Hypertension, a long life untreated diseases?

Dr Zainal Safri SpPD, SpJP, FIHA Dept. Cardiology, Fac. of Medicine USU Adam Malik Hospital

Prevalence of hypertension: Asia

80 70 60 50 40 30 20 10 0
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Prevalence (%)

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Gu DF, et al. Hypertension 2002;40:920-927; Singh RB, et al. J Hum Hypertens 2000;14:749-763; Janus ED. Clin Exp Pharmacol Physiol 1997;24:987-988; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al. Singapore Med J 2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27:405-409; Muhilal H. Asia Pacific J Clin Nutr 1996;5:132-134; Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48:827-836 [in Japanese]

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CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment

8 7 6 CV mortality risk 5 4 3

2
1 0 115/75 135/85 155/95 175/105 SBP/DBP (mm Hg)
*Individuals aged 40-70 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure Lewington S, et al. Lancet. 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.

Effects of blood pressure on the risk of cardiovascular disease

Average annual incidence rate per 10.000
100 90 80 70 60 50 40 30 20

CHD

Stroke

CHF

10
0

<100 120 140 180 Systolic blood pressure (mmHg)

>180

Source : Framingham study (after Gorlin)

Hypertension Syndrome Its More Than Just Blood Pressure

Decreased Arterial Compliance Endothelial Dysfunction Abnormal Glucose Metabolism

Obesity

Abnormal Lipid Metabolism

Accelerated Atherogenesis LV Hypertrophy and Dysfunction

HYPERTENSION

Neurohormonal Dysfunction

Abnormal Insulin Metabolism

Renal-Function Changes Blood-Clotting Mechanism Changes

Kannel WB. JAMA. 1996;275:1571-1576. Weber MA et al. J Hum Hypertens. 1991;5:417-423. Dzau VJ et al. J Cardiovasc Pharmacol. 1993;21(suppl 1):S1-S5.

Hypertension risk
Aortic and other arterial aneurysm Peripheral arterial diseases Coronary Artery Disease Heart failure Ventricular hypertrophy Ventricular systolic dysfunction

Hypertensive retinopathy Fundal hemorrhages Papiloedema

Target organ damage

Renal impairment End Stage Renal Disease Proteinuria modified from : Campbell, et al. CMAJ 2002 Williams B, et al.. BMJ 2004

Cerebrovascular Disease Dementia

KLASIFIKASI HIPERTENSI
Klasifikasi Hipertensi pada orang dewasa :
JNC 7 (The Seventh Report of The Joint National Committee on Prevention Detection, Evaluation, and Treatment of High Blood Pressure)

WHO (World Health Organization) ; ISH (International Society of Hypertension); ESH (European Society of Hypertension); BSH (British Hypertension Society); CHEP (Canadian Hypertension Education Program)

Classification of Hypertension ESC/ESH & JNC VII

BP Optimal Normal <120 / <80 120-129 / 80-84 BP <120/<80 120-139 /80-89 JNC VII Bp Classification Normal Prehypertension

High normal
Grade 1 Hypertension (mild) Grade 2 Hypertension (moderate) Grade 3 Hypertension (severe) Isolated Systolic Hypertension

130-139 / 85-89
140-159 / 90-99 160-179 /100-109 > 180 / >110 140-159 / 90-99 >160 / >100 Stage 1 Hypertension Stage 2 Hypertension

>> 140

< 90

ESH-ESC BP Classification

Kesenjangan antara jumlah penderita HTN dan kontrol tekanan darah

80 70 60

73 68 51 55 54

70

Patient Awareness Treatment

59

Adults, %

50 40 30 20 10 0

31

29

34
27

Control

10

NHANES II 19761980

NHANES III 19881991

NHANES III 19911994

19992000*

*Computed by M. Wolz (unpublished data cited by Chobanian et al.) Adapted from Chobanian AV, et al. JAMA. 2003;289:2560-2572.

Percentages of Patients whose Hypertension is Controlled

< 140/90 mmHg
USA
27

< 160/95 mmHg

Finland
20.5

Canada
16

Spain
20

Australia
19

England 6

France
24

Germany
22.5
> 65 years

Scotland
17.5

India
9

USA: JNC VI. Arch Intern Med 1997 Canada: Joffres et al. Am J Hypertens 1997 England: Colhoun et al. J Hypertens 1998 France: Chamontin et al. Am J Hypertens 1998

Marques-Vidal P et al. J Hum Hypertens 1997

Adapted from G. Mancia / L. Ruilope

Hipertensi Resisten
Prevalensi sekitar : 20 sampai 30% Faktor risiko : Usia tua, Obesitas

Caused of Hipertension :
I. Primer / essential / idiopathic (: 90-95%) II. Sekunder : (5-10%) A. Renal

B. Endocrine
C. Coartation of the aorta D. Pregnancy induced hypertension E. Neurological disorder F. Drug and other abused substancen

Patogenesis Hipertensi

MULTIFAKTORIAL

Tekanan Darah
Blood pressure
Hypertension

= Cardiac output (CO) x Peripheral resistance (PR)

= Increased CO and/or Increased PR

Preload Fluid volume

Contractility Fluid volume

Vasoconstriction

Renal sodium retention Excess sodium intake

Sympathetic nervous system Genetic factors

Reninangiotensinaldosterone system

(Adapted from Kaplan, 1994)

HIPERTENSI DAN KERUSAKAN ORGAN TARGET

Atherosclerosis* Vasoconstriction Vascular hypertrophy

Stroke
Hypertension DEATH

HTN

LV hypertrophy Fibrosis Remodeling Apoptosis

GFR Proteinuria Aldosterone release Glomerular sclerosis
*preclinical data

Heart failure MI

Renal failure

LV = left ventricular; MI = myocardial infarction; GFR = glomerular filtration rate Adapted from Willenheimer R et al Eur Heart J 1999;20(14):997-1008; Dahlf B J Hum Hypertens 1995;9(suppl 5):S37-S44; Daugherty A et al J Clin Invest 2000;105(11):1605-1612; Fyhrquist F et al J Hum Hypertens 1995;9(suppl 5):S19-S24; Booz GW, Baker KM Heart Fail Rev 1998;3:125-130; Beers MH, Berkow R, eds. The Merck Manual. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories, 1999:1682-1704; Anderson S Exp Nephrol 1996;4(suppl 1):34-40; Fogo AB Am J Kidney Dis 2000;35(2):179-188.

HIPERTENSI : The Disease Continuum

Early Paradigm

Natural History of CVD Progression

Elevated BP
More Recent Paradigm

Target Organ Damage

Vascular Dysfunction A Proposed Future Paradigm

Elevated BP

Target Organ Damage

Endothelial Dysfunction

Vascular Dysfunction

Elevated BP LVH

Target Organ Damage Renal Damage MI

Angina Pectoris

Stroke

NEW TREATMENT APPROACH

Hypertension = disease of blood vessels

Vascular biology altered

Therapeutic options

ACE AT1 Calcium Inhibitors blockers channel blockers

Diuretics Others Blockers* *

* Minimal evidence of effects on endothelial function

Masalah hipertensi :
Meningkatnya prevalensi Hipertensi Pasien Hipertensi : terapi (-) ; target (-) Komplikasi Hipertensi (HTN) keberhasilan penanganan HTN tergantung edukasi pasien & komunikasi thd kepatuhan minum obat

How to improve compliance with treatment

Inform the patient of the risk of hypertension and the benet of effective treatment. Provide clear written and oral instructions about treatment. Tailor the treatment regimen to patients lifestyle Simplify treatment by reducing, if possible, the number of daily medicaments. Involve patients partner or family in information on disease and treatment plans. Pay great attention to side effects (even if subtle) and be prepared to change drug doses or types if needed.

KESIMPULAN
Hipertensi esensial merupakan penyakit multifaktorial yang timbul karena interaksi : faktor risiko, sistim saraf simpatis, keseimbangan antara modulator vasodilatasi dan vasokonstriksi, pengaruh sistem renin-angiotensin-aldosteron Disfungsi endotel dan vaskular menyebabkan hipertensi, yg selanjutnya menyebabkan kerusakan target organ : jantung, otak, penyakit ginjal kronis, penyakit arteri perifer, retinopati Prevalensi hipertensi makin meningkat (15-25%), Pendekatan yang baik terhadap hipertensi akan meningkatkan angka pengendalian hipertensi dan mengurangi komplikasi

Thank You