of albuminuria (>300 mg/d or 200 mg/g creatinine).Chobanian AV et al. JAMA. 2003;289:2560-2572.American Diabetes Association. Diabetes Care. 2003;26(Suppl 1):S33-S50.Guidelines Committee. J Hypertens. 2003;21:1011-1053.
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JNC VIIManagement of Hypertension
Drug Combination
Diuretic(Thiazide)
Beta Blocker
ACEI or
ARBCCB
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Reference Card