PENATALAKSANAAN HIPERTENSI

HT ? WHO : ( DULU )

NORMONTENSI SISTOLIK 140 mm Hg DIASTOLIK 90 mm Hg

BORDERLINE SISTOLIK : 141-159 mmHg DIASTOLIK : 91-94 mmHg

HIPERTENSI SISTOLIK 160 mmHg DIASTOLIK 95 mmHg

UMUR X

Table 2.1 JNC Classification of blood pressure in adults age 18 years and olderCategorySystolic Diastolic(mm hg) (mm/Hg)Optimal< 120 and < 80Normal< 130 and < 85High normal130 139 or 85 - 89Hypertension Stage I *140 159 or 90 - 99 Stage II *160 179 or 100 - 109Stage III * 180 or 110* Based on the average of two or more readings taken et each of two or more visits after an initial screeningIn addition to classifying stages of hypertension on the basis of average blood pressure levels, clinicians should specify presence or absence of target organ disease and additional risk factors. This specificity is important for risk classification and decisions about intiation of medical theraphy.Arch Intern Med. 1997; 157; 2413 - 2446

PENGOBATAN HTTujuan Menurunkan T.D.Angka Morbiditas Angka Mortalitas

Bentuk Pengobatan HT Non Farmaka Farmaka

Penatalaksanaan Non farmaka BB Alkohol (-) Aktifitas Fisik Garam Dapat Membantu Penurunan TD Rokok Stop Lemak DM KendalikanFaktor Resiko

Tabel 3.1 Lifestyle Modifications For Control Of Hypertension And / Or Overall Cardiovascular Risk - Weight loss, if overweight *- Reductions of sodium intake to less than 100 mmol/day (2.4 of sodium or approximately 6 g of sodium chloride) *- Limiting alcohol intake to < 1 oz/day of ethanol (24 oz of beer, or 10 oz of wine, or 2 oz of whiskey): approximately one half of these amounts for women and thin people - Cessation of smoking and reduction of dietary saturated fat and cholesterol for overall cardiovasculer health; reduced fat intake also helps reduce caloric intake important for control of weght and type 2 diabetes - Maintain adquate dietary potassium, clcium, and magnesium intake- Relaxation techniques biofeedback- Vegetarian diets, fish oil* These interventions have been found to be effective Data on other interventions are not definitive (see text)Modified from : Arch Intern Med . 1997;157;2413 - 2446

Table 4.1 JNC- IV Risk Strafication Of Hypertension To Guide Treatment Choices *Blood pressure Stages(mm Hg)Intial Theraphy Risk Group A(No risk factors; no TOD / CVD)Risk Group A(At least one risk factors, not including diabetes ; No TOD / CVDRisk Group A(TOD or evidence of CVD and / or diabetes, with / without other risk factors)Stage 0 (130 139/85 89)Lifestyle modification Lifestyle modificationMedicationStage 1 (140 159/90 99)Lifestyle modification (up to 6 months)Lifestyle modification (up to 3 4 months)Medication

Stage 2 and 3 ( 160 / 100)MedicationMedicationMedicationAbbreviations : JNC VI, Joint National Committee on Ptevention, Detection, Evaluation and Treatment of High Blood Pressure ; TOD, target organ disease; CVD, clinical cardiovascular disease; LVH, left ventricular hypertrophy Lifestyle modification should be adjunctive theraphy for all patients recommended for pharmacologic theraphy For example, a patient with diabetes and a blood pressure of 142/94 mm Hg plus LVH shoul be classified as having stage I hypertension with TOD (LVH) and with another major risk factor (diabetes). Patient would be stage I, risk Group C; pharmacologic treatment should be initiated at the same time as lifestyle modifications. For patients with multiple risk factors, clinicians should consider drugs as intial theraphy plus lifestyle modifications.

Penatalaksaan farmakologik Bila Non Farmaka tidak berhasil

Prinsip pengobatan Hipertensi HT. Sekunder Mengutamakan Kausal HT. Essential TD Umur Komplikasi T.D diturunkan Obat Anti Hipertensi Jangka Panjang Seumur hidup

Pemilihan Obat Anti Hipertensi Aman Efektifitas Tinggi Efek Samping ()/ Toksisitas Oral Toleransi (-) Ekonomis/Murah Jangka Panjang

Pemberian Obat - obat Anti HipertensiPilihan Utama :Pendekatan Tradisional : Step Care Langkah I Langkah II Langkah IIILangkah I B. Bloker Diuretik / TiazideBerlanjut KombinasiResistent VasodilatorSekarang Langkah I termasuk CA Antagonis ACEIObat-oabt Langkah I : Tiazide B. Blockers Ca. Blockers ACEI ( Blokers ) X Blocker Obat Sentral

Table 4.5 JNC VI AND WHO ISH RECOMMENDATIONS FOR INITIAL ANTIHYPERTENSIVE THERAPHYJVC VIWHO ISH 1. Diuretics or - blokers 9unless contraindicated in special situations)All available drugs classes suitable for initial theraphyDiuretics and - blockersGood data on outcome2. Specific indications * for : Angiotensin converting enzyme (ACE) inhibitors - blockers Angiotensin II receptor blockers (ARBs) Diureties Calcium channel blockers (CCBs)ACE inhibitors and CCBs

ARBS and - blockersSome outcome dataVery limited data

3. Low dose combination theraphy appropriate Abbreviation : WHO ISH, World Health Organization International Society of Hypertension.* See Tables 15.2 and 15.3

Diuretik TiazideDiberi pada :Cegah : Usia Tua Kulit Hitam Gagal Jantung Ringan DM (Maturity Omset) HiperuricemiaEfek Samping : Hipokalemi, Hiperuricemi Hiperglikemi, Impotensi Rash Diskrashia Darah

Cara KerjaKombinasi : Ekresi renal Sodium Air Vol Darah Dan Kerja langsung Otot polos Varkular PVR

KEUNTUNGAN Murah Efektif Mudah Dipakai 1x/hari Absorbsi Diusus : Baik,Ekresi Ginjal

. BlockersDiberi Pada : Usia muda Angina (+) Perokok (-) MCI (+) Anxious

Cegah Asma Gagal Jantung Blok JantungEfek Samping Bronchospasm Fatigue Bradikardi Vivid dream Negatip Inotropik Hiperlipidemia Tangan dan Kaki dingin Hiperglikemi - Hiperuricemia Peny. Periperal Brittle IDDM

CARA KERJAKompetitip Menghambat Kerja Katekholamin pada B. Adrenoceptor dan yang lainnya, Hambatan Masing-masing B1.Receptor (HR < Kontrakliti) dan B2 Receptor (Vaskular dan otot polos Bronkhial).Lainnya : Paling Utama Block B1 Receptor dan kardio selektip.

Absorbsi Usus : Baik (terbanyak) Liver GinjalDosisPropanolol : Mulai : 10 20 mg (2x/hari) Maintenance : 80 mg (2x/hari) Maksimum : 320 (2x/hari) Metoprolol : Mulai : 50 (2x/hari) Maintenance : 100 (2x/hari) Maksimum : 200 (2x/hari)

Tablet 6.1 Some Commonly Used . Blockers For Treating Hypertension Generic (Trade) Name Recommended Dosage Range *Physiologic EffectsCommentsDose (mg)FrequencyAtenolol (Tenormin)25 1001 / day Cardiac output;Plasma renin activity; blood pressure; pulse rateCardioselective agents may also inhibit 2 - receptors in hinger doses (eg, all may aggravate asthma)Betaxolol (kerlone)5 301 / dayBisoprolol (Zebeta)5 10 1 / dayMetoprolol (Lopressor)50 - 2001 / dayNadolol (Corgard)20 240 1 / dayPropranolol (Inderal)40 240 2 or 3 / dayPropranolol LA (Inderal LA)80 160 1 / day

- Blockers With ISA Acebutolol (Sectral)200 - 8002 / dayLees effect on heart rate and vasculer and bronchial smooth muscleCarteolol (Cartrol)2.5 5.01 / dayPanbutolol (Levatol)201 / dayPindolol (Visken)10 402 / dayAs in the other tables, not all available medications are listed. Dosages may also differ from the manufacturers Cardioselective ISA = intrinsic sympathomimetic action (slight 2 receptor stimulation )

Table 7.1 Combined 1And -Blockers In The Treatment Of Hypertension Generic (Trade) Name Recommended Dosage RangePhysiologic EffectsCommentsDose (mg)FrequencyCarvedilol (Coreg)6.25 251 or 2 / dayCardiac output and renal blood flow maintained, blood pressure decreased, antioxidant effectsBeneficial effects in heart failure; may decrease myocardial demage post myocardial infarction Labetalol (Normodyne, Trandate)200 500 or 6002 / dayCardiac output Plasma renin activity, blood pressure, some decrease in pulse rateProbably more effective in blacks than other -Blockers ; may cause postural effects; tiration should be based on standing blood pressures

Calcium AntagonistDiberi pada : Asthma Angina (+) Peny. Periperal VascularCegah : Verapamil, Diltiazem + Block Jantung Hati-hati dengan Digoxin, B.Blockers.Efek Samping : Flushing Sakit Kepala Swelling Ankle Hiperplasia Gusi/Gigi

Cara KerjaMenghambat Transport ion Ca melalui sel.Membrane.Penting untuk kerja pontensial dan kontraksi otot.Menurunkan T.D. dengan Vasodilatasi.Jenis Nifedipine Verapamil DiltiazemBeda Cardiac Conducting Tissue (memperlambat hantaran Atrionodal) Cardiac Muscle (mengurangi Kontraktiliti) P.D. Otot Polos (Vasodilatasi Perifer)

DosisNifedipin : 10 20 mg 3-4x/hariVerapamil : 160 mg 3 x/hari

Cara Kerja :Berperan Converting Angiotensin I. Angiotensin II ( Vasokonstriktor + Merangsang Sekresi Aldosteron). Breakdown Bradykinin (Vasodilator) .T.D PVR Mencegah Reabsorbsi Sodium oleh : Aldosteron.ACEI

Diberi : Gagal Jantung (Hati-hati Diuretik) Peny. Peripheral VascularHati hati : GG T.U Diuretic Potassium Sparring (Spironolactone ) NSAIDCegah : Stenosis A. Renalis Bilateral

Efek Samping : Gangguan Pengecapan Batuk Hipertensi pada Vol deplesi Rashes Neutropenia Proteinuri Angioneurotic OedemaJenis Captopril Enalapril Dll

Dosis & Cara pemakaian Orang Tua Captopril : 2 x 12,5 mg/h Enalapril : 1 x 2,5 5 mg/h GG Diuretik Dosis dinaikkan gradualFungsi Ginjal Normal 150 mg/h Captopril 40 mg/h Enalapril

PrazosinCara kerjaAntagonis Merangsang Vascular 1 receptor Dilatasi Arteri & Vena PVR Takhikardi (-)Dosis dan cara pemakaianDosis mula : Rendah Sinkope (+) 0,5 mg malam hari mau tidur Naikkan pelan-pelan s/d maksimum 30 mg, 2-3x/hrObat obat Lain : Blocker

Indikasi : Asthma Peny. Peripheral Vascular Gagal JantungEfek Samping : Sinkop Dosis I Sedasi, Retensi Cairan Mulut kering

Methyl DopaCara kerja : Tak Seluruhnya diketahui Kerja pada SSP Sympathetic Outflow Dosis dan Cara Pemakaian Dosis besar E.S Muncul Segera (1 gr/h ) Anjuran Dosis : 250 500 mg 3x/h. GG (+) Dosis (Eksresi melalui ginjal)Indikasi : Asthma Gagal Jantung Claudicatio DMCegah : Depresi Peny. Hati

Efek Samping Hepatitis Anemia Hemolitik Sedasi Mulut kering Impotensi

Table 9.1 Central AgonistsGeneric (Trade) Name Recommended Dosage Range *Adverse ReactionsPhysiologi EffectsCommentsDose (mg)FrequencyColonidine (Catapres)0.1 0.82 / dayDry mounth, drow siness, headache, fatigue, depressionStimulate central 2 receptors that inhibit efferent sympathetic activity blood pressure ; peripheral resistance ; no significant effect on heart rate, CO, renal blood flow or GFRClonidine patch is replaced once a week. None of these agents should be withdrawn abruptly because of rebound hypertension Clonidine (Catapres TTS (patch)0.1 0.21 / weekGuanabenz (Wytensin)4 16 2 / day Guanfacine )Tenex)1 31 / dayMethldopa (Aldomet)250 10002 / dayPossible immune reactionsAbbreviations : CO, cardiac output; GFR, glomerular filtration rate

Tabel 1 SPECIFIC INDICATIONS AND CONTRAINDICATIONSFOR PARTICULAR ANTIHYPERTENSIVE DRUGS *

Clinical SituationMay Have Favorable EffectsRequires Careful Follow UpContraindicatedCardiovascularAngina pectoris- Blockers, calcium channel blockers-Direct vasodilatorsBradycardial/heart block, sick sinus sybdrome--- Blockers, labetalol, verapamil, diltiazemCardiac failure systolic dysfunctionDiuretics, ACE inhibitors, AB receptor blockres, 1- - Blockers (carvedilol), some - BlockersSome - Blockers, calcium channel blockersHypertrophic cardiomyopathy with diastolic dysfunction- Blockers,ditiazem, verapamil, 1 - - Blockers(carvedilol)DiureticsACE inhibitors, 1 blockers, hydralazine, minoxidil, AB receptor antagonistsHyperdynamic circulation (rapid heart rate)- Blockers-Direct vasodilatorsPeripheral vascular occlusive disease-- Blockers-

After mycardial infarctionNon ISA - - Blockers, ACE inhibitors (selected patients), verapmil, or diltiazenDirect vasodilatorsRenalBilateral renal arterial disease or severe stenosis of artery to solitary kidney--ACE inhibitors, AB receptor antagonistsRenal insufficiency; carly (serum creatinine 1.5 2.5 mg/dl)--Potassium sparing agents, postassium supplementsAdvanced (serum creatinin 2.5 3.0 mg/dl)Loop diureticsACE inhibitors, diuretics, AB receptor blokers Potassium sparing agents, postassium supplementsDepression-2 AgonistsReserpineDiabetes mellitus type 2 (insulin dependent)ACE inhibitors (or possibly AB receptor blockres) with a diuretics- Blockers-Diabetes mellitus type 2 (with or without proteinemia)ACE inhibitors (or possibly AB receptor blockers) usually with a diuretic, - Blockers / diureticUse with caution in patients with serum creatinine > 3 mg/dl-Liver disease-LabetalolMethylopaVascular headache (migraine)- Blockers, nondihydropyridine CCBs--* Not all indications or contraindications are listed. See also Tables 15.3 and 15.4

KPD 262*KPD 262*