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PendekatanPendekatan KomprehensifKomprehensifdalamdalam
TatalaksanaTatalaksana HipertensiHipertensi
Rochmad RomdoniDepartemen Kardiologi dan Kedokteran Vaskuler FK Unair
RS Dr Soetomo Surabaya
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Effects of blood pressure on the risk Effects of blood pressure on the risk of cardiovascular diseaseof cardiovascular disease
Average annual incidence rate per 10.000
Source : Framingham study (after Gorlin)
100
90
80
70
60
50
40
30
20
10
0
180
Systolic blood pressure (mmHg)
CHD
Stroke
CHF
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Staessen et al., (2001)Metaanalysis 27 trials of 136,124 patients, conclude :
Norman M. Kaplan, Clinical Hypertension 8th ed. P.177, 2002
Lowering blood pressure as much as possible to achieve the greatest reduction in cardiovascular complications.
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Benefits of Lowering BPBenefits of Lowering BP
Average Percent Reduction
Stroke incidence 3540%
Myocardial infarction 2025%
Heart failure 50%
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Percentages of Patients whose Hypertension is Controlled
Adapted from G. Mancia / L. Ruilope
USA: JNC VI. Arch Intern Med 1997Canada: Joffres et al. Am J Hypertens 1997 England: Colhoun et al. J Hypertens 1998France: Chamontin et al. Am J Hypertens 1998
< 140/90 mmHg < 160/95 mmHgUSA
27
England6
Canada
16
France
24
Finland
20.5
Germany
22.5
Spain
20
Scotland
17.5
Australia
19
India9
> 65 years
Marques-Vidal P et al. J Hum Hypertens 1997
- Majority of US Hypertensive Patients Are Not at Majority of US Hypertensive Patients Are Not at SBP Goal of
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We can do a better job for We can do a better job for controlling hypertensioncontrolling hypertension
Marvin MoserJ.Clin.Hypertens. 1999 ;1:91
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ESH ESC 2003
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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 140159or DBP 9099
SBP 160179or DBP 100109
SBP 180or DBP 110
I No other risk factors Low risk Med risk High risk
II 12 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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JNC VII GuidelinesJNC VII Guidelines
Amy P. Witte, Pharm.D. University of the Incarnate Word Feik School of PharmacyAdapted from JNC VII Guidelines 2003
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Changes in Blood Pressure Changes in Blood Pressure ClassificationClassification
JNC 6 Category JNC 7 Category SBP/DBP (mm Hg)
Optimal < 120/80 Normal Normal 120-129/80-84
Borderline 130-139/85-89 Prehypertension
Hypertension 140/90 Hypertension Stage 1 Stage 2 Stage 3
140-159/90-99 160-179/100-109 180/110
Stage 1 Stage 2
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Blood Pressure GoalsBlood Pressure Goals
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Target Blood Pressure GoalsTarget Blood Pressure Goals
Most patients < 140/90 mm Hg Patients with diabetes or chronic kidney
disease < 130/80 mm Hg Patients with proteinuria < 125/75 mm Hg
Amy P. Witte, Pharm.D. University of the Incarnate Word Feik School of Pharmacy JNC VII Guidelines 2003
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White Coat HypertensionWhite Coat Hypertension
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White coat hypertensionWhite coat hypertension
Office BP 140/90 mmHg, daytime ABPM < 135/85 mmHg
Clinical implications: few clinical characteristics to assist diagnosis considered in newly diagnosed HT before prescribe drug placed in context of overall risk profile common in the elderly and pregnancy needed less drug prescribing, follow up & monitoring
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Home/Ambulatory BP MonitoringHome/Ambulatory BP Monitoring
WCH in patients: manifest symptom of overmedication, or home BP < office BP
Clinical indications for ABPM: exclusion of WCH decide diagnosis in borderline HT elderly patients, pregnancy HT identify nocturnal HT, diagnosis hypotension resistant HT, as guide to treatment
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Home Blood Pressure Monitoring
Mercury sphygmomanometer
Standard for BP monitoring No calibration Need a second person to use machine May be difficult for hearing impaired or patients with arthritis
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Home Blood Pressure Monitoring
z Aneroid equipment
Inexpensive, lightweight and portable Two person operation/need stethoscope Delicate mechanism, easily damaged Needs calibration with mercury sphygmomanometer
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Home Blood Pressure Monitoring
z Automatic equipment
Contained in one unit Portable with easy-to-read digital display Expensive, fragile Must be calibrated Requires careful cuff placement
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Algorithm for Treatment of HypertensionAlgorithm for Treatment of Hypertension
Not at Goal Blood Pressure (100 mmHg)
2-drug combination for most (usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension(SBP 140159 or DBP 9099 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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Lifestyle ModificationLifestyle ModificationModification Approximate SBP reduction
(range)
Weight reduction 520 mmHg/10 kg weight loss
Adopt DASH eating plan 814 mmHg
Dietary sodium reduction 28 mmHg
Physical activity 49 mmHg
Moderation of alcohol consumption
24 mmHg
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Era of Antihypertensive AgentsEra of Antihypertensive Agents50 Classic antihypertension60 Diuretics70 Adrenoceptor-Blockers80 Calcium-Channel-Blockers90 ACE-Inhibitors2000 AIIRA (Angiotensin II Receptor
Antagonists) or ARB (Angiotensin II Receptor Blocker)Direct Renin Inhibitor
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Development of Antihypertensive Therapies
Directvasodilators
-blockers Direct Renin InhibitorPeripheral
sympatholytics
Ganglion blockers
Veratrumalkaloids
Central 2agonists
Calciumantagonists-non DHPs
-blockers
Thiazidesdiuretics
Calciumantagonists-DHPs
ARBs
1940s 1950 1957 1960s 1970s 1980s 1990s 2001
ACEinhibitors
Effectiveness
Tolerability
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What is New?
1999 WHO-ISH 1993 WHO-ISH JNC-VI / VII
Suitable first-line 6 drug 5 drug 2-3 drugdrug therapy classes classes classes
Combination Low dose Low dosetherapy combinations combinations
recommended if may be used tomonotherapy initiate therapyinadequate
101999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS
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Classification and Management Classification and Management of BP for adultsof BP for adults
Initial drug therapyBP
classificationSBP*
mmHgDBP*
mmHgLifestyle
modification Without compelling indication
With compelling indications
Normal 100 Yes Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).
Drug(s) for the compelling indications.
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.
*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
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Prescription errors / inadequate therapyPrescription errors / inadequate therapy
Inadequate drug doses or failure to titrate medicine to reach the goal.
Inappropriately low doses of drugs multiple drug regimens compliance
Consequences of monotherapy dose titration:
Uncontrolled BP
Increased dose
Increased incidence of adverse effects
Poor compliance
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Antihypertensive Agents CombinationAntihypertensive Agents Combination
ACE INHIBITOR
DIURETIC
AT-2 RB
Ca-ANTAGONIST-BLOCKER
-BLOCKER
ESC-ESH 2003
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Therapy of Hypertension with CoTherapy of Hypertension with Co--morbid conditionsmorbid conditions
Specific Indication Treatment
CHF Diuretic, ACE I, AIIRA
Angina Diuretic, blocker, CCB MI blocker MI + LV dysfunction ACE I
Diabetic nephropathy ACE I
Dyslipidemia ACE I, CCB, - blocker I S H Diuretic, CCB (DHP)
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Conclusion
Detecting and Treating Hypertension cannot be overestimated
Effective treatment of hypertension significantly reduces the risk of stroke and cardiovascular disease
Physician play a critical role in helping to decrease this healthcare burden
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Pendekatan KomprehensifdalamTatalaksana HipertensiEffects of blood pressure on the risk of cardiovascular diseaseBenefits of Lowering BPMajority of US Hypertensive Patients Are Not at SBP Goal of
