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Blood Pressure Classification(JNC7)
Normal100
BP ClassificationSBP mmHgDBP mmHg
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Essential (95%) Secondary about 5%-10% of cases-Renal : renal artery stenosis ; parenchymal disease -Endocrine : Hyperaldosteronism; hyperthyroidsm ; Cushing syndrome-Vascular: Coarctation of aorta, Aortic insufficiency -Toxemia of pregnancy
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RAS (kulit hitam)Usia > 60thJenis kelamin (laki-laki dan wanita menopouse)KeturunanMerokokKolesterolPenyakit penyerta, DM, obesitas, and hyperlipidemiaTinggi garamAlkohol
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Asupan garam berlebihJumlah nefron berkurangStress Perubahan genetisObesitas Bahan-bahan yang berasal dari endotelRetensi natrium ginjalAktivitas berlebih saraf simpatisPenurunan permukaan filtrasiRenin angiotensin berlebihPerubahan membran selHiper-insulinesmia Volume cairan Konstriksi vena Preload KontraktilitasKonstriksi fungsionilHipertrofi strukturalCURAH JANTUNGTAHANAN PERIFERTEKANAN DARAH curah jantung tahanan periferHipertensi Autoregulasi =X
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Serial blood pressure determinations Blood pressure in both armsFunduscopic examination :arteriovenous nicking , hemorrhage, Exudates Palpation of thyroidAuscultationLungs for wheezing and rales Cardiac: heart beat; S3 ,S4 murmur , PMI , thrill . Abdominal and cervical ( check bruit )Palpation of pulses, especially femoral artery :delayed pulse and decrease pressure -> coarctation
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Routine screen ,including CBC ,biochemistry Urinalysis : albumin , microalbumin Serum potassium , Calcium ,Creatinine Thyroid function , Cortisol level Cholesterol , TG EKGChest X-Ray Catecholamines only in presence of diastolic pressure >110 mmHg in patient younger than 30 Echocardiography
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Heart Left ventricular hypertrophyAngina or prior myocardial infarctionPrior coronary revasculariztionBrainStroke or transient ischemic attackChronic kidney diseasePeripheral arterial diseaseRetinopathy
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Cerebrovascular disease: tromboembolic, intracranial bleeding, TIACardiovascular disease: MI, HF, CADLVH: enhanced incidence of HF, ventricular arrythmia, sudden cardiac deathPeriveral vascular diseaseRenal failure
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SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin- converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=b-blocker; CCB=calcium channel blockerJNC 7. May 2003. NIH publication 03-5233.Lifestyle modifications
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JNC 7: Classification and Management of Blood Pressure for AdultsJNC 7. May 2003. NIH publication 03-5233.
Initial Drug TherapyBP ClassificationSBP* (mm Hg)DBP* (mm Hg)Lifestyle ModificationWithout Compelling IndicationsWith Compelling IndicationsNormal
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Heart Failure:
Post- MI:High CVD risk:DM:
CRFCr > 1.5 in menCr > 1.3 in womenS/P CVAThiazide/loop, BB, ACEi, ARB, Aldosterone antagonist BB, ACE, Aldosterone antagonistThiazide, BB, ACE, Ca channel blockerThiazide, BB, ACE, ARB, CCB
ACE, ARB. For creatinine 2-3 try loop diuretic
Thiazide, ACE inhibitor
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Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.
ModificationRecommendationsApproximate Systolic Blood Pressure ReductionWeight ReductionMaintain normal body weight (BMI 18.5-24.9)5-20 mm Hg for each 10 kg weight lossAdapt eating planConsume diets rich in fruits, vegetables, low fat dairy and low saturated fat8-14 mm HgDietary sodium reductionReduce sodium to no more than 2.4 g/day sodium or 6 g/day NaCl2-8 mm HgIncrease physical activityEngage in regular aerobic activity such as walking (30 min/day on most days)4-9 mm HgModerate alcohol consumptionLimit alcohol to no more than 2 drinks/d for men and 1 drinks/day for women.2-4 mm Hg
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The cardiovascular risk profileCoexisting disordersTarget organ damageInteractions with other drugsTolerability of the drugCost of the drug
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Reduce cardiac output-adrenergic blockersCa-channel blockersDilate resistance vesselsCa-channel blockersRenin-angiotensin system blockers1 adrenoreceptor blockersNitratesReduce vascular volumeDiureticsDirect vasodilators
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CCB OK for isolated systolic hypertension (ISH)For DM: ACEi or ARB with or without diuretic, then add BB or CCBWhen ACEi causes cough, substitute ARBDont use short acting CCB (increases deaths due to arrhythmias).Alpha blockers (e.g. clonidine) only as second line (more side effects).
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THIAZIDELOOP DIURETIK
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POTASSIUM-SPARING DIURETICS
ALDOSTERON RESPTOR BLOKER
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BETA BLOKERACEI
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ARBCCB
****************Treatment determined by highest BP category Treat patients with chronic kidney disease or diabetes to BP goal of
