HIPERTENSI

DEFINISI

Blood pressure:

is the pressure of the blood against the walls of

the arteries.

results from two forces.

One is created by the heart as it pumps blood into

the arteries and through the circulatory system.

The other is the force of the arteries as they resist the

blood flow.

TEKANAN DARAH

CARDIAC OUTPUT

RESISTENSI PERIFER

HIPERTENSI

Hypertension is the most

common condition in primary
care.

1 in 4 patients have
hypertension according to
Badan Penelitian dan
Pengembangan Kesehatan
Kementrian Kesehatan,
Indonesia

Risk factor for MI, CVA, ARF,

diabetes

Merujuk pada data ISH,

tingkat kematian akibat
hipertensi di Indonesia pada
2013 mencapai 25,8 persen.

Dari keseluruhan angka

tersebut, 22,8 persen di
antaranya diidap oleh lakilaki, sementara perempuan
memakan porsi 28,8 persen

Mencegah dan Mengontrol

Hipertensi Agar Terhindar dari
Kerusakan Organ Jantung,
Otak dan Ginjal

Tekanan darah

Systolic blood pressure is a measure of blood

pressure while the heart is beating

Diastolic pressure is a measure of blood pressure

while the heart is relaxed, between heartbeats.

PREVALENSI DAN
EPIDEMIOLOGI

Prevalensi nasional Hipertensi Pada

Penduduk Umur > 18 Tahun adalah
sebesar 29,8%
31% penduduk Amerika mengalami
hipertensi 140/90 mmHg
Tekanan darah akan meningkat
dengan bertambahnya usia
(hipertensi banyak terjadi pada
lansia)
menurut WHO prevalensi hipertensi di
dunia 33.6% pd thn 2006

ETIOLOGI

Hipertensi primer (90%): tidak diketahui

penyebabnya, hanya bisa dikontrol (faktor
genetik)

Hipertensi sekunder (10%):

disfungsi ginjal (gagal ginjal kronis, penyakit thyroid,

Cushing syndrome)

Obat: dekongestan, steroid, NSAID

Makanan: Natrium, etanol, tiramin

Multiple factors may contribute to the development of

primary hypertension, including:

Humoral abnormalities involving the renin-angiotensinaldosterone system, natriuretic Hormone, or

hyperinsulinemia;

A pathologic disturbance in the CNS, autonomic nerve

fibers, adrenergic receptors, or baroreceptors;

Abnormalities in either the renal or tissue autoregulatory

processes for sodium excretion, plasma volume, and
arteriolar constriction;

A deficiency in the local synthesis of vasodilating

substances in the vascular endothelium, such as
prostacyclin, bradykinin, and nitric oxide, or an increase in
production of vasoconstricting substances such as
angiotensin II and endothelin I;

Krisis hipertensi
A hypertensive crisis (BP >180/120 mm Hg) may be
categorized as either :

a hypertensive emergency (extreme BP elevation

with acute or progressing target organ damage)
or

a hypertensive urgency (severe BP elevation

without acute or progressing target organ injury)

PATOFISIOLOGI

Malfungsi sistem renin-angiotensin-aldosteron

PATOPHYSIOLOGY

Renin is an enzyme secreted into the

blood from the kidneys
sensitive to changes in blood flow and
blood pressure
The primary stimulus for increased
renin secretion is decreased blood
flow to the kidneys, which may be
caused by loss of sodium and water
(as a result of diarrhea, persistent
vomiting, or excessive perspiration)
Renin catalyzes the conversion of
angiotensinogen into angiotensin I

PATOPHYSIOLOGY

An enzyme in the serum called

angiotensin-converting enzyme (ACE)
then converts angiotensin I into
angiotensin II
Angiotensin II acts via receptors in the
adrenal glands to stimulate the secretion
of aldosterone:

which stimulates salt and water reabsorption

by the kidneys,
and the constriction of small arteries
(arterioles), which causes an increase in blood
pressure.

Angiotensin II further constricts blood

vessels through its inhibitory actions on
the reuptake into nerve terminals of the
hormone norepinephrine

FISIOLOGIS TEKANAN DARAH

JNC VII: Classification of blood pressure

Blood pressure
classification
Normal

Systolic BP
(mm Hg)

Diastolic BP
(mm Hg)

<120

or

<80

Prehypertension

120-139

or

80-89

Stage 1
hypertension

140-159

or

90-99

Stage 2
hypertension

160

or

100

The JNC VII. JAMA 2003;289:2560-72

JNC VII and ESHESC summary: target

blood pressure goals

Type of hypertension

BP goal (mmHg)

Uncomplicated

<140/90

Complicated
Diabetes mellitus

<130/80

Kidney disease

<130/80

Kaplan (Clinical Hypertension, 9th ed.,2006)

BP target is to lower BP below the threshold for
starting therapy

Chobanian et al. JAMA 2003;289:256072

Guidelines Committee. J Hypertens 2003;21:101153

Komplikasi

Otak: stroke

Jantung: penyakit jantung koroner, gagal jantung

Mata: hipertensif retinopati

Ginjal : gagal ginjal (kreatinin tinggi, proteinuria)

Penyakit vaskular perifer: aneurisma

KOMPLIKASI

Risk of CV disease doubles with every 20/10 mm

Hg increase.

Even patients with prehypertension have an

increased risk of CV disease.

DIAGNOSIS

Silent killer

Pengukuran tekanan darah (sesuaikan dgn

klasifikasi tekanan darah JNC VII)

Evaluasi hipertensi

TERAPI

Nonfarmakologi

Farmakologi:

Tujuan: menurunkan mortalitas dan morbiditas yang

berhubungan dengan kerusakan hipertensi

Mortalitas dan morbiditas berkaitan dgn organ

target spt: kejadian kardiovaskular/serebrovaskular,
gagal jantung, penyakit ginjal

Terapi nonfarmakologi

Algoritma terapi hipertensi JNC 7

Development of JNC-8
3 critical questions for adults with hypertension
Does initiating antihypertensive pharmacologic
therapy at specific blood pressure thresholds
improve health outcomes? [When to start therapy?]
Does treatment with antihypertensive
pharmacologic therapy to a specified blood
pressure goal lead to improvements in health
outcomes? [How low should I go?]
Do various antihypertensive drugs or drug classes
differ in comparative benefits and harms on specific
health outcomes? [What drug do I use?]

JNC 8: Graded
Recommendations
A Strong evidence

B Moderate evidence

C Weak evidence

D Against

E Expert Opinion

N No recommendation

JNC 8: Drug Treatment

Thresholds and Goals
Age > 60 yo

Systolic:

Threshold > 150 mmHg

Goal < 150 mmHg

LOE: Grade A

Diastolic:

Threshold > 90 mmHg

Goal < 90 mmHg

LOE: Grade A

JNC 8: Drug Treatment

Thresholds and Goals
Age < 60 yo
Systolic:
Threshold > 140 mmHg
Goal < 140 mmHg
LOE: Grade E

Diastolic:

Threshold > 90 mmHg

Goal < 90 mmHg
LOE: Grade A for ages 40-59; Grade E for ages
18-39

JNC 8: Drug Treatment

Thresholds and Goals
Age > 18 yo with CKD or DM

JNC 7: < 130/80 (MDRD NEJM 1994)

Systolic:

Threshold > 140 mmHg

Goal < 140 mmHg

LOE: Grade E

Diastolic:

Threshold > 90 mmHg

Goal < 90 mmHg

LOE: Grade E

JNC 8: Initial Drug Choice

Nonblack, including DM

Thiazide diuretic, CCB, ACEI, ARB

LOE: Grade B

Black, including DM

Thiazide diuretic, CCB

LOE: Grade B (Grade C for diabetics)

JNC 8: Initial Drug Choice

Age > 18 yo with CKD and HTN (regardless of race

or diabetes)

Initial (or add-on) therapy should include an ACEI or

ARB to improve kidney outcomes

LOE: Grade B

Blacks w/ or w/o proteinuria

ACEI or ARB as initial therapy (LOE: Grade E)

No evidence for RAS-blockers > 75 yo

Diuretic is an option for initial therapy

JNC 8: Subsequent
Management
Reassess treatment monthly
Avoid ACEI/ARB combination
Consider 2-drug initial therapy for Stage 2 HTN (>
160/100)
Goal BP not reached with 3 drugs, use drugs from
other classes

Consider referral to HTN specialist

LOE: Grade E

Oral antihypertensive drugs*

Class Drug (Trade Name) Usual dose range in mg/day (Daily Frequency)
ACE inhibitors
benazepril
captopril
enalapril
fosinopril
lisinopril
moexipril
perindopril
quinapril
ramipril
trandolapril

(Lotensin)
(Capoten)
(Vasotec)
(Monopril)
(Prinivil, Zestril)
(Univasc)
(Aceon)
(Accupril)
(Altace)
(Mavik)

Angiotensin II antagonists
candesartan
(Atacand)
eprosartan
(Tevetan)
irbesartan
(Avapro)
losartan
(Cozaar)
olmesartan
(Benicar)
telmisartan
(Micardis)
valsartan
(Diovan)

1040
25100
2.540
1040
1040
7.530
48
1040
2.520
14

832
400800
150300
25100
2040
2080
80320

(12)
(2)
(12)
(1)
(1)
(1)
(12)
(1)
(1)
(1)

(1)
(12)
(1)
(12)
(1)
(1)
(1)

Classification
Calcium Antagonists
Generation:
First
Second
Verapamil
Nifedipine
Diltiazem

Felodipine RTD
Isradipine CR
Verapamil SR
Nifedipine GITS
Diltiazem CD

J Clin Basic Cardiol 1999;2:155

Third

Latest

Amlodipine Lercanidipine
(hydrophilic) (lipophilic)

DIURETIK

Tiazid: HCT

Loop: furosemid

Hemat kalium: amilorid, triamteren

Antagonis aldosteron: spironolakton

ES tiazid: hipokalemia, hipomagnesia,

hiperkalsemia, hiperurisemia, hiperglikemia,
hiperlipidemia dan disfungsi seksual

ACE Inhibitor

Menghambat angiotensin I menjadi angiotensin II

Angiotensin II adalah vasokonstriktor kuat dan jg

merangsang sekresi aldosteron

ACEI memblok degradasi bradikinin--

meningkatkan efek penurunan tekanan darah
dan ES batuk kering

Penyekat reseptor angiotensin II

(ARB)

Efek angiotensin II: vasokonstriksi, pelepasan aldosteron,

aktivasi simpatik, pelepasan hormon antidiuretik

Beta blocker
Reseptor beta 1 : jantung, ginjal
Reseptor beta 2: paru-paru, liver, pankreas dan otot
halus arteri
Stimulasi:

Beta 1: meningkatkan denyut jantung, kontraktilitas,

dan pelepasan renin,

Beta 2: bronkodilatasi, vasodilatasi, sekresi insulin,

glikogenolisis

Penghambatan/inhibisi reseptor beta: beta blocker

Kardioselektif kecil kemungkinan terjadi spasme
bronkus dan vasokonstriksi (beta-1 blocker)
Beta-2 blocker: Vasokonstriksi dan spasme bronkus,
hiperglikemia

Antihipertensi alternatif

Alfa 1 blocker

Alfa 1 blocker selektif: prazosin, terazosin,

doxazosin

bekerja pada pembuluh darah perifer dan

menghambat mengambilan katekolamin pada
sel otot halus, menyebabkan vasodilatasi dan
penurunan tekanan darah

Bermanfaat pd laki-laki dengan BPH (beningna

prostatic hyperplasia)

Memblok reseptor alfa 1postsinaps adrenergik di

tempat kapsul prostat menyebabkan relaksasi
dan berkurangnya hambatan pengeluaran urin

Agonis alfa 2 central

Klonidin dan metildopa

Merangsang reseptor alfa2 adrenergik di otak -- Menurunkan aliran simpatetik dari pusat
vasomotor di otak (aktivitas parasimpatik
meningkat) ---- menurunkan denyut jantung,
cardiac output, tota periferal resistance, aktivitas
plasma renin, dan reflex baroreseptor

Klonidin: hipertensi resisten

Metildopa: hipertensi pada kehamilan

Vasodilator arteri langsung

Hidralazin
relaksasi

dan minoksidil:

langsung otot polos arteriol tapi tidak

meyebabkan vasodilatasi pembuluh darah vena
Penurunan tekanan perfusi yang kuat
mengaktifkan refleks baroreseptor ----- aliran
simpatik meningkat ------- meningkatkan
denyut jantung, curah jantung dan pelepasan
renin ----- terbentuk takifilaksis shg efek
hipotensi hilang pd penggunaan terus menerus.
Diatasi dengan penggunaan beta blocker
bersamaan.

Interaksi obat

Studi kasus

L.N. is a 49-year-old white woman with a history of type 2

diabetes, obesity, hypertension, and migraine headaches.
The patient was diagnosed with type 2 diabetes 9 years
ago when she presented with mild polyuria and polydipsia.
L.N. is 54 and has always been on the large side, with her
weight fluctuating between 165 and 185 lb.
Initial treatment for her diabetes consisted of an oral
sulfonylurea with the rapid addition of metformin. Her
diabetes has been under fair control with a most recent
hemoglobin A1c of 7.4%.
Hypertension was diagnosed 5 years ago when blood
pressure (BP) measured in the office was noted to be
consistently elevated in the range of 160/90 mmHg on
three occasions. L.N. was initially treated with lisinopril,
starting at 10 mg daily and increasing to 20 mg daily, yet
her BP control has fluctuated.
One year ago, microalbuminuria was detected on an
annual urine screen, with 1,943 mg/dl of microalbumin
identified on a spot urine sample. L.N. comes into the
office today for her usual follow-up visit for diabetes.
Physical examination reveals an obese woman with a BP
of 154/86 mmHg and a pulse of 78 bpm.

Pertanyaan

Apa pengaruh mengontrol tekanan darah pada

pasien DM

Berapa target tekanan darah pd pasien DM

Obat antihipertensi yg mana yg

direkomendasikan utk pasien tsb

Studi kasus

A 58 year old Javanese woman with diabetes

and dyslipidemia has a BP of 158/94 confirmed on
several office visits.

Other than obesity, the exam is normal. Labs

show normal renal function, well-controlled lipids
on atorvastatin and well-controlled diabetes on
metformin.

Urine micro-albumin is mildly elevated.

Pertanyaan 1
What goal BP is most appropriate for this patient?

1.<150/90 mmHg

2.<130/80 mmHg

3.<140/90 mmHg

4.<140/80 mmHg

5.<140/85 mmHg

Pertanyaan 2
What is the drug of choice to start?

1.Hydrochlorothiazide

2.Amlodipine

3.Lisinopril

4.Losartan

5.Metoprolol

6.Combination therapy

KUIS 1

JF is a 52-year-old Balinese man who has just

been diagnosed with hypertension. He has no
other comorbidities or contraindications to
medications. According to the JNC8 guidelines,
which of the following medications would be most
appropriate for the initial management of JFs
blood pressure?

1.Lisinopril

2.Chlorthalidone

3.Atenolol

4.Valsartan

KUIS 2

According to the JNC8 guidelines, the goal blood

pressure for an adult patient with diabetes mellitus
is:

1.<120/80

2.<130/80

3.<140/90

4.<150/90