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Dr. Dr. Suryono,Suryono,SpJPSpJP.FIHA.FIHA
Bagian-Bagian-SMF KardiologiSMF Kardiologi & Kedokteran Vaskular & Kedokteran VaskularFK UNEJ / RSD dr. SoebandiFK UNEJ / RSD dr. Soebandi
J E M B E RJ E M B E R
HipertensiHipertensi
Diagnosis, Pencegahan dan TerapiDiagnosis, Pencegahan dan Terapi
Definisi Hipertensi (JNC VII)Definisi Hipertensi (JNC VII) Klasifikasi tekanan darah pada seseorang berumur 18 dan lebih
Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36
Hipertensi salah satu dari penyakit yang sering dijumpai di klinik
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
4454
64 65
Prevalensi dari HipertensiPrevalensi dari Hipertensi
Hypertension Prevalence and Treatment: North America and Europe
Prevalence of Hypertension
0
5
10
15
20
25
30
35
40
45
50
55
Country
%
USCanada
Germany
ItalySwedenEnglandSpainFinland
0
10
20
30
40
50
60
70
80
90
100
Country
%
Wolf-Maier K et al. JAMA. 2003;289:2363-2369.
Patients on Therapy
23%16%
42%19%
Hypertensive patients who are treated but uncontrolled
Hypertensive patientswho are treated and controlled
Hypertensive patients who are unaware
Patients who are awarebut remain untreated
and uncontrolled
22 % of American adults 18 to 70 years of age have hypertension20 % of Indonesian adults have hypertension
New Criteria (WHO-ISH 1999) ≥ 140 / 90 mmHg
Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102
Presentasi pasien hipertensi yang terkontrol
Presentasi pasien hipertensi yang terkontrol
Adapted from G. Mancia / L. Ruilope
USA: JNC VI. Arch Intern Med 1997Canada: Joffres et al. Am J Hypertens 1997 England: Colhoun et al. J Hypertens 1998France: Chamontin et al. Am J Hypertens 1998
< 140/90 mmHg< 140/90 mmHg
Canada
16
USA
27
England6
France
24
Marques-Vidal P et al. J Hum Hypertens 1997
< 160/95 mmHg< 160/95 mmHg
Finland
20.5
Spain
20
Australia
19
Germany
22.5
> 65 years
Scotland
17.5
India
9
Diagnosis of Hypertension
Hypertension is defined as:
- BP 140/90 mm Hg- during 1-5 visits- with an average of 2 readings per visit
Caused of Hipertension :Caused of Hipertension :
I. Primer / essential / idiopathic
II. Sekunder :
A. Renal
B. Endocrine
C. Coartation of the aorta
D. Pregnancy induced hypertension
E. Neurological disorder
F. Drug and other abused substancen
PATOPHYSIOLOGY
The factors affecting cardiac output: - sodium intake, renal function, & mineralocorticoids - the inotropic effects occur via extracellular fluid volume augmentation - an increase in heart rate and contractility
Peripheral vascular resistance is dependent upon the sympathetic nervous system, humoral factors, and local autoregulation
(Sharma, 2003)
Neurohormonal control of blood pressure
Blood pressure = Cardiac output (CO) x Peripheral resistance (PR)
Hypertension = Increased CO and/or Increased PR
Preload
Fluid volume
Renal sodiumretention
Contractility
Fluid volume
Vasoconstriction
Sympatheticnervoussystem
Renin-angiotensin-aldosterone
system
Geneticfactors
Excesssodiumintake
(Adapted from Kaplan, 1994)
Acute neurohormonal effects on blood pressure homeostasis
Acute neurohormonal effects on blood pressure homeostasis
Heart rate and cardiac output
Perfusion
Sodium and water retention
Blood pressure
RAA SNS
Renin inhibitors
AII receptor blockers
Angiotensin II
Renin
Converting enzyme
Angiotensinreceptors
Angiotensinogen
ACE inhibitor
Angiotensin I
Liver TissueCirculating Local
Non Renin pathways - t-PA - Cathepsin G - Tonin
Non-ACE pathways - Chymase - CAGE - Cathepsin G
The Renin-Angiotensin SystemAlternate Pathway
Effects of Angiotensin II at AT1 and AT2 Receptors
Blocked by ARB s
AT2AT1
- Vasoconstriction- Aldosterone release- Oxidative stress- Vasopressin release- SNS activation- Inhibits renin release - Renal Na+ and H2O reabsorption- Cell growth and proliferation
- Vasodilation- Antiproliferation- Apoptosis- Antidiuresis/antinatriuresis- Bradykinin production- NO release
Siragy H. Am J Cardiol. 1999;84:3S–8S.
Diagnosa HipertensiDiagnosa Hipertensi
Riwayat Klinik (Ax):Riwayat Klinik (Ax):
• Lama, tingkat TD
• Adanya Penyakit penyerta
• Faktor risiko
• obat-obatan
• Faktor pribadi,psikososial dan lingkungan.
SymptomsSymptoms
• Headache
• Dizziness
• Fatigue
• Pounding of the heart
• Symptoms of complications : heart failure, chest pain, claudication, vision
Pemeriksaan Fisik :Pemeriksaan Fisik :
• Pemeriksaan fisik & TD yang teliti• TB, BB, & BMI • Sistim kardiovaskuler • Paru • abdomen. • Fundus optikus & sistim syaraf (mengetahui
kerusakan serebro-vaskuler).
Technique of blood pressure measurement recommended by the British Hypertension Society
Technique of blood pressure measurement recommended by the British Hypertension Society
2.The patient should be relaxed and the arm must be supported. Ensure no tight clothing constricts the arm
3.The cuff must be level with the heart. If the circumference exceeds 33cm, a large cuff must be used (2/3 of arm). Place stethoscope diaphram over brachial artery
4.The column of mercury must be vertical. Inflate to occlude the pulse (>30 mmHg). Deflate at 2-3 mm/s. measure systolic ( first sound / Korotkoff I ) & diastolic (disappearence / Korotkoff IV or V ) to nearest 2 mmHg
(From British Hypertension Society 1985)
1.Several time, rest 5 minutes before
Recommended Technique for Measuring Blood Pressure
Standardized technique:
• Have the patient rest for 5 minutes
• Use an appropriate cuff size
• Use a mercury manometer or a recently calibrated electronic device
• Position cuff appropriately
• Increase pressure rapidly
• Support arm with antecubital fossa or heart level
• To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 30 mmHg above level of diseappearance of radial pulse
• Place stethoscope over the brachial artery
Recommended Technique for Measuring Blood Pressure (cont.)
Recommended Technique for Measuring Blood Pressure (cont.)
• Drop pressure by 2 mmHg / beat:
- appearance of sound (phase I Korotkoff)
= systolic pressure
- disappearance of sound (phase V
Korotkoff) = diastolic pressure
• Take 2 blood pressure measurements, 1 minute apart
Pengukuran tekanan darah ambulatory(ABPM)
Pengukuran tekanan darah ambulatory(ABPM)
Indikasi1. Adanya variasi tekanan darah yang besar 2. Office hypertension 3.Dicurigai adanya episode hipotensi4. Hipertensi yang resisten terhadap pengobatan
Pemeriksaan penunjangPemeriksaan penunjang
• Laboratorium •EKG & Foto polos dada•Ekhokardiografi •Ultrasonografi vaskuler •Ultrasonografi renal Angiografi
Evaluasi Klinik Hipertensi : Evaluasi Klinik Hipertensi :
Tujuan :
1. Konfirmasi hipertensi dan tingkatnya
2. Menyingkirkan & menemukan hipertensi sekunder
3. Menentukan kerusakan organ target
4. Mencari faktor risiko kardiovaskuler dan kondisi
klinik lain
Komplikasi HipertensiKomplikasi Hipertensi
Kerusakan yang disebabkan oleh hipertensi tergantung :
• Besarnya peningkatan tekanan darah
• Lamanya kondisi tekanan darah yang tidak terdiagnosis dan tidak diobati
Kerusakan Target Organ!!Eyesretinopathy
Kidneysrenal failure
Brainstroke
Heartischaemic heart disease
left ventricular hypertrophyheart failure
Peripheral arterial disease
Hypertension :The Disease Continuum
Hypertension :The Disease Continuum
Early Paradigm
Elevated BP Target Organ Damage
Natural History of CVD ProgressionNatural History of CVD Progression
More Recent Paradigm
Vascular Dysfunction Elevated BP Target Organ Damage
A Proposed Future Paradigm
EndothelialDysfunction
LVHRenal
DamageMI Stroke
AnginaPectoris
VascularDysfunction
Elevated BP Target OrganDamage
?
Brown, M.J., Lancet 2000;355:653-4
Risiko Infark Miokard dan Stroke Risiko Infark Miokard dan Stroke
Systolic blood pressure (mm Hg)
5-ye
ar r
isk
(%)
0
5
10
15
0 100 200 300
StrokeStrokeMIMI
CHFCumulativeIncidence
(%)
Years From Baseline Exam
5 10 15
20
15
10
5
0
Lenfant C, Roccella EJ. J Hypertens Suppl. 1999;17:S3-S7.Data from Levy D et al. JAMA. 1996;275:1557-1562.
Stage 2+ hypertension
Stage 1+ hypertension
Normal BP
Cumulative Incidence of CHF : Normotensives and Stage 1 and 2 Hypertensives
Cumulative Incidence of CHF : Normotensives and Stage 1 and 2 Hypertensives
Effects of blood pressure on the risk of cardiovascular disease
Average annual incidence rate per 10.000
Source : Framingham study (after Gorlin)
100
90
80
70
60
50
40
30
20
10
0<100 120 140 180 >180
Systolic blood pressure (mmHg)
CHD
Stroke
CHF
Khattar, R.S. et al. Circulation 1999; 100:1071-4
Assessment of the 24-hour blood pressure load isa good clinical method to identify high-risk patients
even
ts/1
00 p
t/yr
s
200+
mm Hg
< 140 140-159 160-179 180-199
1
2
3
4
5
6
7
Systolic Blood PressureSystolic Blood Pressure
Total Mortality and Continuous Ambulatory Blood Pressure
Total Mortality and Continuous Ambulatory Blood Pressure
1
2
3
4
5
Diastolic Blood PressureDiastolic Blood Pressure
mm Hg
< 80 80-89 90-99 100-109 110+
NON-FarmakologisNON-Farmakologis
FarmakologisFarmakologis
Non Pharmacologic ( lifestyle modification )
Modification Approximate SBP
reduction (range)Weight reduction 5–20 mmHg/10 kg loss
Adopt DASH eating plan 8–14 mmHg
Dietary sodium reduction 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol
consumption 2–4 mmHg
DahuluDahulu :: stepped care therapystepped care therapy
KiniKini :: individualized therapyindividualized therapy
Taylored therapyTaylored therapy
– Goal of treatment• Improved endothel function • Decreased systemic vascular resistance• Maintain cardiac output & blood suply to organ
– Life long therapy– Bad compliance failed of therapy
Therapy of Hypertension ( pharmacologic )
Benefits of Lowering BPBenefits of Lowering BP
Average Percent Average Percent
ReductionReduction
Stroke incidence Stroke incidence 35–40% 35–40%
Myocardial infarction Myocardial infarction 20–25% 20–25%
Heart failureHeart failure 50% 50%
Minimal BP Goal of TherapyMinimal BP Goal of Therapy
Recommendations (SBP/DBP mmHg)
Patient Type
Uncomplicated HTN
Hypertension with diabetes mellitus
Heart failure
Hypertension with renal impairment†
JNC VI
< 140/90
< 130/85 < 130/80*
< 130/85
< 125/75
(Bakris GL, et al for the National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis. 2000) (JNC VI. Arch Intern Med. 1997)
*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.†Proteinuria > 1 g/24h.
RecomendationRecomendation
Compelling Indications for Individual Drug Classes
Compelling Indications for Individual Drug Classes
Clinical Trial BasisInitial Therapy Options Compelling Indication
ALLHAT, HOPE, ANBP2, LIFE, CONVINCE
ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS
ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES
THIAZ, BB, ACE, CCB
BB, ACEI, ALDO ANT
THIAZ, BB, ACEI, ARB, ALDO ANT
High CAD risk
Postmyocardialinfarction
Heart failure
Compelling Indications for Individual Drug Classes
Compelling Indications for Individual Drug Classes
Recurrent stroke prevention
Chronic kidney disease
Diabetes
Clinical Trial BasisInitial Therapy Options Compelling Indication
PROGRESS
NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK
NKF-ADA Guideline, UKPDS, ALLHAT
THIAZ, ACEI
ACEI, ARB
THIAZ, BB, ACE, ARB, CCB
Possible combinations of different classes of antihypertensive agents. The most rational combinations are represented as thick lines. ACE, angiotensin-converting enzyme; AT1, angiotensin II type 1.
ACE inhibitorsACE inhibitors
DiureticsDiuretics
11-blockers-blockers
-blockers-blockersATAT11 receptor receptor
blockersblockers
CalciumCalciumantagonistsantagonists