HIPERTENSI

Dr. Refli Hasan, SpPD, SpJP(K)Dr. Refli Hasan, SpPD, SpJP(K)

Dept. Cardiology and Vascular Medicine Dept. Cardiology and Vascular Medicine Fac. Medicine USU / Adam Malik Fac. Medicine USU / Adam Malik

HospitalHospital

B P = CO x B P = CO x SVRSVR

SV x HRSV x HRBP-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.

Framingham – StudyBlood pressure and Age

WomenMen

MenWomen

Systolic BP

Diastolic BP

36 41 46 51 56 61 66 71 76 81 Years age

160

150

140

130

120

90

80

70

BP

mm

Hg

Kannel et al 1978

Definisi dan Definisi dan klasifikasi/kriteria klasifikasi/kriteria

menurut WHO, ISH, JNC.menurut WHO, ISH, JNC.

• 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 anti hipertensi.

HIPERTENSI

The JNC VI classification of blood pressure The JNC VI classification of blood pressure for adults ³18 years oldfor adults ³18 years old11

CategoryCategory Systolic blood Systolic blood Diastolic bloodDiastolic bloodpressure (mmHg)pressure (mmHg) pressure (mmHg)pressure (mmHg)

OptimalOptimal22 <120<120 andand <80<80

NormalNormal <130<130 andand <85<85

High normalHigh normal 130–139130–139 oror 85–8985–89

HypertensionHypertension33 Stage 1Stage 1 140–159140–159 oror 90–9990–99Stage 2Stage 2 160–179160–179 oror 100–109100–109Stage 3Stage 3 180180 oror 110110

11Not taking antihypertensives and not acutely illNot taking antihypertensives and not acutely ill22Optimal blood pressure with respect to cardiovascular risk is Optimal blood pressure with respect to cardiovascular risk is <<120 mmHg 120 mmHg

systolic and systolic and <<80 mmHg diastolic.80 mmHg diastolic.33Based on the average of two or more readings taken at each of two or more Based on the average of two or more readings taken at each of two or more visits after an initial screening.visits after an initial screening.

Based on JNC VI, National Institutes of Health, Nov. 1997Based on JNC VI, National Institutes of Health, Nov. 1997

Definitions and classification of blood pressure levels

(mmHg), 1999 WHO-ISH guidelines

Category Systolic Diastolic

Optimal < 120 < 80

Normal <130 < 85

High-normal 130-139 85-89

Grade 1 hypertension (mild) 140-159 90-99

Subgroup: borderline 140-149 90-94

Grade 2 hypertension (moderate) 160-179 100-109

Grade 3 hypertension (severe) > 180 > 110

Isolated systolic hypertension > 140 < 90

Subgroup: borderline 140-149 < 90

When a patient’s systolic and diastolic blood pressures fall into different categories, the higher category should apply.

Guidelines Subcommittee. 1999. WHO-Int’l Society of Hypertension. Guidelines for Management of Hypertension. J Hypertens 1999;17:151-83.

JNC VII

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

Hypertension is one of the most frequent clinical discorders.

0

10

20

30

40

50

60

70

18-29 30-39 40-49 50-59 60-69 70-79 80+

SBP > 140 mm Hg DBP > 90 mm Hg

age (yrs)

pre

vale

nce

of

hyp

erte

nsi

on

(%

)

4 11

21

44

54

64 65

Prevalence of Prevalence of HypertensionHypertensionPrevalence of Prevalence of HypertensionHypertension

10 %

90 %

Secondary hypertension

Primary hypertension

Renal Renal Parenchymal Parenchymal Vascular Vascular Others Others

Endocrine Endocrine Neurogenic Neurogenic Miscellaneous Miscellaneous UnknownUnknown

No underlying cause

Fase HipertensiFase Hipertensi

Early or Hyperkinetic Early or Hyperkinetic hypertensionhypertension

Clinical signs : systolic blood Clinical signs : systolic blood pressure higher than normal, pressure higher than normal, diastolic blood pressure diastolic blood pressure normal.normal.

Pathophysiology : high cardiac Pathophysiology : high cardiac output or tachycardia.output or tachycardia.

Young adult patients.Young adult patients.

Chronic or Established Chronic or Established HypertensionHypertension

Clinical signs : systolic and Clinical signs : systolic and diastolic blood pressure diastolic blood pressure elevated.elevated.

Pathophysiogy : higher vascular Pathophysiogy : higher vascular resistance, but cardiac output resistance, but cardiac output normal or little lower than normal or little lower than normal. Aortic compliance normal. Aortic compliance normal.normal.

Isolated Systolic Isolated Systolic Hypertension (ISH)Hypertension (ISH)

Clinical signs : high systolic blood Clinical signs : high systolic blood pressure, diastolic blood pressure pressure, diastolic blood pressure normal or low.normal or low.

Pathophysiology : Decreased Pathophysiology : Decreased aortic compliance caused by aortic compliance caused by atherosclerotic in aortic and atherosclerotic in aortic and artery vascular system.artery vascular system.

Elderly patientsElderly patients

Crisis HypertensiveCrisis Hypertensive

• Hypertensive encephalopathy.

• Acute aortic dissection.• Pulmonary edema.• Pheochromocytoma crisis.• MAO inhibitor + tyramine

interaction.• Eclampsia.

Hypertensive emergency

• Hypertension associated with CAD.

• Accelerated and malignant hypertension.

• Severe hypertension in the kidney transplant patient.

• Postoperative hypertension.• Uncontrolled hypertension

in the patient with emergency surgery.

Hypertensive urgency

Hemodynamic changes in Hemodynamic changes in HypertensionHypertension

Consequences of Consequences of hypertensionhypertension

ConsequencesConsequences

Left Ventricular HypertrophyLeft Ventricular Hypertrophy

-angina-angina

-arrythmias-arrythmias

-myocardial infarction-myocardial infarction

-contributes to congestive heart -contributes to congestive heart failurefailure

Consequences cont…Consequences cont…

Coronary Artery DiseaseCoronary Artery Disease

-accelerated atherosclerosis-accelerated atherosclerosis

-decrease in oxygen supply-decrease in oxygen supply

-in addition to high stystolic work -in addition to high stystolic work load also contributes to risk of load also contributes to risk of myocardial infarctionmyocardial infarction

Consequences cont…Consequences cont…

StrokeStroke

-Hypertension induced strokes -Hypertension induced strokes result from hemorragic (rupture of result from hemorragic (rupture of microaneurysms in cerebral vessels) microaneurysms in cerebral vessels) or atherothrombotic (plaques in or atherothrombotic (plaques in carotids or major cerebral arteries carotids or major cerebral arteries break off and embolize in smaller break off and embolize in smaller vessels conditions.)vessels conditions.)

Target Organ Damage in Target Organ Damage in HypertensionHypertension

Organ SystemOrgan System ManifestationsManifestationsHeartHeart -Left ventricular Left ventricular

hypertrophyhypertrophy-Heart failureHeart failure-Myocardial ischemia and Myocardial ischemia and infarctioninfarction

CerebrovascularCerebrovascular StrokeStroke

Aorta and peripheral Aorta and peripheral vascularvascular

-Aortic aneurysm and/or Aortic aneurysm and/or dissectiondissection-ArteriosclerosisArteriosclerosis

KidneyKidney -NephrosclerosisNephrosclerosis-Renal failureRenal failure

RetinaRetina -Arterial narrowingArterial narrowing-Hemorrhages, exudates, Hemorrhages, exudates, papilledemapapilledema

TARGET ORGAN TARGET ORGAN DAMAGEDAMAGE

Rekomendasi pengobatan Rekomendasi pengobatan hipertensihipertensi

Pemilihan obat anti Pemilihan obat anti hipertensi hipertensi berkaitan dengan berkaitan dengan kerusakan target kerusakan target organ, penyakit organ, penyakit kardiovaskuler dan kardiovaskuler dan ada/tidak ada DM.ada/tidak ada DM.

RULE OF HALVESRULE OF HALVES

Only HALF of all hypertensive patients are Only HALF of all hypertensive patients are AWAREAWARE

Only HALF of those aware areOnly HALF of those aware are TREATED TREATED

Only HALF of those treated have their Only HALF of those treated have their BP CONTROLLEDBP CONTROLLED

= 50% x 50% x 50%

Classes of antihypertensive agentsClasses of antihypertensive agents

DiureticsDiuretics thiazides and related agentsthiazides and related agents loop diureticsloop diuretics KK++-sparing diuretics-sparing diuretics

Sympatholytic drugsSympatholytic drugs centrally acting agentscentrally acting agents adrenergic neurone-adrenergic neurone-

blocking agentsblocking agents adrenergic antagonistsadrenergic antagonists 11 adrenergic antagonists adrenergic antagonists multiple-action multiple-action

neurohormonal antagonistsneurohormonal antagonists

VasodilatorsVasodilators arterial dilatorsarterial dilators arterial and venous dilatorsarterial and venous dilators

CaCa2+ 2+ channel blockerschannel blockers

ACE inhibitorsACE inhibitors

Angiotensin II receptor Angiotensin II receptor antagonistsantagonists

Goodman and Gilman (1996)

Guidelines for Selecting Drug Treatment of Guidelines for Selecting Drug Treatment of HypertensionHypertension

Class of DrugClass of Drug Compelling Compelling PossiblePossible CompellingCompelling PossiblePossibleindicationindication indicationindication contraindicationcontraindication contraindicationcontraindication

DiureticDiuretic Heart failureHeart failure DiabetesDiabetes GoutGout DyslipidaemiaDyslipidaemiaElderly patientsElderly patients Sexually active malesSexually active malesSystolic hypertension Systolic hypertension

Beta BlockersBeta Blockers AnginaAngina Heart failure Heart failure Asthma and COPDAsthma and COPD DyslipidaemiaDyslipidaemiaAfter myocardial infarct After myocardial infarct PregnancyPregnancy Heart blockHeart block a a

Athletes and Athletes and TachyarrhytmiasTachyarrhytmias DiabetesDiabetes physically patients physically patients

Peripheral vascularPeripheral vascular diseasedisease

ACE inhibitorsACE inhibitors Heart failureHeart failure PregnancyPregnancyLeft ventricular Left ventricular HyperkalaemiaHyperkalaemia dysfunctiondysfunctionAfter myocardial After myocardial Bilateral renal arteryBilateral renal artery infarctinfarct stenosis stenosisDiabetic nephropathyDiabetic nephropathy

CalciumCalcium AnginaAngina PeripheralPeripheral Heart block Heart block bb Congestive heartCongestive heart antagonistsantagonists Elderly patientsElderly patients vascularvascular

Systolic hypertensionSystolic hypertension disease disease

Alfa Blockers Alfa Blockers Prostatic hypertrophyProstatic hypertrophy Glucose Glucose Orthostatic Orthostatic

intoleranceintoleranceDyslipidaemiaDyslipidaemia hypotensionhypotension

Angiotensine IIAngiotensine II ACE inhibitors coughACE inhibitors coughHeart failureHeart failure PregnancyPregnancyantagonistsantagonists Bilateral renalBilateral renal

artery stenosisartery stenosisHyperkalaemiaHyperkalaemia

Ideal Hypertension Ideal Hypertension Agent :Agent :

• Once DailyOnce Daily

• Smooth anti HT effectSmooth anti HT effect

• Well tolerated, minimal SEWell tolerated, minimal SE

• Beneficial CV effect independent of BP loweringBeneficial CV effect independent of BP lowering

Int’l Forum on Angiotensin Receptor Antagonism, Monte Carlo 1999

“ “Is to achieve the maximum Is to achieve the maximum reduction in the total risk of reduction in the total risk of Cardiovascular morbidity and Cardiovascular morbidity and mortality”mortality”

GOALS OF GOALS OF TREATMENTTREATMENT

Reduce CVD and renal morbidity and mortality. Treat to BP <140/90 mmHg or BP <130/80 mmHg in

patients with diabetes or chronic kidney disease. Achieve SBP goal especially in persons >50 years of

age.

JNC VI - NEW BP GOALSJNC VI - NEW BP GOALS <140/<90 and lower if tolerated<140/<90 and lower if tolerated

<130/<85 in diabetics (types 1 &2)<130/<85 in diabetics (types 1 &2)

<130/<85 in cardiac failure<130/<85 in cardiac failure

<130/<85 in renal failure<130/<85 in renal failure

<125/<75 in renal failure with proteinuria > 1.0 <125/<75 in renal failure with proteinuria > 1.0 gm/24 hrgm/24 hr

Adapted from JNC VI.1997

WHO-ISH new BP GoalsWHO-ISH new BP Goals < 140/90 in elderly< 140/90 in elderly < 130/85 in young, middle-aged< 130/85 in young, middle-aged < 130/85 in diabetic< 130/85 in diabetic

JNC VI

ALGORITHM FOR THE TREATMENT OF ALGORITHM FOR THE TREATMENT OF HYPERTENSIONHYPERTENSION

Begin or Continue Lifestyle ModificationBegin or Continue Lifestyle Modification

Not at Goal Blood Pressure (< 140/90 mm Hg)Not at Goal Blood Pressure (< 140/90 mm Hg)Lower goals for patients with diabetes or renal disease Lower goals for patients with diabetes or renal disease

Initial Drugs Choices*Initial Drugs Choices*Uncomplicated HypertensionUncomplicated Hypertension Compelling IndicationCompelling IndicationDiureticsDiuretics Diabetes mellitus (type 1) with proteinuriaDiabetes mellitus (type 1) with proteinuriaBeta-blockersBeta-blockers * ACE Inhibitors * ACE Inhibitors

Heart failureHeart failureSpecific indications for theSpecific indications for the * ACE inhibitors* ACE inhibitorsFollowing DrugsFollowing Drugs * Diuretics* DiureticsACE inhibitorsACE inhibitors Isolated systolic hypertension (older persons)Isolated systolic hypertension (older persons)Angiotensine II receptors blockersAngiotensine II receptors blockers * diuretics preferred * diuretics preferredAlpha - blockersAlpha - blockers * Long acting dihydropyridine * Long acting dihydropyridineAlpha-beta-blockersAlpha-beta-blockers * calcium antagonists * calcium antagonistsBeta-blockersBeta-blockers Myocardial infactionMyocardial infactionCalcium AntagonistsCalcium Antagonists * Beta-blockers (non ISA) * Beta-blockers (non ISA)DiureticsDiuretics * ACE inhibitors (with systolic dysfunction) * ACE inhibitors (with systolic dysfunction)

* Start with a low dose of a long acting once daily drug, and titrate dose* Start with a low dose of a long acting once daily drug, and titrate dose* Low-dose combinations may be appropriate* Low-dose combinations may be appropriate

BP ClassificationBP Classification

Systolic Systolic BPBP

mm Hgmm Hg

Diastolic Diastolic BPBP

mm Hgmm Hg Lifestyle Lifestyle

ModificationModification

Initial Drug TherapyInitial Drug Therapy

Without Compelling Without Compelling Indication Indication

With Compelling With Compelling IndicationsIndications

NormalNormal <120<120 and <80and <80 EncourageEncourage

PrehypertensionPrehypertension 120–139120–139 or 80–89or 80–89 YesYes No antihypertensive No antihypertensive drug indicateddrug indicated

Drug(s) for Drug(s) for compelling compelling indications indications

Stage 1 Stage 1 hypertensionhypertension

140–159140–159 or 90–99or 90–99 YesYes Thiazide-type Thiazide-type diuretics for most. diuretics for most. May consider ACEi, May consider ACEi, ARB, BB, CCB, or ARB, BB, CCB, or combinationcombination

Drug(s) for the Drug(s) for the compelling compelling indicationsindications

Other Other antihypertensive antihypertensive drugs (diuretics, drugs (diuretics, ACEi, ARB, BB, ACEi, ARB, BB, CCB) as needed CCB) as needed

Stage 2 Stage 2 hypertensionhypertension

>>160160 or or >>100100 YesYes Two-drug Two-drug combination for most combination for most (usually thiazide-type (usually thiazide-type diuretic and ACEi or diuretic and ACEi or ARB or BB or CCB)ARB or BB or CCB)

ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin II type 1-receptor blocker; BB, beta-blocker; CCB, calcium channel blocker.Chobanian AV et al. JAMA. 2003;289:2560-2572.

JNC 7 Report on the Prevention, Detection, Evaluation, JNC 7 Report on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressureand Treatment of High Blood Pressure

Stratification of Risk to Quantify Stratification of Risk to Quantify PrognosisPrognosis

Blood Pressure (mmHg)

Other Risk Factors& Disease History

Grade 1(mild hypertension)

SBP 140-159or DBP 90-99

Grade 2(moderate hypertension)

SBP 160-179or DBP 100-109

Grade 3(severe hypertension)

SBP > 180 or DBP > 110

I no other risk factorsLOW RISK MED RISK HIGH RISK

II 1-2 risk factorsMED 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

Guidelines Subcommittee. 1999. WHO-Int’l Society of Hypertension. Guidelines for Management of Hypertension. J Hypertens 1999;17:151-83

TOD = Target Organ Damage

Initiation of TreatmentSBP 140-180 mmHg or DBP 90-110 mmHg

on several occasions (Grades 1 & 2 hypertension)

Assess other risk factors, TOD and CCD

Initate Lifestyle Measures

Stratify Absolute Risk

Very High High Medium Low

Begin drug

treatment

Begin drug

treatment

Monitor BP andother risk factorsfor 3 - 6 months

Monitor BP andother risk factorsfor 6 - 12 months

SBP > 140 or DBP > 90

Begin drug treatment

SBP < 140 or DBP < 90

Continue tomonitor

SBP > 140 or DBP > 90Begin drug treatment

SBP < 140 or DBP < 90Continue to

monitor

1. TOD - Taeget Organ Damage (precious WHO Stage 2 hypertension) [6]2. ACC - Associated Clinical Condition including clinical cardiovascular disease and renal disease

(previous WHO Stage 3 hypertension) [6]

• Lose weight if overweight. • Limit alcohol intake to no more than 1-2 drinks per day

(equivalent to approximately 15-30 mL ethanol per day). • Increase aerobic physical activity to 30 - 45 minutes on

most days. • Reduce sodium intake to no more than 100 mmol per day

(2.4 g sodium or 6 g sodium chloride per day). • Maintain adequate intake of dietary potassium

(approximately 90 mmol per day). Inadequate intake may increase blood pressure.

• Maintain adequate intake of dietary calcium and magnesium for general health. Inadequate intake may increase blood pressure.

• Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health.

The lifestyle modifications

Hypertensive Heart Hypertensive Heart DiseasesDiseases

Target Organ Damage in Target Organ Damage in HypertensionHypertension

Organ SystemOrgan System ManifestationsManifestationsHeartHeart -Left ventricular Left ventricular

hypertrophyhypertrophy-Heart failureHeart failure-Myocardial ischemia and Myocardial ischemia and infarctioninfarction

CerebrovascularCerebrovascular StrokeStroke

Aorta and peripheral Aorta and peripheral vascularvascular

-Aortic aneurysm and/or Aortic aneurysm and/or dissectiondissection-ArteriosclerosisArteriosclerosis

KidneyKidney -NephrosclerosisNephrosclerosis-Renal failureRenal failure

RetinaRetina -Arterial narrowingArterial narrowing-Hemorrhages, exudates, Hemorrhages, exudates, papilledemapapilledema

ECG of a 47-year-old man with a long-ECG of a 47-year-old man with a long-standing history of uncontrolled standing history of uncontrolled hypertension showing left atrial hypertension showing left atrial enlargement and left ventricular enlargement and left ventricular

hypertrophy.hypertrophy.

ECG of a 46-year-old man with long-ECG of a 46-year-old man with long-standing hypertension showing left atrial standing hypertension showing left atrial

abnormality and left ventricular abnormality and left ventricular

hypertrophy with strain.hypertrophy with strain.

Two-dimensional echocardiogram of a 70-Two-dimensional echocardiogram of a 70-year-old woman (parasternal long axis view) year-old woman (parasternal long axis view)

showing concentric left ventricular showing concentric left ventricular

hypertrophy.hypertrophy.

Short axis view : concentric left Short axis view : concentric left ventricular hypertrophicventricular hypertrophic

Gross specimen of the heart with Gross specimen of the heart with concentric left ventricular concentric left ventricular

hypertrophy.hypertrophy.

Guidelines for Selecting Drug Treatment of Guidelines for Selecting Drug Treatment of HypertensionHypertension

Class of DrugClass of Drug Compelling Compelling PossiblePossible CompellingCompelling PossiblePossibleindicationindication indicationindication contraindicationcontraindication contraindicationcontraindication

DiureticDiuretic Heart failureHeart failure DiabetesDiabetes GoutGout DyslipidaemiaDyslipidaemiaElderly patientsElderly patients Sexually active malesSexually active malesSystolic hypertension Systolic hypertension

Beta BlockersBeta Blockers AnginaAngina Heart failure Heart failure Asthma and COPDAsthma and COPD DyslipidaemiaDyslipidaemiaAfter myocardial infarct After myocardial infarct PregnancyPregnancy Heart blockHeart block a a

Athletes and Athletes and TachyarrhytmiasTachyarrhytmias DiabetesDiabetes physically patients physically patients

Peripheral vascularPeripheral vascular diseasedisease

ACE inhibitorsACE inhibitors Heart failureHeart failure PregnancyPregnancyLeft ventricular Left ventricular HyperkalaemiaHyperkalaemia dysfunctiondysfunctionAfter myocardial After myocardial Bilateral renal arteryBilateral renal artery infarctinfarct stenosis stenosisDiabetic nephropathyDiabetic nephropathy

CalciumCalcium AnginaAngina PeripheralPeripheral Heart block Heart block bb Congestive heartCongestive heart antagonistsantagonists Elderly patientsElderly patients vascularvascular

Systolic hypertensionSystolic hypertension disease disease

Alfa Blockers Alfa Blockers Prostatic hypertrophyProstatic hypertrophy Glucose Glucose Orthostatic Orthostatic

intoleranceintoleranceDyslipidaemiaDyslipidaemia hypotensionhypotension

Angiotensine IIAngiotensine II ACE inhibitors coughACE inhibitors coughHeart failureHeart failure PregnancyPregnancyantagonistsantagonists Bilateral renalBilateral renal

artery stenosisartery stenosisHyperkalaemiaHyperkalaemia

THANK YOUTHANK YOU