hhd upn 2010

Download HHD upn 2010

Post on 13-Apr-2015

13 views

Category:

Documents

0 download

Embed Size (px)

TRANSCRIPT

HIPERTENSI HEART DISEASE CLINICAL EVIDENCEProf.DR.dr. Zainal Musthafa, SpJP, MSi, FS, FIHA Gatot Soebroto Military Hospital Dept. of Cardiology, FKUPNV 2010

Hipertensi Heart Disease HHDHipertensi yg sudah mempunyai komplikasi ke Jantung Ditandai Peningkatan Pressure intracardiac Hipertrofi ventrikel Delatasi Ventrikel Cardiomegali Mitral Regurgitasi Penyakit jantung koroner

KLASIFIKASIJNC III TH 1984 Normal < 85 Normal 140/90 High Normal 85-89 HT Ringan 90-104 HT Sedang 105-114 HT Definitif > 160/95 HT Berat > 114

HT Borderline 160/95

1993

Usia > 18 th

High Normal 139/89

HT stadium 1 159/99 HT stadium 2 179/109 HT stadium 3 209/119 HT stadium 4 210/120

Normal 130/85

Klasifikasi Tekanan DarahJNC-VI

Katagori Normal

Sistolik (mmHg) < 130

Diastollik (mmHg) < 85

Normal TinggiHipertensi Tingkat 1 Tingkat 2

130 139140 159 160 179

85 - 8990 -99 100

Tingkat 3

180

110

Klasifikasi Tekanan DarahJNC-VII

TUGAS ANDA

Hipertensi EmergensiHipertensi Ensefalopati Kejadian intrakranial akut Diseksi aorta akut Sindroma koroner akut (angina tidak stabil / Infark miokard akut) Payah jantung kiri akut Krisis feokromositoma Eklamsia

Hipertensi UrgensiAccelerated 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 / HORMONALCoartasio Aorta

HIPERTENSI SEKUNDER

KEHAMILAN NEUROLOGI Sress Akut

Volume IntravaskulerObat obatan

Cathepsin Tonin

chymase

Aldosterone

EP ACE2

The BHS recommendations for combining blood pressure-lowering drugs< 55 years aaaaaaaaaaStep 1

55 years or black patients at any age

A A + C or A + D

C or D

Step 2

Step 3

A

+

C

+

D

Step 4

Add: further diuretic therapy or alpha-blocker or beta-blockerConsider seeking specialist advice

A: ACE inhibitor or ARB, if ACE inhibitor intolerant C: Calcium-channel blocker D: Diuretic (thiazide)BHS, British Hypertension Society; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blockerNational Collaborating Centre for Chronic Conditions. Hypertension: management in adults in primary care: partial update. London: Royal College of Physicians, 2006

2006 update

Rationale for dual RAS blockade with an ACE inhibitor and ARBBradykinin/NO ACE Inhibitor Inactive fragments Vasodilation Tissue protection AT1 RECEPTOR Vasoconstriction Sodium retention SNS activation Inflammation Growth-promoting effects Aldosterone Apoptosis Angiotensin II ARB AT2 RECEPTOR Vasodilation Natriuresis Tissue regeneration Inhibition of inappropriate cell growth Differentiation Anti-inflammation Apoptosis Angiotensin I ACE-independent ANG II formation by Chymase, etc. Angiotensin II escape

Bradykinin?NO?

ACE = angiotensin converting enzyme; ARB = angiotensin II receptor blocker; AT = angiotensin; SNS = sympathetic nervous system Hanon S, et al. J Renin Angiotensin Aldosterone Syst 2000;1:147150; Chen R, et al. Hypertension 2003;42:542547; Hurairah H, et al. Int J Clin Pract 2004;58:173183; Steckelings UM, et al. Peptides 2005;26:14011409

ACE inhibitors atau AT1 receptor blockersObat 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.

Assessing CVD risk: the effect of high blood pressureBlood Pressure (mmHg)Other risk factors* and disease history Normal SBP 120129 or DBP 8084 High Normal SBP 130139 or DBP 8589 Grade 1 SBP 140159 or DBP 9099 Grade 2 SBP 160179 or DBP 100109 Grade 3 SBP >180 or DBP >110

No other risk factors

Average risk

Average risk

Low added risk Moderate added risk High added risk

Moderate added risk Moderate added risk High added risk

High added risk Very high added risk Very high added risk

12 risk factors >3 risk factors, metabolic syndrome, target organ damage or diabetes Associated clinical conditions

Low added risk

Low added risk

Moderate added risk

High added risk

High added risk

Very high added risk

Very high added risk

Very high added risk

Very high added risk

Approximate absolute risk in patients over 60 years of age 1015% 8% Cardiovascular event rate in 10 years Risk of cardiovascular death in 10 years (SCORE)

*Includes smoking, abdominal obesity and age 16CVD = cardiovascular disease; SBP = systolic blood pressure; DBP = diastolic blood pressure Guidelines Committee. J Hypertens 2003;21:10111053; J Hypertens 2007;21:11051187

North America 3 countries

Europe 23 countries

Asia 9 countries Africa 1 country South America 2 countries Australasia 2 countries

HOPE: Risk Reduction With Ramipril 10 mgNew-Onset Stroke CABG/PTCA Diabetes

CVD DeathNonfatal MI

0 -5 -10 -15 -20 -25 -30 -35 -40%

-15%* -20%* -26%* -32%* -34%

*P