Hypertension

How to Choose Antihypertension Drug Heri Sutrisno, MD

Internal Medicine WZ Johannes Hospital - Kupang

DIBAWAKAN PADA SEMINAR IDI WILAYAH KUPANG DALAM RANGKA HUT IDI KE-63 & HARKESNAS 2013

Treatment of hypertension

is still an unsolved issue

Menurut Riskesdas tahun 2007, prevalensi hipertensi di Indonesia sebesar 32,2%4

Sekitar 20% populasi dewasa di dunia menderita hipertensi1

Namun, hipertensi terkontrol hanya didapatkanpada 36,8% pasien1-3

Di AS, hipertensi ditemukan pada 30% penduduk dewasa1-3

Kegagalan terapi hipertensi

1. Keenan NL, Rosendorf KA. Prevalence of hypertension and conttrolled hypertension. MMWR. 2011: 60 (Supp): 1-116 2. Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455):217–223. 3. Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999–2004. Hypertension. 2007;49(1):69–75. 4. Rahajeng E, Tuminah S. Prevalence of hypertension and its determinants in Indonesia. MKI 2009: 59;580-7

9 November 2013 Seminar IDI Wilayah NTT 3

Role of fifty

Hypertension

100

Awareness

Unregular Treatment Regular Treatment

Uncontrolled Controlled

50 50

25 25

12.5 12.5

Unawareness

Multifactor disease Relative efficacy Inadequate education / inadequate Ignorance Tolerance Genetic Counter regulation Environment Adverse effect Compliance

The reasons for uncontrolled

blood pressure

J Cardiovasc Pharmacol 1998 ; 31 (suppl) : S41-S44

Patient-related Drug-related Doctor-related


ESH 2003 & JNC VII

Isolated Systolic Hypertension

Isolated Systolic Hypertension

> 180 / >110 Grade 3 Hypertension (severe)

Stage 2 Hypertension

>160 / >100 160-179 /100-109 Grade 2 Hypertension (moderate)

Stage 1 Hypertension

140-159 / 90-99 140-159 / 90-99 Grade 1 Hypertension (mild)

Pre hypertension

130-139 / 85-89 130-139 / 85-89 High normal

Pre hypertension

120-129 /80-84 120-129 / 80-84 Normal

<120/<80 <120 / <80 Optimal

BP BP ESH-ESC BP Classification

> 140 < 90

JNC VII

Bp Classification

Normal


JNC 6 vs JNC 7


What should we done to patients

with hypertension ?


3 point evaluation to patients before treatment

1.Exclude secondary causes of hypertension

2.Ascertain the presence or absence of TOD (target organ damage)

3.Assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that affect risk factors, prognosis and guide treatment


Secondary Causes of Hypertension

Sleep apnoea

Drug-induced or drug-related

Chronic kidney disease

Primary aldosteronism

Renovascular disease

Chronic steroid therapy and Cushing syndrome

Phaeochromocytoma

Acromegaly

Thyroid or parathyroid disease

Coarctation of the aorta

Takayasu Arteritis


Target Organ Damage

Heart

• Left ventricular hypertrophy

• Angina or prior myocardial infarction

• Prior coronary revascularisation

• Heart failure

Brain

• Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease

Retinopathy


How to asses TOD ?

Full blood count Urinalysis Measurement of urine albumin excretion or

albumin/creatinine ratio Renal function tests (urea, creatinine, serum

electrolytes and uric acid) Fasting blood sugar Lipid profile (total cholesterol, HDL cholesterol, LDL

cholesterol and triglycerides) Electrocardiogram (ECG) Chest X-ray


Manifestations of target organ damage (TOD)/ target organ complication (TOC)


COMPONENTS OF CARDIOVASCULAR RISK

STRATIFICATION IN PATIENTS WITH

HYPERTENSION

Major Risk Factors

Smoking

Dyslipidemia

Diabetes mellitus

Age older than 60 years

Sex (men and postmenopausal women)

Family history cardiovascular disease: women

under age 65 or men under age 55 9 November 2013 Seminar IDI Wilayah NTT 14

Hipertensi

Merokok

Obesitas

Kurang aktivitas fisik

Dislipidemia

Diabetes melitus

Mikroalbuminuria atau estimasi GFR <60 mL/menit

Usia (>55 thn untuk pria, >65 thn untuk wanita)

Riwayat keluarga dengan penyakit kardiovaskular prematur (<55 thn untuk

pria, <65 thn untuk wanita)

COMPONENTS OF CARDIOVASCULAR RISK

STRATIFICATION IN PATIENTS WITH HYPERTENSION

Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42 (6):1206-52


CEREBROVASCULAR

CARDIOVASCULAR

RENAL

HIGH BLOOD PRESSURE OR HYPERTENSIVE DISEASE

HIGH BP :

- Genetic predisposition

- Life stye

- Environment

DISEASE CLINICAL EVENTS

TIA

STROKE

DEMENTIA

ANGINA

IMA

CHF

ESRD


V. HIGH RISK

V. HIGH RISK

V. HIGH RISK

HIGH RISK

Grade 3 (severe

hypertension) SBP > 180 or

DBP > 110

V. HIGH RISK

HIGH RISK

MED RISK

MED RISK

Grade 2 (moderate

hypertension) SBP 160-179 or

DBP 100-109

V. HIGH RISK

HIGH RISK

MED RISK

LOW RISK

Grade 1 (mild hypertension) SBP 140-159 or

DBP 90-99

IV. ACC2

III. 3 or more risk

factors or

TOD1 or

diabetes

II. 1-2 risk

factors

I. no other risk

factors

Other Risk Factors & Disease History

Stratification of Risk to Quantify Prognosis

Risk strata (typical 10 year risk of stroke or myocardial infarction): Low risk = less than 15%;

medium risk = about 15-20% risk; high risk = about 20-30%; very high risk = 30% or more

1. TOD = Target Organ Damage

2. ACC = Associated Clinical Conditions, including clinical cardiovascular disease or renal disease


Risk Stratification and Treatment

Blood Pressure

Stages (mm Hg)

Stages 2+3

160/100

Risk Group A (No risk factors;

No TOD/CCD*)

Risk Group B (At least 1 risk factor;

Not including

Diabetes; No TOD/CCD)

Risk Group C (TOD/CCD and/or

Diabetes; with or

without other risk

factor)

High-normal

130-139/85-89

Stage 1

140-159/90-99

Lifestyle

modification

Lifestyle

modification (up to 12 months)

Drug therapy

Lifestyle

modification

Lifestyle

modification (up to 6 months)

Drug therapy

Drug therapy

Drug therapy

Drug therapy

JNC VI, Arch Intern Med 1997; 157: 2413-46


Goal of Treatment


Goal of Hypertensive Treatment

To achieve the maximum reduction in the total

risk of cardiovascular, cerebrovascular,

nephrosclerosis morbidity and mortality

( WHO-ISH 1999 )


Goals of treatment

JNC VII ( 2003 ) :

• < 140 / 90 mmHg or < 130 / 80 mmHg for those

with Diabetes or Chronic Kidney disease.

• Achieve SBP goal especially in persons >50

years of age. 9 November 2013 Seminar IDI Wilayah NTT 21

• At least below 140 / 90 mmHg ( lower

values if tolerated )

• Below 130 / 80 mmHg in Diabetics.

• Keeping in mind, however, that systolic

below 140 mmHg may be difficult to

achieved in elderly (more flexible )

EUROPEAN SOCIETY of HYPERTENSION ( 2003 )

How to Manage Hypertension Patients


NON-PHARMACOLOGICAL MANAGEMENT

Weight reduction

Target BMI: 18.5 to 23.5 kg/m2

Practical: reduce minimum 5% BW, + 4.5 kg

Sodium intake

< 6 g (equivalent to <1¼ teaspoonfuls of salt or 3 teaspoonfuls of MSG)

Avoidance of alcohol intake

<170 mL beer, 300 mL wine, or 60 mL whiskey per day

Regular physical exercise

Brisk walking for 30 – 60 minutes at least 3 times a week

Healthy eating

Diet rich in fruits, vegetables and dairy products with reduced saturated and total fat

Cessation of smoking


Lifestyle modifications to prevent and manage hypertension


PHARMACOLOGICAL MANAGEMENT


28


Panduan Terapi Hipertensi berdasarkan JNC VII

Prinsip terapi: •Target tekanan darah <140/90 mmHg atau <130/80 mmHg pada pasien diabetes atau CKD •Mayoritas pasien mencapai target tersebut dengan kombinasi 2 obat

Modifikasi gaya hidup

Target tekanan darah tidak tercapai

Pilihan obat awal

Tanpa indikasi

mendesak

Dengan indikasi

mendesak Lihat

panduan agen

antihipertensi pada kondisi dengan indikasi

mendesak

Hipertensi stage I (140-159/90-99

mmHg)

Diuretik tipe tiazid. Pertimbangkan ACE-i,

ARB, BB, CCB, atau kombinasi

Hipertensi stage II

(>160/>100 mmHg)

Kombinasi 2

obat (biasanya tiazid dengan

ACE-i, ARB, BB, atau CCB)


Optimalisasi dosis atau tambah obat. Konsul ke spesialis hipertensi 9 November 2013 Seminar IDI Wilayah NTT

29

Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure. Hypertension 2003; 42 (6):1206-52

Panduan Terapi

Hipertensi berdasarkan

JNC VII

Prinsip terapi:

•Target tekanan darah <140/90 mmHg atau <130/80 mmHg pada

pasien diabetes atau CKD

•Mayoritas pasien mencapai target tersebut dengan kombinasi 2 obat

Modifikasi gaya hidup


Pilihan obat awal

Tanpa indikasi

mendesak

Dengan indikasi

mendesak

Lihat panduan

agen

antihipertensi

pada kondisi

dengan indikasi

mendesak

Hipertensi stage I (140-

159/90-99 mmHg)

Diuretik tipe tiazid.

Pertimbangkan ACE-i, ARB,

BB, CCB, atau kombinasi

Hipertensi stage II

(>160/>100 mmHg)

Kombinasi 2 obat

(biasanya tiazid

dengan ACE-i, ARB,

BB, atau CCB)


Optimalisasi dosis atau tambah obat. Konsul ke spesialis hipertensi

9 November 2013 Seminar IDI Wilayah NTT

Principles of drug treatment

Independent of particular drugs

• Low doses to initiate therapy

• Drugs combination to maximize hypotensive

efficacy while minimizing side effects.

• Changing to a different drug class if there is very

little response or poor tolerability

• Long acting drugs : provide greater protection

against target organ damage


Algorithm for treatment of hypertension

Lifestyle Modification

Not at Goal Blood Pressure (<140/90mmHg)

(<130mmHg for those who with diabetes or

Chronic Kidney Disease)

Initial Drug Choices

Without Compelling Indications With Compelling Indication

Stage 1

Hypertension

(SBP 140-159 or DPB

90-99 mmHg)

Thiazide –type diuretics for

most. May consider ACEI, ARB,

BB, CCB, or combination

Stage 2

Hypertension

(SBP > 160 or DPB

> 100 mmHg)

Two –drugs combinationfor

most ( usually Thiazide-type

diuretics and ECI, or ARB, or BB

or CCB

Drugs for the compelling

indications.

Other antihypertensive

drugs (Diuretics, ACEI,

ARB, BB, CCB) as needed

Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal Blood pressure is achieved. Consider consultation with Hypertension specialist

Compelling Indication


Indikasi mendesak

Diuretik BB ACE-i ARB CCB Antagonis aldosteron

Dasar uji klinis

Gagal jantung v v v v v ACCA/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES

Pasca-infark miokardial

v v v ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS

Risiko tinggi PJK

v v v v ALHAT, HOPE, ANBP2, LIFE, CONVINCE

Diabetes v v v v v NKF-ADA Guideline, UKPDS, ALLHAT

Gagal ginjal kronik

v v NFK Guideline, Captopril trial, RENAAL, IDNT, REIN, AASK

Pencegahan stroke berulang

v v PROGRESS

Penggunaan Agen Antihipertensi berdasarkan Indikasi mendesak



Contraindication


How to combine AH ?

AB / CD Scheme

Birmingham Square


The AB / CD Scheme for Optimizing Abtihypertensive Therapy

A or B

C or D

C or D

C or D A or B

A or B

Resistant HT / Intolerance

1 :

2 :

3 :

4 :

Add/substitute alpha blocker

Reconsider secondary causes + trial of spironolactone 5 :

/ D

Diuretic

C Calcium

Antagonist

B Beta

Blockers

A Angiotensin

Inhibitor

AGE

STEP :

Old (>55)

Young (<55)

RENIN


DIURETICS

ACE INHIBITORS

BETA-BLOCKERS

CALCIUM CHANNEL BLOCKERS

+

+

+ + -

BIRMINGHAM SQUARE


Effective drug combinations

Diuretic and -blocker

Diuretic and angiotensin converting enzyme

(ACE) inhibitor (or angiotensin II antagonists).

Calcium antagonist (dihydropyridine) and

-blocker.

Calcium antagonist and ACE inhibitor or

Angiotensin II antagonists

-Blocker and -blocker.


Indications and Contraindications to

Major Classes of Antihypertensive Drugs,

According to the Guidelines of

European Society of Hypertension


Class Conditions favoring

their use Contraindications

Diuretics (thiazide) CHF /elderly / ISH /

African origin

ESRF / CHF

CHF / post-MI

Compelling

Gout

Renal failure

Hyperpotasemia

Possible

Pregnancy

Meredith P. Eur Heart J, Supp. (2004)

Class Conditions favouring their use Contraindications

-blockers Angina pectoris / post-MI /

CHF (up-titration)

Pregnancy

Tachyarrhytmias

Younger people

Compelling

Asthma

COPD

A-V block (gr 2-3)

Possible

PVD

Glucose intolerance

Athletes / physically active

patients


Class Conditions favouring their use Contraindications

Calcium antagonist

(dihydropiridine)

Elderly / ISH / angina / PVD

Carotid atherosclerosis

Pregnancy

Compelling

-

Possible

Tachyarrhytmias

CHF

Calcium antganoist

(verapamil, dilitiazem)

Angina

SV tachycardia

Carotid atherosclerosis

Compelling

A-V block (gr 2 or 3)

CHF

Possible

-


Class Conditions favoring their use Contraindications

ACE inhibitors CHF/LV dysfunction/post-MI

Non-diabetic nephropathy

Type-1 diabetes

Proteinuria

Compelling

Pregnancy

Hyperkalemia

Bilateral renal artery

stenosis

Possible

-

AT1-receptor blockers Type-2 diabetes

Proteinuria

Diabetic micoralbuminuria

LVH

ACE inhibitor cough

Compelling

Pregnancy

Hyperkalaemia

Bilateral renal artery

stenosis

Possible

-


HYPERTENSION IN SPECIAL GROUPS

Hypertension and diabetes mellitus

ACEIs are the agents of choice for patients with diabetes without proteinuria

ACEIs or ARBs are the agents of choice for patients with diabetes and proteinuria

Beta-blockers, diuretics or CCBs may be considered if either of the above cannot be used.

Hypertension and the metabolic syndrome

Beta-blockers and thiazide diuretics have the potential to increase the incidence of new onset diabetes and this should be taken into consideration when choosing drugs for patients diagnosed with the metabolic syndrome.



Hypertension and non-diabetic renal disease

Target BP should be <130/80 mmHg for those with proteinuria of <1g/24 hours and <125/75 mmHg for those with proteinuria of >1g/24 hours

ACEIs are recommended as initial anti-hypertensive therapy

ARBs should be used in patients intolerant to ACEIs

Dietary salt and protein restriction is important

Concurrent diuretic therapy is useful in patients with fluid overload

Non-dihydropyridine CCBs can be added on if the BP goal is still not achieved


Pasien CKD-ND dewasa dengan DM, ekskresi albumin urin < 30 mg/24

jam, TD sistolik >140 mmHg, TD diastolik > 90 mmHg

Pasien CKD-ND dewasa dengan DM, ekskresi albumin urin > 30 mg/24

jam, TD sistolik >130 mmHg, TD diastolik > 80 mmHg

Disarankan pemberian ARB atau ACE-i pada

pasien CKD ND dewasa dengan DM dengan ekskresi albumin urin 30-300 mg/24 jam [2D]

Direkomendasikan untuk diberikan

obat penurun TD untuk

mempertahankan TD sistolik < 140

mmHg dan TD diastolik < 90

mmHg [1B]

Disarankan untuk diberikan obat

penurun TD untuk mempertahankan

TD sistolik < 130 mmHg dan TD

diastolik < 80 mmHg [2D]

Pasien CKD-ND

dengan DM

KDIGO 2012: Manajemen TD pada pasien CKD-Non dialisis dengan DM

Direkomendasikan pemberian ARB atau ACE-i pada pasien CKD ND dewasa dengan DM dengan ekskresi

albumin urin > 300 mg/24 jam [1B]

TD: tekanan darah CKD-ND: Chronic kidney disease nondialisis DM: diabetes melitus

Kidney International Supplements (2012) 2, 363-9; doi:10.1038/kisup.2012.54 ARB: angiotensin receptor blockers ACE-i: angiotensin-converting enzyme inhibitor


Jadi . . . REKOMENDASI KDIGO 2012

Sudah mulai di balik rekomendasinya, biasanya setiap guideline : ACE or ARB. Tapi dalam Guideline terbaru KDIGO 2012 sudah di balik pilihannya : ARB atau ACE

Hypertension and cardiovascular disease

Hypertensive patients with LVH should receive an ARB as the first line treatment

In CHD, beta-blockers, ACEIs and long acting CCBs are the drugs of choice

Beta-blockers, ACEIs and aldosterone antagonists should be considered in patients with CHD especially in post myocardial infarction and when associated with LV dysfunction

Beta-blockers need to be cautiously used in patients with peripheral vascular disease. They are contraindicated in patients with severe PVD

Diuretics, ACEIs, beta-blockers, ARBs and aldosterone antagonists are drugs of choice for heart failure



Hypertension and stroke

Lowering blood pressure is the key to both primary and secondary prevention of stroke

In acute stroke, lowering BP is best avoided in the first few days unless hypertensive emergencies co-exist

In primary prevention, a CCB-based therapy is preferred

In secondary prevention, the benefits of BP lowering is seen in both normotensive and hypertensive patients

ACEI- or ARB- based treatment is preferred in secondary prevention



Hypertension in the elderly

Isolated Systolic hypertension is particularly common in the elderly and should be recognized and treated

Standing BP should be measured to detect postural hypotension

Decreasing dietary salt intake is particularly useful

When prescribing drugs, remember to start low and go slow



Hypertension in pregnancy

Pregnant women who are at high risk of developing preeclampsia should be referred to the obstetrican for screening and commencement of prophylaxis with aspirin

Prophylactic calcium supplementation from early pregnancy is beneficial and recommended

Pregnant women with hypertension should be referred to the obstetrician for further management

The antihypertensives of choice are methyldopa and labetalol

Oral nifedipine 10mg stat dose can be used to rapidly control BP in an acute hypertensive crisis prior to transfer to hospital


Bradikinin/NO

Fragmen inaktif

Angiotensin I

Angiotensin II

ACEI dan ARBs memblok RAS dengan cara yang berbeda

52

ARB

ACE-independent

ANG II formation

by Chymase, etc.

RESEPTOR AT2

Vasodilatasi

Natriuresis

Regenerasi jaringan

Inhibisi pertumbuhan sel yang tidak sesuai

Diferensiasi

Antiinflamasi

Apoptosis

ACE ACE

Inhibitor

RESEPTOR AT1

Vasokonstriksi

Retensi natrium

Aktivasi SNS

Inflamasi

Growth-promoting effects

Aldosterone

Apoptosis

SNS = sympathetic nervous system

Hanon 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

9 November 2013

Seminar IDI Wilayah NTT

Kelemahan ACE-i

• Intoleransi ACEi

– SPICE (Study of Patients Intolerant of Converting Enzyme Inhibitors)

• 20% pasien CHF tidak toleran terhadap ACE-i

– Pada HOPE trial, 25% pasien pada grup perlakuan menghentikan pengobatan ACE-i dengan alasan batuk, angioedema, dan hipotensi

– Pada studi pasien DM berusia >65 tahun, 38% pasien menghentikan pengobatan karena efek samping ACE-i. Bila agen pengobatan diganti dengan ARB, hanya 8% yang menghentikan terapi (Bogaisky, Allu,

Messenger, 2008)

Penekanan produksi AT II tidak lengkap

-Terdapat 2 jaras yang memproduksi AT II

pada miokardium

-ACE-i tidak memperlihatkan efek

penekanan AT II jangka panjang (Kirlin PC,

et al. 1995)

-Inhibitor kimase secara signifikan menekan

pembentukan AT II

HOPE trial

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Seminar IDI Wilayah NTT 54

P H Y S I C I A N S ’ A C A D E M Y F O R C A R D I O V A S C U L A R E D U C A T I O N

Why ARB ? ( Candesartan / Telmisartan )

Conlin et al 2001

0

10

20

30

40

50

60

70

%

AT1-blocker ACE-I CCBs Beta- blockers Diuretics

AT1-blocker p<0.02 dibandingkan golongan obat lainnya

1 year

4 years

56

Compliance terhadap terapi antihipertensi selama terapi 1 tahun dan 4 tahun

9 November 2013


Elliott & Meyer 2007

Efek berbagai terapi antihipertensi yang berbeda terhadap insidens diabetes

0.9 0.5 0.7

ARB

ACEI

CCB

Plasebo

Beta bloker

Diuretik

0.57 (0.46, 0.72) p<0.0001

0.67 90.56-0.80) p<0.0001

0.75 (0.62, 0.90) p=0.002

0.77 (0.63, 0.94) p=0.009

0.90 (0.75, 1.09) p=0.30

Odd rasio insidens diabetes

1.25

Metaanalisis dari 22 uji klinis

57 9 November 2013



Why Telmisartan ? (Micardis)

Plasma half life (h)

Kalkuta et al. Int J Clin Pharmacol Res 2005;25:41-46


Telmisartan improves glucose metabolism more than Irbesartan in diabetics with metabolic syndrome

-30

-25

-20

-15

-10

-5

0FPG FPI HOMA-IR HbA1c

Irbesartan 150 mg (n=93)

Telmisartan 40 mg (n=95)

Study duration = 12 months All patients taking rosiglitzone 4 mg/d

G. DeRosa et al, Hypertension Research, 2006 9 November 2013 Seminar IDI Wilayah NTT 60

Meta-Analysis of the Effects of Telmisartan on New Onset Diabetes in PRoFESS and TRANCEND Trials

(comparisons againts placebo groups)

Significant anti –diabetic effect of telmisartan vs placebo 16% risk reduction for diabetes (3% - 28%) 9 November 2013 Seminar IDI Wilayah NTT 61


Why Candesartan ? (Canderin)

63 9 November 2013


Candesartan lebih superior dalam

menurunkan kolesterol total dan LDL

dibanding agen ARB yang lain

Profil Lipid

Hellenic J Cardiol, 2006, Effects of Antihypertensive Treatment with Angiotensin II Receptor Blockers on Lipid Profile 64

9 November 2013


New-onset Diabetes

-41%

-47%

-62%

4%

-80%

-60%

-40%

-20%

0%

<22 ≥22 ≥25 ≥27.5

P=0.947 P=0.015 P=0.028 P=0.0034

BMI

Risk Reduction

in Candesartan group

0,0%

1,0%

2,0%

3,0%

4,0%

5,0%

6,0%

0 6 12 18 24 30 36 42 48

months

P=0.301

HR=0.64; 95%

CI 0.43-0.97

Amlodipine

Candesartan

9 November 2013


CAD Fibrilasi

atrial

Stroke

Pre-hipertensi Hipertensi

Demensia

TIA

Hipertensi

Mikroalbuminuria

Albuminuria

Proteinuria

Nefrosklerosis

Gagal ginjal

kronik

ESRD

CHF

Hipertensi

LVH MI

Pre-hipertensi

Mikroaneurisma

NPDR

PDR

Edema

makular

KEMATIAN

Trophy

SCOPE

ACCESS

Pre-hipertensi

CALM

Trophy

Trophy

CHARM CATCH HOPE-3

CHARM

DIRECT

SCAST

SMART

Uji Klinis

Candesartan

66

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67

CANDESARTAN VS AMLODIPINE

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68

Perubahan Tekanan darah

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69

Perubahan LVMI pada pasien LVH

LVMI = Left ventricular mass index 9 November 2013


70

Tingkat mortalitas

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SUMMARY Treatment of hypertension still an unsolved issues

Goal of blood pressure is the chief target

- < 140/90 mmHg for uncomplicated patients

- < 130/80 mmHg for the high risk patients

(e.g. Diabetes, CKD)

Management of hypertension always start with

lifestyle modifications

Choice of hypertension drugs depend on :

- mode of action

- compelling or not compelling indications

Drugs combination has a special role in

hypertensive medical treatment

9 November 2013


Terima Kasih . . . 9 November 2013 Seminar IDI Wilayah NTT 73

Documents

Hypertension