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