Bimbingan Hypertension

7/21/2019 Bimbingan Hypertension

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How to control blood pressure ?

Athira Fitriah

Chiquita Putri Vania RauFeby Adiguna



Blood Pressure Classification(JNC VII ; office BP)

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension 140–159 or 90–99

Stage 2 Hypertension >10 or >100

BP Classification SBP mmHg DBP mmHg



Definitions and classification of office BP levels (mmHg)* (ESHES!)

!ategor" S"stolic Diastolic

Optimal <120 and <80

Normal 12012! and"or 808#

$igh normal 1%01%! and"or 8&8!

'rade 1 hyperten(ion 1#01&! and"or !0!!

'rade 2 hyperten(ion 1)01*! and"or 10010!

'rade % hyperten(ion +180 and"or +110

,(olated (y(toli- hyperten(ion +1#0 and <!0

* The blood pressure (BP) category is defned by the highest level o BP, whether systolic or diastolic. Isolatedsystolic hypertension should be graded , !, or " according to systolic BP values in the ranges indicated.

$yperten(ion.

/P 1#0 mm$g 3P !0 mm$g



#ircadian BP rhyth$ in nor$otensive (lower curve)and hypertensive (upper curve) individuals



Blood pressure monitoring

Home BP # measured at $ %& and $

P&' at least da"s%BP& (ambulator" bloodpressure monitoring)



%edical &ducation ' Inor$ation or all %edia, all isciplines, ro$ all overthe orld

Po4ered by

201% 5/$"5/C 'uideline( 6or the management o6 arterial hyperten(ion

7he 7a( For-e 6or the management o6 arterial hyperten(ion o6 the 5uropean /o-iety o6 $yperten(ion 95/$: and o6 the 5uropean /o-iety o6 Cardiology 95/C: ; $yperten(ion 201%=%1.1281;1%&*

Definitions of "pertension b" office and outofoffice BP levels

!ategor" S"stolic BP

(mmHg)

Diastolic BP

(mmHg)

ffice BP +1#0 and +!0

%mbulator" BP

Da"time (or awa+e) +1%& and"or +8&

,igttime (or asleep) +120 and"or +*0

-. +1%0 and"or +80

Home BP +1%& and"or +8&

BP, blood pressure.



hite coat hypertension

O66i-e P per(i(tently 1#0"!0mm$g

Normal daytime ambulatory 9<1%01%&"8&mm$g: or

home 9<1%&"8& mm$g: P



&as+ed "pertension

> O66i-e P per(i(tently normal 9<1#0"!0mm$g:

> 5le?ated ambulatory 9+ 1%0"80mm$g: or home

9+ 1%&"8&mm$g: P

> 10 to #0 per-ent o6 patient( 4ho are normoten(i?e by

-on?entional -lini- mea(urement

> #*@ de?eloped to (u(tained $7

> Cardio?a(-ular ri(. (imilar a( 4ith (u(tained $7



Treatment strategies in white-coatand masked hypertension

95/$;5/C 201%:



BP target +# -III (!/)

Aged ≥ 18 yrs to <60 yrs , CKD,DM 0

>1BP 2 / $$3g

>BP 2 4 $$3g

Aged ≥60 yrs 0>1BP 25 $$3g

>BP 24 $$3g

+# -III 6 id li %



+# -III 6uideline %anage$ent7lgorith$

C3

Add third medi-ation i6 not at

goal blood pre((ure



Blood pressure goals in "pertensive patients (ESHES!)

1BP, systolic blood pressure8 #-, cardiovascular8 TI7, transient ischae$ic attac98 #3, coronary heart disease8 #:, chronic 9idney disease8BP, diastolic blood pressure.

/ecommendations

SBP goal for 0most1>Patient( at lo4moderate CV ri(>Patient( 4ith diabete(>Con(ider 4ith pre?iou( (troe or 7,A>Con(ider 4ith C$3>Con(ider 4ith diabeti- or non;diabeti- C3

23.4 mmHg

SBP goal for elderl">Age( <80 year(>,nitial /P +1)0 mm$g

3.4354 mmHg

SBP goal for fit elderl" Aged <80 year(

23.4 mmHg

SBP goal for elderl" 674 "ears wit SBP

>+1)0 mm$g

3.4354 mmHg

DBP goal for 0most1 284 mmHg

DB goal for patients wit diabetes 275 mmHg



9ifest"le canges for "pertensive patients

* ;nless contraindicated. B%I, body $ass inde<.

/ecommendations to reduce BP and:or !; ris+ factors

/alt intae Re(tri-t &;) g"day

Boderate al-ohol intae imit to 20;%0 g"day menD10;20 g"day 4omen

,n-rea(e ?egetableD 6ruitD lo4;6at dairy intae

B, goal 2& g"m2

Eai(t -ir-um6eren-e goal Ben. <102 -m 9#0 in:GEomen. <88 -m 9%# in:G

5Her-i(e goal( +%0 min"dayD &;* day("4ee9moderateD dynami- eHer-i(e:

Iuit (moing



<actors=oter tan office BP=influencing prognosis(used for stratification of total !; ris+ )

B%I, body $ass inde<8 BP, blood pressure8 B17, body surace area8 #7B6, coronary artery bypass grat8 #3, coronary heart disease8 #:,chronic 9idney disease8 #-, cardiovascular8 #-, cardiovascular disease8 &=, e>ection raction8 e6=?, esti$ated glo$erular fltration rate83b7c, glycated hae$oglobin8 I%T, inti$a@$edia thic9ness8 A-3, let ventricular hypertrophy8 A-%, let ventricular $ass8 P#I, percutaneous

coronary intervention8 P-, pulse wave velocity.a ?is9 $a<i$al or concentric A-30 increased A-% inde< with a wall thic9nessradius ratio o ./!.

/is+ factors

> Bale (eH

> Age 9men +&& year(= 4omen +)& year(:

> /moing

> 3y(lipidaemia

; 7otal -hole(terol #! mmol" 91!0 mg"d:D and"or

; o4;den(ity lipoprotein -hole(terol %0 mmol" 911& mg"d:D and"or

; $igh;den(ity lipoprotein -hole(terol. men <10 mmol" 9#0 mg"d:D

4omen <12 mmol" 9#) mg"d:D and"or

; 7rigly-eride( 1* mmol" 91&0 mg"d:

> Fa(ting pla(ma glu-o(e &))! mmol" 910212& mg"d:> Abnormal glu-o(e toleran-e te(t

> Obe(ity JB, +%0 g"m2 9height2:K

> Abdominal obe(ity 94ai(t -ir-um6eren-e. men +102 -m=

4omen +88 -m: 9in Cau-a(ian(:

> Family hi(tory o6 premature CV3 9men aged <&& year(=

4omen aged <)& year(

Diabetes &ellitus> Fa(ting pla(ma glu-o(e +*0 mmol" 912) mg"d: on t4o repeated

mea(urement(D and"or > $bA1- *@ 9&% mmol"mol:D and"or

> Po(t;load pla(ma glu-o(e 110 mmol" 91!8 mg"d:

%s"mptomatic organ damage

> Pul(e pre((ure 9in the elderly: +)0 mm$g

> 5le-tro-ardiographi- V$ 9/oolo4yon indeH %& mV= RaV 11

mV= Cornell ?oltage duration produ-t 2## mVGm(:D or

> 5-ho-ardiographi- V$ JVB indeH. men 11& g"m 2= 4omen !& g"m2

9/A:Ka

> Carotid 4all thi-ening 9,B7 0! mm: or plaque

> Carotid;6emoral PEV 10 m"(

> Anle"bra-hial P indeH <0!

> C3 4ith e'FR %0)0 ml"min"1*% m2 9/A:

> Bi-roalbuminuria 9%0%00 mg"2# h:D or albumin-reatinine ratio9%0%00 mg"g= %#%# mg"mmol: 9pre6erentially on morning (pot urine:

Establised !; or renal disease

> Cerebro?a(-ular di(ea(e. i(-haemi- (troe= -erebral haemorrhage=

tran(ient i(-haemi- atta-

> C$3. myo-ardial in6ar-tion= angina= myo-ardial re?a(-ulariLation 4ith

PC, or CA'

> $eart 6ailureD in-luding heart 6ailure 4ith pre(er?ed 5F

> /ymptomati- lo4er eHtremitie( peripheral artery di(ea(e> C3 4ith e'FR <%0 m"min"1*%m2 9/A:= proteinuria 9%00 mg"2# h:

> Ad?an-ed retinopathy. haemorrhage( or eHudate(D papilloedema


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>nitiation of lifest"le canges and anti"pertensive drug treatment

BP, blood pressure8 #:, chronic 9idney disease8 #-, cardiovascular8 #-, cardiovascular disease8 BP, diastolic blood pressure8 3T,hypertension8 C, organ da$age8 ?=, ris9 actor8 1BP, systolic blood pressure.

ter ris+ factors'

as"mptomatic organ

damage or disease

Blood pressure (mmHg)

Hig normal SBP

3438

or DBP 7578

@rade 3 HA

SBP 3.4358 or

DBP 8488

@rade - HA

SBP 343$8

or DBP 344348

@rade HA

SBP C374

or DBP C334

No other RF > No P inter?ention

> i6e(tyle -hange( 6or(e?eral month(

> 7hen add P drug(targeting <1#0"!0

> i6e(tyle -hange( 6or(e?eral 4ee(


> i6e(tyle -hange(> ,mmediate Pdrug( targeting<1#0"!0

1M2 RF> i6e(tyle -hange(> No P inter?ention






+% RF> i6e(tyle -hange(> No P inter?ention



> i6e(tyle -hange(> P drug( targeting<1#0"!0


O3D C3 (tage % or diabete( > i6e(tyle -hange(> No P inter?ention



> i6e(tyle -hange(

> ,mmediate Pdrug( targeting<1#0"!0

/ymptomati- CV3D C3 (tage+# or diabete( 4ith O3"RF(

> i6e(tyle -hange(> No P inter?ention






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&onoterap" vs drug combination strategies to acieve target BP

&oving from a less intensive to a more intensive terapeutic strateg"

sould be done wenever BP target is not acieved

Choo(e bet4een

/ingle agent 74odrug -ombination

Pre?iou( agent

at 6ull do(e

/4it-h

to di66erent agent

Pre?iou( -ombination

at 6ull do(e

Add a third drug

74o drug

-ombination

at 6ull do(e(

Bild P ele?ation

o4"moderate CV ri(

Bared P ele?ation

$igh"?ery high CV ri(

7hree drug

-ombination

at 6ull do(e(

/4it-h

to di66erent t4odrug

-ombination

Full do(e

monotherapy

BP, blood pressure8 #-, cardiovascular.



6uidelines orldwide 7c9nowledge That %ost Patientseed #o$bination Therapy to 7chieve BP 6oals

%ost patients with hypertension will reDuire two or $oreantihypertensive $edications to achieve their BP goals

hen BP is E ! $$3g above goal, considerationshould be given to initiating therapy with two drugs

#o$bination treat$ent should be considered as frst choicewhen there is high #- ris9

i.e., in individuals in who$ BP is $ar9edly above the

hypertension threshold (E ! $$3g), or associatedwith $ultiple ris9 actors sub@clinical organ da$age,diabetes, renal or #- disease

Chobanian et al JAMA. 200%=28!.2&)02&*2= Ban-ia et al Eur Heart J. 200*=28.1#)21&%)= http.""444ni-eorgu"do4nloada(pHoC'0%#6ullguideline 9a--e((ed anuary 2010:= Ogihara et al Hypertens Res. 200!=%2.%10*

Bany patient( 4ill require more tan one drug to acieve adeuateBP control

Pathophy(iologi-al rea(oning (ugge(t( that adding an AC5;,"ARto a CC or a diureti- 9or ?i-e ?er(a in the younger group: are

logi-al -ombination(

7he u(e o6 two or tree drugs in combination is often necessar"to acieve te target BP control

A lo4 do(e o6 a diureti- (hould be in-luded in thi( -ombination

F , ! ;

> >

E S H : E S !

, > ! E

The Japanese Society ofHypertension Committee forGuidelines for theManagement of Hypertension

-448 F S H



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Possible combinations of classes of anti"pertensive drugs

@reen continuous lines. pre6erred -ombination(= green dased line. u(e6ul -ombination 94ith (ome limitation(:= blac+

dased lines. po((ible but le(( 4ell te(ted -ombination(= red continuous line. not re-ommended -ombination Although

?erapamil and diltiaLem are (ometime( u(ed 4ith a beta;blo-er to impro?e ?entri-ular rate -ontrol in permanent atrial

6ibrillationD only dihydropyridine -al-ium antagoni(t( (hould normally be -ombined 4ith beta;blo-er(

AiaGide diuretics

bloc+ers %ngiotensinreceptor

bloc+ers

ter

anti"pertensives

%!E inibitors

!alcium

antagonists



Preferred "pertension treatment in specific conditions!ondition Drug

%s"mptomatic organ damage

V$ V$ AC5 inhibitorD -al-ium antagoni(tD AR A(ymptomati- athero(-lero(i( Cal-ium antagoni(tD AC5 inhibitor

Bi-roalbuminuria AC5 inhibitorD AR

Renal dy(6un-tion AC5 inhibitorD AR

!linical !; event

Pre?iou( (troe Any agent e66e-ti?ely lo4ering P

Pre?iou( myo-ardial in6ar-tion D AC5 inhibitorD AR

Angina pe-tori( D -al-ium antagoni(t

$eart 6ailure 3iureti-D D AC5 inhibitorD ARD mineralo-orti-oid re-eptor antagoni(t(

Aorti- aneury(m

Atrial 6ibrillationD pre?ention Con(ider ARD AC5 inhibitorD or mineralo-orti-oid re-eptor antagoni(t

Atrial 6ibrillationD ?entri-ular rate -ontrol D non;dihydropyridine -al-ium antagoni(t

5/R3"proteinuria AC5 inhibitorD AR

Peripheral artery di(ea(e AC5 inhibitorD -al-ium antagoni(t

ter

,/$ 9elderly: 3iureti-D -al-ium antagoni(t

Betaboli- (yndrome AC5 inhibitorD ARD -al-ium antagoni(t

3iabete( mellitu( AC5 inhibitorD AR

Pregnan-y BethyldopaD D -al-ium antagoni(t

la-( 3iureti-D -al-ium antagoni(t

7#&, angiotensin@converting enFy$e8 7?B, angiotensin receptor bloc9er8 BB, beta@bloc9er8 BP, blood pressure8 #-, cardiovascular8 &1?, end@stage renaldisease8

I13, isolated systolic hypertension8 A-3, let ventricular hypertrophy.



!ompelling indications for "pertension treatment

!lass !ontraindications

!ompelling Possible

3iureti-(

9thiaLide(:

'out Betaboli- (yndrome

'lu-o(e intoleran-ePregnan-y

$yper-al-emia

$ypoalaemia

eta;blo-er( A(thma

AV blo- 9grade 2 or %:

Betaboli- (yndrome

'lu-o(e intoleran-e

Athlete( and phy(i-ally a-ti?e patient(

COP3 9eH-ept 6or ?a(odilator beta;blo-er(:

Cal-ium antagoni(t(

9dihydropyridine(:

7a-hyarrhythmia

$eart 6ailure

Cal-ium antagoni(t(

9?erapamilD diltiaLem:

AV blo- 9grade 2 or %D tri6a(-i-ular blo-:

/e?ere V dy(6un-tion

$eart 6ailure

AC5 inhibitor( Pregnan-y

Angioneuroti- oedema

$yperalaemia

ilateral renal artery (teno(i(

Eomen 4ith -hild bearing potential

Angioten(in re-eptor blo-er( Pregnan-y

$yperalaemia

ilateral renal artery (teno(i(

Eomen 4ith -hild bearing potential

Bineralo-orti-oid

re-eptor antagoni(t(

A-ute or (e?ere renal 6ailure 9e'FR <%0 m"min:

$yperalaemia

7@-, atrio@ventricular8 #CP, chronic obstructive pul$onary disease8 e6=?, esti$ated glo$erular fltration rate8 A-, let

ventricular.



Oral antihypertensive drugs*



Oral antihypertensive drugs* (continued)





/e-ondary -au(e( o6 hyperten(ion

> 7he mo(t -ommon 4ere renal di(ea(e

)8@

> 5ndo-rine 11@> Reno?a(-ular di(ea(e( 10@



!linical features of secondar" "pertension

Disorder Suggestive clinical features

@eneral Severe or refractor" "pertension%ccelarated BP in stable condition

%ge less tan 4 "ears wit no famil" istor" of "pertension andno obesit"

%n acute elevation in serum creatinine after administration of

%!E:%/B

%nemiaElevated serum creatinine concentration

Ariad of eadace (usuall" pounding)' palpitations' and sweating

IneJplained "po+alemia

!usingoid facies

S"mptoms of "per:"pot"roidism



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Bimbingan Hypertension