HIPERTENSI PBL

HYPERTENSIONMAIMUN SYUKRI

Blood Pressure Classification

Normal100

BP ClassificationSBP mmHgDBP mmHg

ESC/ESH 2003 .

AUSTRALIA 2003

BP Measurement TechniquesJNC 7 2003

MethodBrief DescriptionIn-officeTwo readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm. Ambulatory BP monitoringIndicated for evaluation of white-coat HTN. Absence of 1020% BP decrease during sleep may indicate increased CVD risk. Self-measurementProvides information on response to therapy. May help improve adherence to therapy and evaluate white-coat HTN.

Office BP MeasurementUse 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

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 accuratelyAustralia, 2004

Box 2 Procedures for blood pressure measurementWhen 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

HIPERTENSI Tekanan Darah : Rata-rata dari 2 kali pemeriksaan Pengukuran pada waktu yang berbeda Pengukuran pada waktu duduk *

TD kekuatan darah ketika melewati dinding arteriJenis Hipertensi Hipertensi Resisten Hipertensi Emergensi Hipertensi UrgensiBerdasarkan Penyebab Hipertensi Primer idiopatik 90-95% Hipertensi Skunder Sistemik

Prevalensi Hipertensi USA 50 Juta dari total Penduduk ( 1 dari 4 orang dewasa) Indonesia Baliem 0,65% Sukabumi 28,6%

EtiologyPrimary hypertension95% of all casesSecondary hypertension5% of all casesChronic renal disease most common

Identifiable Causes of HypertensionSleep apneaDrug-induced or related causesChronic kidney diseasePrimary aldosteronismRenovascular diseaseChronic steroid therapy and Cushings syndromePheochromocytomaCoarctation of the aortaThyroid or parathyroid disease

Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failureBrain Stroke or transient ischemic attackChronic kidney diseasePeripheral arterial diseaseRetinopathy

Origin Category Large arteries Loss of compliance(Dissecting) aneurysmPeripheral occlusive arterial disease KidneyNephrosclerosis Categories of hypertensive end-organ damageBirkenhger and de Leeuw (1992)

*Hipertensi & Kerusakan Organ Target

Laboratory TestsRoutine 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

TreatmentOverviewGoals of therapyLifestyle modificationPharmacologic treatment Algorithm for treatment of hypertensionClassification and management of BP for adultsFollowup and monitoring

Goals of Therapy

Reduce CVD and renal morbidity and mortality. Treat to BP

Sign and SymptomsEssential HTN is usually - asymptomatic - undetected for many years - headache, BP elevated systolic beyond 200 mmHg or BP rising rapidly (can occur in malignant HTN)

Symptomatic associated with malignant HTNHeadacheBlurred visionChest painBreathlessnessNausea, vomitingAnxiety, confusion, comaSeizures

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

Consequences of hypertensionCardiac disease Left ventricular failure Angina Myocardial infarction

Cerebrovascular disease Transient ischemic attacks Stroke Multi-infarct dementia Hypertensive encephalopathy

Consequences of hypertensionVascular disease Aortic aneurysm Occlusive peripheral vascular disease Arterial dissection

Others Progressive renal failure Hypertensive retinopathy

Risk of HypertensionAdvancing agePositive family history of premature cardiovascular disease SmokingHypercholesterolemia

Hypertension is thought to account for :Onehalf of all deaths due to strokeUp to one quarter of coronary heart disease deaths

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%

Aetiology of hypertensionEssential hypertension (primer/idiopathic hypertension remain uncertain (genetic and environmental factors contribute to development of hypertension)

Secondary hypertension

Secondary hypertension

Renal parenchymal disease, causes : - the glomerulonephritides - diabetic nephropathy - analgesic nephropathy - adult polycystic kidney diseaseRenal artery stenosisPrimary hyperaldosteronismPhaeochromocytoma

Secondary hypertension

Aortic coarctationCushings syndromeDrug induced hypertension - the oral contraception pill - steroids - NSAID - immunosuppressive - sympathomimetics - anabolic steroids - erythropoieti n - monoamin oxidase inhibitorsThyrotoxicosisRare monogenic syndrome

Clinical assesment of hypertensionSign and symptomsPointers to secondary hypertensionFeatures of malignant hypertensionEnd organ damageHypertensive nephropathyLeft ventricular hypertrophyHypertensive retinopathy

Grades of hypertension retinopathy

Grade FeaturesIMild narrowing or sclerosis of the retinal arteriole, no symptoms, Good general healthIIVenous compression at artriovenous crossing (A-V nipping) no symptoms, good general healthIIIRetinal oedema, cotton wool spots, hemmorhages, often symptomsIVAll abovePapiloedema,SymptomaticCardiac and renal function often impaired, reduced survival

TreatmentNon Pharmacotherapy (lifestyle modification)Pharmacotherapy

Tujuan:

ANGKA KESAKITAN KERUSAKAN ORGAN TARGET ANGKA KEMATIAN

Pengobatan

Sasaran PengelolaanMenilai gaya hidup dan identifikasi faktor risiko kardiovaskular lain atau gangguan yang menyertai yang dapat mempengaruhi prognosis & pengobatanMengetahui penyebab tekanan darah yang tinggiMenilai adanya kerusakan organ dan penyakit kardiovaskular*

Strategi Penatalaksanaan HipertensiJNC:PreventifDeteksiEvaluasiPengobatanJNC VI, 1997

PreventifUntuk mencegah atau memperlambat terjadinya Hipertensi

Merupakan solusi jangka panjang masalah hipertensiMencegah terjadi komplikasi

Dapat menghentikan atau mengurangi biaya pengobatan dan komplikasi NHBPEP Working Group Report on Primary Prevention of Hypertension

Preventif

Upaya preventif primer: Terhadap individu yang potensial hipertensi:TD normal tinggiRiwayat keluarga hipertensiObesitasKonsumsi tinggi garamKurang aktifitasKonsumsi tinggi alkohol

Diharapkan prevalensi Hipertensi turun

Intervensi Preventif PrimerTerbukti Efektif

Turunkan BBKurangi GaramKurangi AlkoholOlah RagaEfektif terbatas

Manajemen StresKaliumMinyak Ikan (Fish oil)KalsiumMagnesiumSeratCegak makronutrien

DeteksiDilakukan di fasilitas kesehatan dengan alat ukur yang standar dan cara yang benarPasien diberitahu tentang makna TDnyaPasien dianjurkan melakukan pemeriksaan periodik sesuai dengan TD pertama

Diharapkan ditemukan kasus tahap awal

EvaluasiMencari penyebab hipertensi (sekunder)

Memeriksa adanya kerusakan organ target dan penyakit lain

Mencari faktor risiko

Mengetahui respon pengobatan, efek samping dan kepatuhan pasien

WHO-ISH Guidelines for Management of Hypertension: Stratification of Cardiovascular RiskTOD = Target-organ damage ACC = Associated clinical conditionsGuidelines subcommittee. WHO-ISH Guidelines. J Hypertens 1999;17:151-183.

Blood Pressure (mm Hg)

Grade 1

Grade 2

Grade 3

Mild hypertension

Moderate hypertension

Severe hypertension

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

BP TARGETS:

WITHOUT COMPLICATION : 1 g/d :

Lifestyle Modification

ModificationApproximate SBP reduction (range)

Weight reduction 520mmHg/10 kg weight loss

Adopt DASH eating plan 814 mmHg

Dietary sodium reduction 28 mmHg

Physical activity 49 mmHg

Moderation of alcoholconsumption 24 mmHg

For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapyLifestyle Recommendations for Hypertension: Physical Activity

Treatment of HypertensionDiureticACE-InhARBBeta blockerAlpha blocker Direct renin inhibitor

Indications for PharmacotherapyStrongly consider prescription if:Average DBP equal or over 90 mmHg and:Hypertensive Target-organ damage (or CVD) orIndependant cardiovascular risk factorsElevated systolic BPCigarette smokingAbnormal lipid profileStrong family history of premature CV diseaseTruncal obesitySedentary Lifestyle Average DBP equal or over 80 mmHg and diabetes

Diuretics-blockersAT1 receptor blockersCa Antagonist-blockersACE Inhibitors2003 Guidelines for Management of Hypertension, J of Hypertension 2003C.I. : Verapamil + BlockerESH-ESC 2003

JNC 7: Management of Hypertension by Blood Pressure ClassificationACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker; CCB = calcium channel blocker.Chobanian AV et al. JAMA. 2003;289:2560-2572.Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as neededDrug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed

BP ClassificationLifestyle ModificationInitial Drug TherapyWithout Compelling IndicationWith Compelling IndicationNormal

Compelling Indications for Individual Drug ClassesJNC 7 2003

Diabetes Chronic kidney disease Recurrent stroke prevention

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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