Oleh : Bagian Ilmu Penyakit Dalam

FK Universitas Sultan Agung Semarang

2012

The ‘rule of halves’ – the need for effective The ‘rule of halves’ – the need for effective diagnosis and treatment of hypertensiondiagnosis and treatment of hypertension

Men (n=1262)

Proportions of the general population who have undiagnosed hypertension (160/95 mmHg) or who are untreated or inadequately treated (Scotland, 1984-1986)

Women (n=1061)

Smith et al (1990)

Undiagnosed hypertension Diagnosed but untreated Treated but uncontrolled Treated and controlled

Blood Pressure ClassificationBlood Pressure ClassificationJNC-VII 2003JNC-VII 2003

NormalNormal <120<120 andand <80<80

PrehypertensionPrehypertension 120120––139139 oror 8080––8989

Stage 1 Stage 1 HypertensionHypertension

140140––159159 oror 9090––9999

Stage 2 Stage 2 HypertensionHypertension

>>160160 oror >>100100

BP ClassificationBP Classification SBP mmHgSBP mmHg DBP mmHgDBP mmHg

Diagnostic evaluationDiagnostic evaluation

Types of hypertensionTypes of hypertension

Essential HypertensionEssential Hypertensionhypertension with no apparent cause hypertension with no apparent cause 90-95%90-95%

Secondary HypertensionSecondary Hypertensionhypertension of known causehypertension of known cause

chronic renal diseaseschronic renal diseases 2.5-5%2.5-5% Renovascular diseasesRenovascular diseases 0.5-4%0.5-4% Oral contraceptive pills Oral contraceptive pills 0.2-1%0.2-1% Coarctation of the AortaCoarctation of the Aorta 0.1-1%0.1-1% Primary aldosteronismPrimary aldosteronism 0.1-0.5%0.1-0.5% PheochromocytomaPheochromocytoma 0.1-0.2%0.1-0.2%

Garry P. Reams & John H. Bauer

RiskRisk FactorsFactors

AgeAge Gender Gender RaceRace Genetic factorsGenetic factors other:other:

• obesityobesity• high alcohol intakehigh alcohol intake• high Na intakehigh Na intake• abnormal renin valuesabnormal renin values• high stress levelhigh stress level• low birth weightlow birth weight• drugsdrugs

Complications of HTNComplications of HTN1 VascularVascular2 RetinalRetinal3 CardiacCardiac4 CNSCNS5 RenalRenal

Vascular ComplicationsVascular ComplicationsKomplikasi pada pembuluh darahKomplikasi pada pembuluh darah

ArterioscelorosisArterioscelorosis wall:lumen ratiowall:lumen ratio• remodelingremodeling

Atherosclerosis Atherosclerosis • PlaquePlaque

Fibrous capFibrous cap necrotic centernecrotic center

Fibrinoid necrosis.Fibrinoid necrosis. Aortic dissection.Aortic dissection.

Retinal complicationsRetinal complications

Hypertensive Hypertensive retinopathyretinopathy

Blurred optic disc

Increased light reflexes from arterioles

Venous tapering

Punctate hard exudate

hemorrhageNormalKW : I - IV

Cardiac complicationsCardiac complications

This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.

CNS ComplicationsCNS Complications

Hypertensive Hypertensive encephalopathyencephalopathy

Cerebral Cerebral hemorrhagehemorrhage

Ischemic strokeIschemic stroke TIAsTIAs

Renal ComplicationsRenal Complications

Benign arteriolar NephrosclerosisBenign arteriolar Nephrosclerosis Malignant arteriolar Malignant arteriolar

NephrosclerosisNephrosclerosis Chronic Renal FailureChronic Renal Failure

lanjutanlanjutan

Goal of HypertensionGoal of HypertensionPrevention and ManagementPrevention and Management

To reduce morbidity and mortality by the To reduce morbidity and mortality by the least intrusive means possible. This may least intrusive means possible. This may be accomplished by achieving and be accomplished by achieving and maintaining:maintaining:

• SBP < 140 mm HgSBP < 140 mm Hg

• DBP < 90 mm HgDBP < 90 mm Hg

• controlling other cardiovascular risk controlling other cardiovascular risk factorsfactors

Anti-Hypertensive Drugs: Anti-Hypertensive Drugs: Sites of ActionSites of Action

-Blockers

CCBs*

Diuretics

ACE Inhibitors AT1 Blockersa-Blockersa2-Agonists

CCBsDA1 Agonists

DiureticsSympatholytics

Vasodilators

Blood Pressure

Cardiac Output

Total Peripheral Resistance

= X

* = non-dihydropyridine CCBs

Classification and Management Classification and Management of BP for adults (JNC-VII 2003)of BP for adults (JNC-VII 2003)

BP BP classificaticlassificati

onon

SBP* SBP* mmHmmH

gg

DBP* DBP* mmHmmH

gg

Lifestyle Lifestyle modificatmodificat

ionion

Initial drug therapyInitial drug therapy

Without compelling Without compelling indication indication

With With compelling compelling indicationsindications

NormalNormal <120<120 and and <80<80

EncouragEncouragee

PrehypertePrehypertensionnsion

120120––139139

or 80or 80––8989

YesYes No No antihypertensive antihypertensive drug indicated.drug indicated.

Drug(s) for Drug(s) for compelling compelling indications. indications. ‡‡

Stage 1 Stage 1 HypertensiHypertensionon

140140––159159

or 90or 90––9999

YesYes Thiazide-type Thiazide-type diuretics for most. diuretics for most. May consider ACEI, May consider ACEI, ARB, BB, CCB, or ARB, BB, CCB, or combination.combination.

Drug(s) for the Drug(s) for the compelling compelling indications.indications.‡‡

Other Other antihypertensiantihypertensive drugs ve drugs (diuretics, (diuretics, ACEI, ARB, BB, ACEI, ARB, BB, CCB) as CCB) as needed. needed.

Stage 2 Stage 2 HypertensioHypertensionn

>>160160 or or >>100100

YesYes Two-drug combination Two-drug combination for mostfor most†† (usually (usually thiazide-type diuretic thiazide-type diuretic and ACEI or ARB or BB and ACEI or ARB or BB or CCB).or CCB).

*Treatment determined by highest BP category.†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

• Hypertension is the major risk factor for coronary heart disease and congestive heart failure

• Hypertension is second only to diabetes as the cause of renal failure

• In a recent meta analysis, treating hypertension reduced the incidence of stroke by 38% and coronary heart disease by 16%

• In a US survey, only 21% of hypertensive patients had their blood pressure controlled at <140/90 mmHg

Treatment of Hypertension Background

Not at Goal Blood Pressure

Algorithm for Treatment of Algorithm for Treatment of Hypertension Hypertension

Begin or Continue Lifestyle Modifications

• Lose weight• Limit alcohol• Increase physical activity• Reduce Sodium

• Maintain potassium• Maintain calcium and

magnesium• Stop smoking• Reduce saturated fat,

cholesterol

Lifestyle Modifications

Initial Drug Choices

Not at Goal BP ( <140/ 90 mmHg or <130/80 mmHg for those with diabetes or chronic kidney disease )

Hypertension without Compelling Indication

Stage 1 Hypertension(Systolic BP 140-159 mmHg or

diastolic BP 90-99 mmHg)Thiazide , ACE-I, ARB, B-Blocker, CCB,

or combination

Not at Goal BP

Optimize dosages or Add Drugs Until Goal BP is AchievedConsider Consultation With hypertension Specialist

Algorithm for Treatment of hypertension

Hypertension with Compelling Indication

Stage 2 Hypertension(Systolic BP > 160 mmHg or diastolic

BP > 100 mmHg)2 drug combination ( Thiazide and ACE-I or ARB or B-Blocker or CCB )

Drug for the compelling indication

Other AH drug ( Diuretic ACE-I , ARB, B-Blocker,

CCB) as needed

JNC. VII, 2003

Initial Drug Choices*

Uncomplicated• Diuretics• -blockers

Algorithm for Treatment ofHypertension (continued)

*Based on randomized controlled trials.

Initial Drug Choices*

Algorithm for Treatment of Hypertension (continued)

Compelling Indications • Heart failure

– ACE inhibitors– Diuretics

• Myocardial infarction -blockers (non-ISA)– ACE inhibitors (with systolic dysfunction)

• Diabetes mellitus (type 2) with proteinuria– ACE inhibitors

• Isolated systolic hypertension (older persons) – Diuretics preferred– Long-acting dihydropyridine calcium antagonists

*Based on randomized controlled trials.

MonotherapyMonotherapy RespnseRespnse(after 4 to 6 weeks)(after 4 to 6 weeks)

PartialPartial

SatisfactorySatisfactory

MinimalMinimal

Add 2nd drugAdd 2nd drug

DoseDose

Substitute drugSubstitute drug

Individualized approach to treating Individualized approach to treating hypertensionhypertension

Menard (1992); Materson (1995)Menard (1992); Materson (1995)

Combination Therapy ARB/ACE-I and CCB

Concept of Counteregulation

Calcium ChanelBlockers

RAS = renin-angiotensin systemSNS = sympathetic nervous system

Arteriole Dilatation

RAS IN-ActivationSNS IN-Activation-Veno- artery dilatation

ACE-I or ARBCCB

Obesity Weight reductionObesity Weight reduction

Weight reduction will lead to Weight reduction will lead to a fall in BP of a rate of 2-3 a fall in BP of a rate of 2-3 mmHg/Kg for SBP and 2 mmHg/Kg for SBP and 2 mmHg/Kg for DBP.mmHg/Kg for DBP.

Reduces the risk of CAD, Reduces the risk of CAD, cerebrovascular and cerebrovascular and peripheral vascular disorders.peripheral vascular disorders.

Weight reduction Weight reduction decreased insulin and decreased insulin and adrenaline levels adrenaline levels decreased sympathetic decreased sympathetic activity activity reduction in BP. reduction in BP.

Pregnant WomenPregnant Women Chronic hypertension is high blood pressure Chronic hypertension is high blood pressure

present before pregnancy or diagnosed before present before pregnancy or diagnosed before 20 week of gestation.20 week of gestation.

Preeclampsia is increased blood pressure that Preeclampsia is increased blood pressure that occurs occurs in pregnancy (generally after the 20th week) and in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both.is accompanied by edema, proteinuria, or both.

ACE inhibitors and angiotensin II receptor ACE inhibitors and angiotensin II receptor blockers blockers are contraindicated for pregnant women. are contraindicated for pregnant women.

Methyldopa, Methyldopa, bolckers and Ca Antagonis bolckers and Ca Antagonis recommended for women diagnosed during recommended for women diagnosed during pregnancy.pregnancy.

Older Persons Older Persons

Therapy should begin with lifestyle Therapy should begin with lifestyle modifications.modifications.

Starting doses for drug therapy should Starting doses for drug therapy should be lower than those used in younger be lower than those used in younger adults.adults.

Goal of therapy is the same (< 140/90 Goal of therapy is the same (< 140/90 mm Hg) although an interim goal of mm Hg) although an interim goal of SBP < 160 mm Hg may be necessary.SBP < 160 mm Hg may be necessary.

Renal DiseaseRenal Disease Hypertension may result from renal Hypertension may result from renal

disease that reduces functioning nephrons.disease that reduces functioning nephrons.

Evidence shows a clear relationship Evidence shows a clear relationship between high blood pressure and end-between high blood pressure and end-stage renal disease.stage renal disease.

Blood pressure should be controlled to < Blood pressure should be controlled to < 130/85 mm Hg130/85 mm Hg or lower (< 125/75 mm Hg) or lower (< 125/75 mm Hg) in patients with proteinuria in excess of 1 in patients with proteinuria in excess of 1 gram per 24 hours.gram per 24 hours.

ACE inhibitors work well to control blood ACE inhibitors work well to control blood pressure and slow progression of renal pressure and slow progression of renal failure.failure.

Diabetes MellitusDiabetes Mellitus

Drug therapy should begin along with lifestyle Drug therapy should begin along with lifestyle modifications to reduce blood pressure tomodifications to reduce blood pressure to < < 130/85 mm Hg.130/85 mm Hg.

ACE inhibitors,ACE inhibitors,αα-blockers, calcium antagonists, -blockers, calcium antagonists, and low dose-diuretics are preferred.and low dose-diuretics are preferred.

Insulin resistance or high peripheral insulin Insulin resistance or high peripheral insulin levels may cause hypertension, which can be levels may cause hypertension, which can be treated with lifestyle changes, insulin-treated with lifestyle changes, insulin-sensitizing agents, vasodilating sensitizing agents, vasodilating antihypertensive drugs, and lipid-lowering antihypertensive drugs, and lipid-lowering agents.agents.

Much Thanks~~

今後也請大家多多指教 !!c