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HIPERTENSI
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B P = CO xB P = CO x
SVR SVR
SV x HR SV x HR BP-blood pressure-tekanan darah.BP-blood pressure-tekanan darah.SVR-systemic vascular-resistance-SVR-systemic vascular-resistance-
tahanan perifer.tahanan perifer.
SV-stroke volume-isi sekuncup.SV-stroke volume-isi sekuncup.HR-heart rate-denyut jantung.HR-heart rate-denyut jantung.
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Framingham – Study
Blood pressure and Age
Women
Men
MenWomen
Systolic BP
Diastolic BP
36 41 46 1 6 61 66 !1 !6 "1 #ears age
16$
1$
14$
13$1%$
&$
"$
!$
B P m m '
g
(annel et al 1&!"
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Defnisi danDefnisi dan
klasifkasi/kriteriaklasifkasi/kriteriamenurut WHO, ISH, JNCmenurut WHO, ISH, JNC
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• Tekanan darah sistolik lebih besar
atau sama dengan 140 mmHg, dan /
atau• Tekanan darah diastolik lebih besar
atau sama dengan 90 mmHg, atau
• Pasien dalam pengobatan antihipertensi.
HIPETE!"I
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)he *+, -. classi/ication o/ 0lood pressure)he *+, -. classi/ication o/ 0lood pressure
/or adults 1" years old/or adults 1" years old11
CategoryCategory Systolic bloodSystolic blood Diastolic bloodDiastolic bloodpressure (mmHg)pressure (mmHg) pressure (mmHg)pressure (mmHg)
OptimalOptimal22
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!5 6II
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Hypertension is one o- t"e most -reuent clinical discorders+
0
10
20
0
%0
!0
&0
'0
1832$ 03$ %03%$ !03!$ &03&$ '03'$ 804
S,5 > 1%0 mm Hg
D,5 > $0 mm Hg
age (yrs)
p r e a
l e n c e o - " y p e r t e n s i o n ( 6 )
% 11
21
%%
!%
&% &!
Prevalence ofPrevalence of
HypertensionHypertension
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10 %
90 %
"e3ondar+h+pertension
Primar+
h+pertension
enalenal
Paren3h+malParen3h+mal
6as3ular6as3ular
#thers#thers
Endo3rineEndo3rine
!eurogeni3 !eurogeni3 7is3ellaneous7is3ellaneous
8nknon8nknon
!o underl+ing 3ause
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!ase Hi"ertensi!ase Hi"ertensi
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#arl$ %r H$"erkinetiarl$ %r H$"erkineti&
'$"ertensi%n'$"ertensi%nlinical signs ! systolic bloodlinical signs ! systolic blood
pressure higher than normal"pressure higher than normal"
diastolic blood pressurediastolic blood pressurenormal.normal.
Pathophysiology ! high cardiacPathophysiology ! high cardiacoutput or tachycardia.output or tachycardia.
#oung adult patients. #oung adult patients.
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C'r%ni& %r #sta(lis'edC'r%ni& %r #sta(lis'ed
H$"ertensi%nH$"ertensi%nlinical signs ! systolic andlinical signs ! systolic and
diastolic blood pressure elevated.diastolic blood pressure elevated.
Pathophysiogy ! higher vascularPathophysiogy ! higher vascularresistance" but cardiac outputresistance" but cardiac output
normal or little lo$er thannormal or little lo$er than
normal. %ortic compliancenormal. %ortic compliancenormal.normal.
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Is%lated S$st%li&Is%lated S$st%li&
H$"ertensi%n )ISH*H$"ertensi%n )ISH*linical signs ! high systolic bloodlinical signs ! high systolic blood
pressure" diastolic blood pressurepressure" diastolic blood pressure
normal or lo$.normal or lo$.Pathophysiology ! &ecreasedPathophysiology ! &ecreased
aortic compliance caused byaortic compliance caused by
atherosclerotic in aortic andatherosclerotic in aortic andartery vascular system.artery vascular system.
'lderly patients'lderly patients
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Is%lated S$st%li&Is%lated S$st%li&
H$"ertensi%nH$"ertensi%n)ISH*)ISH*
diastolic blood pressurediastolic blood pressure
Sti(ness )atherosclerotic* of aortic andSti(ness )atherosclerotic* of aortic and
arteryartery
organ damage )morbidity + mortality*organ damage )morbidity + mortality*
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,risis 'ypertensi2e,risis 'ypertensi2e
• H+pertensie
en3ephalopath+.
• :3ute aorti3 disse3tion.
• Pulmonar+ edema.
• Pheo3hromo3+toma 3risis.
• 7:# inhibitor ; t+ramine
intera3tion.
• E3lampsia.
H+pertensie emergen3+
• H+pertension asso3iatedith 5:
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Hem%d$nami& &'an+es inHem%d$nami& &'an+es in
H$"ertensi%nH$"ertensi%n
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C%nseuen&es %-C%nseuen&es %-
'$"ertensi%n'$"ertensi%n
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C%nseuen&esC%nseuen&es
,eft Ventricular Hypertrophy,eft Ventricular Hypertrophy
-angina-angina
-arrythmias-arrythmias-myocardial infarction-myocardial infarction
-contributes to congestive heart-contributes to congestive heart
failurefailure
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C%nseuen&es &%nt.C%nseuen&es &%nt.
oronary %rtery &iseaseoronary %rtery &isease
-accelerated atherosclerosis-accelerated atherosclerosis
-decrease in oygen supply-decrease in oygen supply-in addition to high stystolic $ork-in addition to high stystolic $ork
load also contributes to risk ofload also contributes to risk of
myocardial infarctionmyocardial infarction
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C%nseuen&es &%nt.C%nseuen&es &%nt.
StrokeStroke
-Hypertension induced strokes-Hypertension induced strokes
result from hemorragic )rupture ofresult from hemorragic )rupture of
microaneurysms in cerebral vessels*microaneurysms in cerebral vessels*
or atherothrombotic )plaues inor atherothrombotic )plaues in
carotids or major cerebral arteriescarotids or major cerebral arteries
break o( and emboli/e in smallerbreak o( and emboli/e in smaller vessels conditions.* vessels conditions.*
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ar+et Or+an Dama+e inar+et Or+an Dama+e in
H$"ertensi%nH$"ertensi%nOr+an S$stemOr+an S$stem 0ani-estati%ns0ani-estati%ns
HeartHeart -1e-t 2entri&ular1e-t 2entri&ular'$"ertr%"'$ '$"ertr%"'$
-Heart -ailureHeart -ailure
-0$%&ardial is&'emia and0$%&ardial is&'emia andin-ar&ti%nin-ar&ti%n
Cere(r%2as&ular Cere(r%2as&ular Str%keStr%ke
3%rta and "eri"'eral 3%rta and "eri"'eral 2as&ular 2as&ular
- 3%rti& aneur$sm and/%r 3%rti& aneur$sm and/%rdisse&ti%ndisse&ti%n
- 3rteri%s&ler%sis 3rteri%s&ler%sis
4idne$ 4idne$ -Ne"'r%s&ler%sisNe"'r%s&ler%sis
-Renal -ailureRenal -ailure
RetinaRetina - 3rterial narr%5in+ 3rterial narr%5in+
-Hem%rr'a+es, exudates,Hem%rr'a+es, exudates,
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3R6# OR63N3R6# OR63N
D3036#D3036#
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Rek%mendasi "en+%(atanRek%mendasi "en+%(atan
'i"ertensi'i"ertensi
Pemilihan obatPemilihan obat
anti hipertensianti hipertensi
berkaitan denganberkaitan dengan
kerusakan targetkerusakan target
organ" penyakitorgan" penyakit
kardiovaskulerkardiovaskuler
dan ada+tidak adadan ada+tidak ada
&0.&0.
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ULE OF
ULE OF
HALVES
ALVES
#nl+ H:=> o? all h+pertensie patients are#nl+ H:=> o? all h+pertensie patients are :@:E:@:E
#nl+ H:=> o? those aare are#nl+ H:=> o? those aare are TE:TE o? those treated hae their#nl+ H:=> o? those treated hae their AP 5#!T#==E
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,lasses o/ antihypertensi2e agents,lasses o/ antihypertensi2e agents
&iuretics&iuretics thia/ides and relatedthia/ides and related
agentsagents loop diureticsloop diuretics 1 1 22-sparing diuretics-sparing diuretics
Sympatholytic drugsSympatholytic drugs centrally acting agentscentrally acting agents adrenergic neurone-adrenergic neurone-
blocking agentsblocking agents ββ adrenergic antagonistsadrenergic antagonists αα33 adrenergic antagonistsadrenergic antagonists
multiple-actionmultiple-actionneurohormonalneurohormonal
antagonistsantagonists
Vasodilators Vasodilators arterial dilatorsarterial dilators
arterial and venousarterial and venous
dilatorsdilators
aa4242 channel blockerschannel blockers
%' inhibitors %' inhibitors
%ngiotensin 55 %ngiotensin 55
receptor antagonistsreceptor antagonists
7oodman and 7ilman (1$$&)
8uidelines /or Selecting Drug )reatment o/8uidelines /or Selecting Drug )reatment o/
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8uidelines /or Selecting Drug )reatment o/8uidelines /or Selecting Drug )reatment o/
'ypertension'ypertensionlass of &ruglass of &rug ompellingompelling PossiblePossible ompellingompelling PossiblePossible
indicationindication indicationindication contraindicationcontraindication contraindicationcontraindication
&iuretic&iuretic Heart failureHeart failure &iabetes&iabetes 6out6out &yslipidaemia&yslipidaemia'lderly patients'lderly patients Seually activeSeually activemalesmales
Systolic hypertensionSystolic hypertension
Beta BlockersBeta Blockers %ngina %ngina Heart failureHeart failure %sthma and 7P& %sthma and 7P& &yslipidaemia&yslipidaemia %fter myocardial infarct %fter myocardial infarct PregnancyPregnancy Heart block Heart block
aa %thletes and %thletes and8achyarrhytmias8achyarrhytmias &iabetes&iabetes physically patients physically patients
Peripheral vascularPeripheral vascular diseasedisease
%' inhibitors %' inhibitors Heart failureHeart failure PregnancyPregnancy,eft ventricular,eft ventricular HyperkalaemiaHyperkalaemia dysfunctiondysfunction %fter myocardial %fter myocardial Bilateral renal arteryBilateral renal artery infarctinfarct stenosis stenosis&iabetic nephropathy&iabetic nephropathy
alciumalcium %ngina %ngina PeripheralPeripheral Heart blockHeart block bb ongestive heartongestive heart antagonistsantagonists 'lderly patients'lderly patients vascular vascular
Systolic hypertensionSystolic hypertension disease disease
%lfa Blockers %lfa Blockers Prostatic hypertrophyProstatic hypertrophy 6lucose6lucose7rthostatic7rthostatic
intoleranceintolerance&yslipidaemia&yslipidaemia hypotensionhypotension
%ngiotensine 55 %ngiotensine 55 %' inhibitors cough %' inhibitors coughHeart failureHeart failure PregnancyPregnancyantagonistsantagonists Bilateral renalBilateral renal
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Ideal HypertensionIdeal Hypertension
Agent :Agent :
• Once DailyOnce Daily
• Smooth anti HT efectSmooth anti HT efect
• Well tolerated, minimal SEWell tolerated, minimal SE
• Benecial !" efect independent o# B$ lo%eringBenecial !" efect independent o# B$ lo%ering
Int’l Forum on Angiotensin Receptor Antagonism, Monte
Carlo 1999
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9 95s to achieve the maimum5s to achieve the maimum
reduction in the total risk ofreduction in the total risk of
ardiovascular morbidity andardiovascular morbidity and
mortality:mortality:
8A9S F8A9S F
):;A)M;+)):;A)M;+)
edu3e 56< and renal morbidit+ and mortalit+.Treat to AP $140/90 mmHg or AP $1'0/&0 mmHg in
patients ith diabetes or 3hroni3 kidne+ disease.:3hiee "AP goal espe3iall+ in persons 2(0 +ears o?
age.
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&'! "I ( 'EW B$ )OA*S &'! "I ( 'EW B$ )OA*S
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!5 6I
%,67R58H0 ;7R 8H' 8R'%80'
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%,67R58H0 ;7R 8H' 8R'%80'
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AP 5lassi?i3ationAP 5lassi?i3ation
"+stoli3"+stoli3APAP
mm Hgmm Hg
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Strati=cation of Risk to CuantifyStrati=cation of Risk to Cuantify
PrognosisPrognosis
Blood Pressure mm'g
ther :is> Factors
Disease 'istory
8rade 1mild hypertension
SBP 14$71&
or DBP &$7&&
8rade %moderate hypertension
SBP 16$71!&
or DBP 1$$71$&
8rade 3se2ere hypertension
SBP 1"$
or DBP 11$
. no other ris> /actors
LOW RISK MED RISK HIGH RISK
.. 17% ris> /actors
MED RISK MED RISK VERY HIGH RISK
... 3 or more ris> /actors or )D or dia0etes HIGH RISK HIGH RISK VERY HIGH RISK
.- A,, VERY HIGH RISK VERY HIGH RISK VERY HIGH RISK
Guidelines Subcommittee. 1999. WHO-Int’l Society of Hypertension. Guidelines for Management of Hypertension. Hypertens
TOD = Target Organ Damage
Initiation o? Treatment
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Initiation o? Treatment
S,5 1%03180 mmHg or D,5 $03110 mmHg
on seeral occasions (7rades 1 2 "ypertension)
9ssess ot"er ris -actors :OD and CCD
nitate ;i-estyle easures
Strati-y 9bsolute =is
/ery Hig" Hig" edium ;o*
,egindrug
treatment
,egindrug
treatment
onitor ,5 andot"er ris -actors-or 3 & mont"s
onitor ,5 andot"er ris -actors-or & 3 12 mont"s
S,5 > 1%0 orD,5 > $0
,egin drugtreatment
S,5 < 1%0 orD,5 < $0
Continue tomonitor
S,5 > 1%0or D,5 > $0,egin drugtreatment
S,5 < 1%0or D,5 < $0Continue to
monitor
1. TOD - Taeget Organ Damage (precious WHO Stage 2 hpertension! "#$2. && - ssociate' &inica &on'ition incu'ing cinica car'io)ascuar 'isease an' rena 'isease
(pre)ious WHO Stage * hpertension! "#$
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• =ose eight i? oereight. • =imit al3ohol intake to no more than 1)% drinks per da+
euialent to approFimatel+ 1()'0 m= ethanol per da+-.• In3rease aerobi3 ph+si3al a3tiit+ to '0 ) 4( minutes on
most da+s.• edu3e sodium intake to no more than 100 mmol per da+
%.4 g sodium or g sodium 3hloride per da+-.• 7aintain adeuate intake o? dietar+ potassium
approFimatel+ 90 mmol per da+-. Inadeuate intake ma+
in3rease blood pressure.
• 7aintain adeuate intake o? dietar+ 3al3ium and magnesium ?or general health. Inadeuate intake ma+ in3rease blood
pressure.• "top smoking and redu3e intake o? dietar+ saturated ?at and
3holesterol ?or oerall 3ardioas3ular health.
The li?est+le modi?i3ations
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H$"ertensi2e HeartH$"ertensi2e Heart
DiseasesDiseases
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ar+et Or+an Dama+e inar+et Or+an Dama+e in
H$"ertensi%nH$"ertensi%nOr+an S$stemOr+an S$stem 0ani-estati%ns0ani-estati%ns
HeartHeart -1e-t 2entri&ular1e-t 2entri&ular'$"ertr%"'$ '$"ertr%"'$
-Heart -ailureHeart -ailure
-0$%&ardial is&'emia and0$%&ardial is&'emia andin-ar&ti%nin-ar&ti%n
Cere(r%2as&ular Cere(r%2as&ular Str%keStr%ke
3%rta and "eri"'eral 3%rta and "eri"'eral 2as&ular 2as&ular
- 3%rti& aneur$sm and/%r 3%rti& aneur$sm and/%rdisse&ti%ndisse&ti%n
- 3rteri%s&ler%sis 3rteri%s&ler%sis
4idne$ 4idne$ -Ne"'r%s&ler%sisNe"'r%s&ler%sis
-Renal -ailureRenal -ailure
RetinaRetina - 3rterial narr%5in+ 3rterial narr%5in+
-Hem%rr'a+es, exudates,Hem%rr'a+es, exudates,
- - -- - -t di hi t f t ll dt di hi t f t ll d
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standing history of uncontrolledstanding history of uncontrolled
hypertension sho$ing left atrialhypertension sho$ing left atrial
enlargement and left ventricularenlargement and left ventricular
hypertrophy.hypertrophy.
'6 o a ?E-year-o man $it ong-o a -year-o man $ t ong-
http://www.emedicine.com/med/images/150072-162449-3547.jpg
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6 o a E yea o a t o go a yea o a t o gstanding hypertension sho$ing left atrialstanding hypertension sho$ing left atrial
abnormality and left ventricularabnormality and left ventricular
hypertrophy $ith strain.hypertrophy $ith strain.
8$o-dimensional echocardiogram of a D@-8$o-dimensional echocardiogram of a D@-
http://www.emedicine.com/med/images/150072-162449-3548.jpg
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8$o dimensional echocardiogram of a D@8$o dimensional echocardiogram of a D@
year-old $oman )parasternal long ais vie$* year-old $oman )parasternal long ais vie$*
sho$ing concentric left ventricularsho$ing concentric left ventricular
hypertrophy.hypertrophy.
http://www.emedicine.com/med/images/150072-162449-3550.jpg
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Short ais vie$ ! concentric leftShort ais vie$ ! concentric left
ventricular hypertrophic ventricular hypertrophic
6 i f th h t ith6ross specimen of the heart $ith
http://www.emedicine.com/med/images/150072-162449-3551.jpg
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6ross specimen of the heart $ith6ross specimen of the heart $ith
concentric left ventricularconcentric left ventricular
hypertrophy.hypertrophy.
8uidelines /or Selecting Drug )reatment o/8uidelines /or Selecting Drug )reatment o/
http://www.emedicine.com/med/images/150072-162449-3542.JPGhttp://www.emedicine.com/med/images/150072-162449-3542.JPGhttp://www.emedicine.com/med/images/150072-162449-3542.JPGhttp://www.emedicine.com/med/images/150072-162449-3542.JPG
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g gg g'ypertension'ypertension
lass of &ruglass of &rug ompellingompelling PossiblePossible ompellingompelling PossiblePossibleindicationindication indicationindication contraindicationcontraindication contraindicationcontraindication
&iuretic&iuretic Heart failureHeart failure &iabetes&iabetes 6out6out &yslipidaemia&yslipidaemia'lderly patients'lderly patients Seually activeSeually activemalesmales
Systolic hypertensionSystolic hypertension
Beta BlockersBeta Blockers %ngina %ngina Heart failureHeart failure %sthma and 7P& %sthma and 7P& &yslipidaemia&yslipidaemia %fter myocardial infarct %fter myocardial infarct PregnancyPregnancy Heart block Heart block
aa %thletes and %thletes and8achyarrhytmias8achyarrhytmias &iabetes&iabetes physically patients physically patients
Peripheral vascularPeripheral vascular diseasedisease
%' inhibitors %' inhibitors Heart failureHeart failure PregnancyPregnancy,eft ventricular,eft ventricular HyperkalaemiaHyperkalaemia dysfunctiondysfunction %fter myocardial %fter myocardial Bilateral renal arteryBilateral renal artery infarctinfarct stenosis stenosis&iabetic nephropathy&iabetic nephropathy
alciumalcium %ngina %ngina PeripheralPeripheral Heart blockHeart block bb ongestive heartongestive heart antagonistsantagonists 'lderly patients'lderly patients vascular vascular
Systolic hypertensionSystolic hypertension disease disease
%lfa Blockers %lfa Blockers Prostatic hypertrophyProstatic hypertrophy 6lucose6lucose7rthostatic7rthostatic
intoleranceintolerance&yslipidaemia&yslipidaemia hypotensionhypotension
%ngiotensine 55 %ngiotensine 55 %' inhibitors cough %' inhibitors coughHeart failureHeart failure PregnancyPregnancyantagonistsantagonists Bilateral renalBilateral renal
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H3N4 9O8H3N4 9O8