Dr.

Ginova Nainggolan, SpPD-KGH

Instansi :
Divisi Ginjal Hipertensi
Departemen Ilmu Penyakit Dalam
FK UI/RSCM Jakarta
Pendidikan :
Dokter
: FK UI, 1985
Spesialis Penyakit Dalam : FK UI, 1996
Konsultan Ginjal Hipertensi : PAPDI, 2003
Organisasi :
IDI
: Anggota
PAPDI
: Anggota
PERNEFRI
: Sekretaris Umum
ISN
: Anggota

Epidemiologi, Hipertensi,
Klasifikasi, Diagnosis
Dr Ginova Nainggolan SpPDKGH
FKUI-RSCM

Prevalence in Indonesia
31,7 % in Indonesian population has
hypertension
14,9% of population in Kepulauan Riau
province has stroke
Management of hypertension is important
skill for Indonesian physician.

RISKESDAR 2007

Hypertension Awareness, Treatment and Control

offres MR, Hamet P, MacLean DR, Litalien GJ, Fodor G. Distribution of blood pressure and hypertension in Canada and the United States. Am J Hypertens. 2001;14(11):10991105.
eenen FHH, Dumais J, McInnis NH, Turton P, Stratychuk L, Nemeth K, Lum-Kwong MM, Fodor G. Results of the Ontario Survey on the Prevalence and Control of Hypertension.
CMAJ. 2008;178(11):1441-1449.
Wilkins K, Campbell NRC, Joffres MR, McAlister FA, Nichol M, Quach S, Johansen HL, Tremblay MS. Blood pressure in Canadian adults. Health Reports. 2010;21(1):37-46.
Statistics Canada. Blood pressure of Canadian adults, 2009 to 2011. Ottawa, ON: Statistics Canada, 2012.
http://www.statcan.gc.ca/pub/82-625-x/2012001/article/11714-eng.pdf.

 Kalsifikasi hipertensi

Tek darah
sistolik
mmHg

Tek darah
diastolik
mmHg

120
130

80
90

150
160
180

80
90
100

Penting: Sistolik atau diastolik

Hubungan Tekanan darah - Strok

Complications of Hypertension:
End-Organ Damage
Risk Factors
Hypertension
Hypertension

Hemorrhage,
Stroke

Retinopathy

LVH, CHD, CHF

Peripheral
Vascular
Disease

CHD = coronary heart disease

CHF = congestive heart failure
LVH = left ventricular hypertrophy
Chobanian AV, et al. JAMA. 2003;289:2560-2572.

Renal Failure,
Proteinuria
Slide Source
Hypertension Online
www.hypertensiononline.org

Risk Factors

Hipertensi dan penyakit komorbid

Hipertensi dan DM
Hipertensi dan Penyakit ginjal kronik
Hipertensi dan gagal jantung

Obat hipertensi : menurunkan tekanan darah

dan juga punya efek baik terhadap penyakit
komorbid
Pemilihan obat antihipertensi : berdasarkan
COMPELLING INDICATION

Algorithm for Treatment of Hypertension

Lifestyle Modifications

Not at Goal Blood Pressure (< 140/90 mmHg) (< 130/80

mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling Indications

Stage 1 Hypertension
(SBP 140-159 or DBP 9099 mmHg) Thiazide-type
diuretics for most. May
consider ACEI, ARB,
BB, CCB, or
combination

Stage 2 Hypertension (SBP

160 or DBP 100 mmHg)
Two-drug combination for
most (usualy Thiazide-type
diuretics ACEI, ARB, BB,
CCB)

With Compelling Indications

Drug(s) for the compelling

indications
Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB) as needed

Not at Goal Blood Pressure

Optimized dosages or add additional drugs until goal blood pressure is
achieved consider consultation with hypertension specialist
JNC VII, 2003

Hypertension stage 1 without

compelling indication

Any hypertension drug can be used.

No specific drug
Use old and new drugs
Until the target of blood pressure can be
achieved

Hypertension stage 2 without

compelling indication

Use two drugs in combination

Any hypertension drug can be used.
No specific drug
Use old and new drugs
Until the target of blood pressure can be
achieved

Algorithm for Treatment of Hypertension

Lifestyle Modifications

Not at Goal Blood Pressure (< 140/90 mmHg) (< 130/80

mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling Indications

Stage 1 Hypertension
(SBP 140-159 or DBP 9099 mmHg) Thiazide-type
diuretics for most. May
consider ACEI, ARB,
BB, CCB, or
combination

Stage 2 Hypertension (SBP

160 or DBP 100 mmHg)
Two-drug combination for
most (usualy Thiazide-type
diuretics ACEI, ARB, BB,
CCB)

With Compelling Indications

Drug(s) for the compelling

indications
Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB) as needed

Not at Goal Blood Pressure

Optimized dosages or add additional drugs until goal blood pressure is
achieved consider consultation with hypertension specialist
JNC VII, 2003

Hypertension with compelling

indication
Use specific drugs for certain conditions
Different target of blood presure
Evidence based medicine

Hypertension with compelling

indication

Hypertension with compelling

indication

2013 ESH/ESC Guidelines for the management of arterial hypertension. European Heart Journal (2013) 34, 2159-2219

Primary Hipertension
Maintenance of arterial blood pressure is necessary for
organ perfusion
Blood pressure reacts to changes in the environment to
maintain organ perfusion over a wide variety of
conditions
The pathogenesis of primary hypertension (formerly
called "essential" hypertension) is poorly understood
but is most likely the result of numerous genetic and
environmental factors that have multiple compounding
effects on cardiovascular and renal structure and
function
90-90% of hypertension

Hipertensi sekunder
Tekanan darah dapat meningkat akibat penyakit
hormonal, gangguan organ, obstructive sleep
apnoe atau penggunaan obat
Fokus terapi pada penyebab, bila penyebab dapat
diatasi tekanan darah dapat kembali normal atau
obat darah tinggi dapat berkurang
Biasanya tekanan darah tinggi sekali dan sukar
dikendalikan
5-10% dari hipertensi

The concept of masked hypertension

Home or daytime ABPM SBP
mmHg

140

True
hypertensive

Masked HTN

135

135
True
Normotensive

White Coat HTN

140

Office SBP mmHg

From Pickering. Hypertension 1992

White coat hypertension

Approximately 20 to 25 percent of patients with stage 1
office hypertension have "white coat" or isolated office
hypertension in that their blood pressure is repeatedly
normal when measured at home, at work, or by
ambulatory blood pressure monitoring
This problem is more common in the elderly, but is
infrequent (less than 5 percent) in patients with office
diastolic pressures 105 mmHg.
The blood pressure still high although 2-3
antihypertensive meds

White coat hypertension

One way to minimize the white coat effect is to have the
blood pressure measured while seated after five minutes
in a quiet, unobserved setting by an automated device
that obtains five repeated blood pressure measurements
at one- to fiveminute intervals

The concept of masked hypertension

Home or daytime ABPM SBP
mmHg

140

True
hypertensive

Masked HTN

135

135
True
Normotensive

White Coat HTN

140

Office SBP mmHg

From Pickering. Hypertension 1992

Masked hypertension
Twenty-four-hour monitoring of larger
populations has revealed a significant number of
patients with elevated out-of-office readings
despite normal office readings
Cardiovascular risk appears to be elevated in
such patients to a similar extent as patients with
sustained hypertension. This is consistent with
the risk of hypertensive cardiovascular
complications being more closely correlated with
24-hour or daytime ambulatory monitoring than
with the office pressure

Kesimpulan
Hipertensi stage 1 dan 2
Hipertensi dengan dan tanpa compelling
indication
Hipertensi primer dan sekunder
White coat hypertension
Mask hypertension

THANK YOU

Pengukuran Tekanan
Darah dan Patogenesis Hipertensi
Dr Ginova Nainggolan SpPDKGH
FKUI-RSCM

I. Accurate Measure of Blood Pressure

Assess blood pressure at all appropriate visits
When should blood pressure be measured?
Health care professionals should know the blood
pressure of all of their patients and clients.
Blood pressure of all adults should be measured
whenever it is appropriate using standardized
techniques.
To screen for hypertension
To assess cardiovascular risk
To monitor antihypertensive treatment

New onset hypertension in people with high

normal blood pressure

NEJM 2006;354:1685-97

Life time Risk of Hypertension in

Normotensive Women and men aged 65 years
Risk of Hypertension %

Risk of Hypertension %
100

100

Women

Men

80

80

60

60

40

40

20

20

0
0

10

12

14

16

Years to Follow-up

18

20

10

12

14

16

18

20

Years to Follow-up
JAMA 2002:297:1003-10. Framingham data.

Technique of Blood Pressure Measurement

(Recommended by the British Hypertension Society)

Kaplan NM, Clinical Hypertension1994 ;2 : 23 - 45

Blood Pressure Assessment:

Patient preparation and posture
Standardized Preparation:
Patient
1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the preceding
30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before measurement
8. Patient should stay silent prior and during the
procedure.

Blood Pressure Assessment:

Patient preparation and posture
Standardized technique:
Posture
The patient should be
calmly seated with his or
her back well supported
and arm supported at the
level of the heart.
His or her feet should
touch the floor and legs
should not be crossed.

Blood Pressure Assessment:

Patient position

Recommended Technique
for Measuring Blood Pressure (cont.)
Select a device with an appropriate size cuff

Use an appropriate size cuff

Arm circumference (cm)

Size of Cuff (cm)

From 18 to 26

9 x 18 (child)

From 26 to 33

12 x 23 (standard adult model)

From 33 to 41

15 x 33 (large)

More than 41

18 x 36 (extra large, obese)

For automated devices, follow the manufacturers directions.

For manual readings using a stethoscope and sphygmomanometer, use the table as a guide.

Recommended Technique
for Measuring Blood Pressure (cont.)
Locate the brachial pulse
and centre the cuff
bladder over it
Position cuff at the heart
level
Arm should be supported

Recommended Technique
for Measuring Blood Pressure* (cont.)
To exclude possibility of
auscultatory gap,
increase cuff pressure
rapidly to 30 mmHg
above level of
disappearance of radial
pulse
Place stethoscope over
the brachial artery

*with manual or semi automated devices

Recommended Technique
for Measuring Blood Pressure* (cont.)

Drop pressure by 2 mmHg / beat

Appearance of sound (phase I
Korotkoff) = systolic pressure

Drop pressure by 2 mmHg / beat

Disappearance of sound (phase
V Korotkoff) = diastolic pressure

Record measurement

Take at least 2 blood pressure

measurements, 1 minute apart

*with manual or semi automated devices

Recommended Technique
for Measuring Blood Pressure
Standardized technique:
For initial readings, take
the blood pressure in
both arms and
subsequently measure it
in the arm with the
highest reading.
Thereafter, take two
measurements on the
side where BP is higher.

Recommended Technique
for Measuring Blood Pressure* (cont.)
Record the blood
pressure to the closest 2
mmHg on the manometer
Record patient position
(supine, sitting or
standing).
Aneroid devices should not be used unless they are known to be accurately calibrated
and are checked regularly (minimally every 12 months).
* For manual blood pressure measurement

Recommended Technique
for Measuring Blood Pressure* (cont.)
Avoid digit preference for
five (5) or zeros (0) by not
rounding up or down.
Record the heart rate.

If the needle on an aneroid device is not at zero when the cuff is uninflated, it is
inaccurate; however, the converse is not true.

* For manual blood pressure measurement

Recommended Technique
for Measuring Blood Pressure (cont.)
The seated BP
measurement is the
standard position to
determine diagnostic and
therapeutic treatment
decisions.
The standing blood
pressure is used to test for
postural hypotension,
which may modify the
treatment.

Recommended Technique for Measuring BP:

Standing BP
Perform in patients
over age 65
with diabetes
if there are symptoms of postural hypotension

Check after 1 to 5 minutes in the standing position and if

the patient complains of symptoms suggestive of
hypotension

Pengukuran oleh dokter dan

perawat

Dokter
perawa
t

Home measurement of blood pressure

Pengukuran tekanan darah di rumah
Dapat dilakukan oleh pasien atau
orang lain
Dianjurkan pada setiap pasien
hipertensi

VII. Home measurement of blood pressure

Home BP measurement should be encouraged to
increase patient involvement in care
Which patients?

For the diagnosis of hypertension

Suspected non adherence
White coat hypertension or effect
Masked hypertension

Average BP equal to or over 135/85 mmHg should be

considered elevated

Benefits of Home Blood Pressure Monitoring

Rapid confirmation of the diagnosis of hypertension

Better prediction of cardiovascular prognosis
Diagnosis of white coat and masked hypertension
Reduced medication use in white coat effect
Improved adherence to drug therapy
Better blood pressure control

VII. Suggested Protocol for Home Measurement of

Blood Pressure for the Diagnosis of Hypertension
Home blood pressure values should be based on:
duplicate measures,
morning and evening,
for an initial 7-day period.

Singular and first day home BP values should not be

considered.
Daytime average BP equal to or over 135/85 mmHg
should be considered elevated.

Home Measurement of BP:

Patient Education
How to?
Use devices:
appropriate for the individual
appropriate cuff size
marked with this symbol

Adequate patient training in:

measuring their BP
interpreting these readings
Regular verification
measuring techniques

Values
> 135 / 85 mmHg
should be
considered elevated

Home measurement
can help to improve
patient adherence

Benefits of HBPM
A greater decrease in BP by 2.6/1.7
mmHg
A two-fold increase in the frequency
of reduction in antihypertensive
therapy
An 18 percent reduction in the
relative risk of therapeutic inertia,
defined as the clinician not
intensifying the antihypertensive
regimen in response to an elevated

Home blood pressure

monitoring
Increasing evidence suggests that at least
12 to 14 measurements should be
obtained, with both morning and evening
measurements taken over one week
In stable hypertensive patients with
controlled BP, this same procedure of 12
to 14 measurements taken over one week
should be repeated approximately every
three months to determine whether the
BP remains controlled

Suggested use of HBPM in the Diagnosis of

Hypertension
Office BP > 140/90 mmHg
in low risk patients (with no target-organ disease)

Home-monitored blood pressure

<135/85mmHg

Home-monitored blood pressure

equals or over 135/85mmHg

Repeat HBPM or perform ABPM

Mean awake BP
Less than 135/85 mmHg

Follow-up with periodic HBPM

measurement and or repeated
ABPM every 1-2yr.

Mean awake BP
equals or over 135/85 mmHg

Diagnosis of hypertension

ABPM: Ambulatory Blood Pressure Monitoring ; BP: Blood Pressure

Adapted from White W, NEJM 348:24, June 12, 2003
HBPM: Home Blood Pressure Monitoring

Not all patients are suited to home measurement

Undue anxiety in response to high blood

pressure readings
Physical or mental disability prevents
accurate technique or recording
Arm not suited to blood pressure cuff (e.g.
conical shaped arm)
Irregular pulse or arrhythmias prevent
accurate readings
Lack of interest

Ambulatory Blood Pressure

Monitoring

Ambulatory Blood Pressure

Monitoring
Mengukur tekanan darah 24 secara
berkesinambungan
Melakukan pengukuran tekanan darah
tiap 30-60 menit.
Mengukur secara otomatis
Hasil pengukuran direkam dapat dicetak
Cuff Dipasang di lengan
Mahal

Situations where ABPM is

Helpful
Excluding White Coat Hypertension
in patients with office hypertension
but no target organ damage
Deciding on treatment of elderly
patients
Identifying nocturnal hypertension
(dipping status)
Assessing apparent resistance to
therapy

Situations where ABPM is

Helpful
Assuring efficacy of treatment over
entire 24h
Managing hypertension during
pregnancy
Evaluating hypotension and episodic
hypertension

THANK YOU

Patofisiologi dan
Pendekatan diagnosis
hipertensi

Exess
Sodium
intake

Reduced
nephron
number

Renal
sodium
retention

Genetic

Decreased
filtration
surface

Stress
.

alteration

Sympathetic
nervous
over activity

Reninangiotensin
excess

Fluid

Venous

Volume

constriction

Obesity

Cell
membrane
alteration

Functional
Constriction
Preload

B.P.

Hypertension =

Endothelium
derived
factors

Hyperinsulinemia

Structural
hypertrophy

Contractability

Cardiac output
Increased CO

Peripheral resistance

and / or

Increased PR

Kaplan N. M, Clinical Hypertension, 1997 : p.45

History
The history should search for those facts that
help determine
- the presence of precipitating or aggravating
factors (including prescription medications,
nonprescription nonsteroidal anti-inflammatory
agents, and alcohol consumption),
- the natural course of the blood pressure,
- the extent of target organ damage, and
- the presence of other risk factors for
cardiovascular disease

Physical examination
The main goals on the physical
examination are to evaluate for signs of
end-organ damage (such as retinopathy)
and for evidence of a cause of secondary
hypertension

THANK YOU