hhd upn 2010
TRANSCRIPT
HIPERTENSIHEART DISEASE
CLINICAL EVIDENCE
Prof.DR.dr. Zainal Musthafa, SpJ P, MSi, FS, FIHAGatot Soebroto Military HospitalDept. of Cardiology, FK’UPNV’
2010
Hipertensi Heart DiseaseHHD
Hipertensi yg sudah mempunyaikomplikasi ke Jantung
DitandaiPeningkatan Pressure intracardiac
Hipertrofi ventrikelDelatasi Ventrikel
CardiomegaliMitral Regurgitasi
Penyakit jantung koroner
KLASIFIKASI
JNC III TH 1984 Normal
< 85
High Normal
85-89
HT Ringan
90-104
HT Sedang
105-114
HT Berat
> 114
Normal
140/90
HT Borderline
160/95
HT Definitif
> 160/95
1993 Usia > 18 th
Normal
130/85
High Normal
139/89HT stadium 2
179/109
HT stadium 1
159/99
HT stadium 3
209/119
HT stadium 4
210/120
Klasifikasi Tekanan DarahJNC-VI
Katagori Sistolik (mmHg)
Diastollik (mmHg)
Normal < 130 < 85
Normal Tinggi
130 – 139 85 ‑ 89
Hipertensi
Tingkat 1 140 – 159 90 ‑99
Tingkat 2 160 – 179 100
Tingkat 3 180 110
Klasifikasi Tekanan DarahJNC-VII
TUGAS ANDA
Hipertensi Emergensi
Hipertensi EnsefalopatiKejadian intrakranial akut
Diseksi aorta akutSindroma koroner akut
(angina tidak stabil / Infark miokard akut)Payah jantung kiri akutKrisis feokromositoma
Eklamsia
Hipertensi Urgensi
Accelerated and malignant hypertension
Hipertensi pasca operatif Hipertensi yg tidak terkontrol pada penderita
yang membutuhkan pembedahan akut Hipertensi yang disertai penyakit jantung koroner
HIPERTENSI PRIMER
GINJAL
ENDOKRIN / HORMONAL
Coartasio Aorta
KEHAMILAN
NEUROLOGI
Sress Akut
Volume Intravaskuler
Obat obatan
HIPERTENSI SEKUNDER
EPACE2
CathepsinTonin
chymase
Aldosterone
< 55 years aaaaaaaaaa
55 years or black patients at any age
Step 1
Step 2
Step 3
Step 4 Add: further diuretic therapy or alpha-blocker or beta-blocker
Consider seeking specialist advice
A: ACE inhibitor or ARB, if ACE inhibitor intolerant C: Calcium-channel blocker D: Diuretic (thiazide)
A
A C or D
or
+C D
National Collaborating Centre for Chronic Conditions. Hypertension: management in adults in primary care: partial update. London: Royal College of Physicians, 2006
The BHS recommendations for combining blood pressure-lowering drugs
+
BHS, British Hypertension Society; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker
2006 update
A C+ A D+
Bradykinin/NO
Inactive fragments
Angiotensin I
Angiotensin II
AT1 RECEPTOR AT2 RECEPTOR
Rationale for dual RAS blockade with an ACE inhibitor and
ARB
ARB
VasoconstrictionSodium retention
SNS activationInflammation
Growth-promoting effectsAldosteroneApoptosis
ACEACEInhibitorInhibitor
VasodilationNatriuresis
Tissue regenerationInhibition of inappropriate cell growth
DifferentiationAnti-inflammation
Apoptosis
VasodilationTissue protection
ACE-independentANG II formation by Chymase, etc.
‘Angiotensin II escape’
Bradykinin?
NO?
ACE = angiotensin converting enzyme; ARB = angiotensin II receptor blocker; AT = angiotensin; SNS = sympathetic nervous systemHanon S, et al. J Renin Angiotensin Aldosterone Syst 2000;1:147–150; Chen R, et al. Hypertension 2003;42:542–547; Hurairah H, et al. Int J Clin Pract 2004;58:173–183; Steckelings UM, et al. Peptides 2005;26:1401–1409
ACE inhibitors atau AT1 receptor blockers
Obat golongan ini mempunyai efek spesifik sebagai berikut
Memperbaiki atau mengembalikan fungsi endotel.Antiproliferasi dan antimigrasi pada
sel otot polos, netrofil, dan sel monomuklear.Efek antiplatelet.
Meningkatkan fibrinolisis endogen.Memperbaiki tonus dan kelenturan arteri.
Efek antiatherogenik.Mencegah pecahnya atherosklerosis plaque.
16
Other risk factors* and disease history
NormalSBP 120–129or DBP 80–84
High NormalSBP 130–139or DBP 85–89
Grade 1SBP 140–159or DBP 90–99
Grade 2SBP 160–179
or DBP 100–109
Grade 3SBP >180
or DBP >110
No other risk factors Average risk Average risk Low added riskModerate added
riskHigh added
risk
1–2 risk factors Low added risk Low added riskModerate added
riskModerate added
riskVery high added risk
>3 risk factors, metabolic syndrome,
target organ damage or diabetes
Moderate added risk
High added risk
High added risk
High added risk
Very high added risk
Associated clinical conditions
High added risk
Very high added risk
Very high added risk
Very high added risk
Very high added risk
CVD = cardiovascular disease; SBP = systolic blood pressure; DBP = diastolic blood pressureGuidelines Committee. J Hypertens 2003;21:1011–1053; J Hypertens 2007;21:1105–1187
Assessing CVD risk: the effect of high blood pressure
Approximate absolute risk in patients over 60 years of age
Blood Pressure (mmHg)
10–15% 15–20% 20–30% 30%
<4% 4–5% 5–8% >8%
Cardiovascular event rate in 10 years
Risk of cardiovascular death in 10 years (SCORE)
*Includes smoking, abdominal obesity and age
Africa 1 country
Australasia 2 countries
Asia 9 countries
Europe 23 countriesNorth America
3 countries
South America2 countries
-40-35-30-25-20-15-10
-50
HOPE: Risk Reduction With Ramipril 10 mg
**PP<.001; <.001; ††PP=.002.=.002.The Heart Outcomes Prevention Evaluation Study Investigators. . N Engl J Med.N Engl J Med. 2000;342:145-153.2000;342:145-153.
-26%*-26%*
-20%*-20%*
-32%*-32%*
-15%*-15%*
-34%-34%††
%%
CVD DeathCVD DeathNonfatal MINonfatal MI StrokeStroke CABG/PTCACABG/PTCA
New-OnsetNew-OnsetDiabetesDiabetes
Coronary arterydisease
Hypertension
Cardiomyopathy
Valvular disease
Left ventricular
dysfunction
Lowejectionfraction
Non-cardiacfactors
Remodeling
Symptoms
Arrhythmia
Death
Pump failure
Cohn, N Engl J Med, 1996;335
ChronicHeartfailure
catecholamineRAAS
endothelinnatriuretic peptide
cytokinegrowth factor
Evolution of the Concept of Heart Failure 1950 to 2000
1950 2000 Aetiology Hypertension CHD
Valv heart dis HypertensionDilated CMP
Natural Course Slowly progressive Slowly progressive (remodeling) or unpredictable and rapid
( coronary event )
Understanding Hemodynamicmodel Neurohormonal model
Common cause Pulmonary infection Sudden deathof death Pump failure
Arrhythmia Atrial Ventricular
Treatment goal Control edema Improve quality of life+ reduce mortality + reduce hospitalization
F r a m in g h a m H e a r t S t u d yA n n u a l in c id e n c e o f n e w c a s e s h e a r t f a i lu r e
0
5
10
15
20
25
30
35
45-54 55-64 65-74 75-84 85-94
FemaleMale
Heart Failure Classification N Y H A
Class Definition Terminology
I. Patients with cardiac diseasebut without resultinglimitation of physicalactivity
Asymptomatic
II. Patients with cardiac diseaseresulting in slight limitationof physical activity
Mild
III. Patient with cardiac diseaseresulting in markedlimitation of physicalactivity
Moderate
IV. Patient with cardiac diseaseresulting in ability to carryon any physical activitywithout discomfort
Severe
Treatment of Heart Failure:Objectives
Identify and, if possible correct the underlying cause
Correct aggravating factors: Hypertension, arrhytmia, severe anemia
Correct salt and water overload
Correct major symptoms: Dyspnoea, fatigue and edema
Improve prognosis
F r a m in g h a m S tu d y 5 Y e a r M o r ta l i ty o f H e a r t F a i lu r e
0
10
20
30
40
50
60
70
80
5 years mortality (%)
I II III IV
NYHA
TERIMA KASIHTERIMA KASIH