HYPERTENSION

ERWIN SUKANDI
Internal Medicine Department, Cardiology
Division
Faculty of Medicine, University of Sriwijaya

EPIDEMIOLOGY

Hypertension: A Worldwide
Problem

Hypertension defined as BP>= 140/90mmHg or ttt on antihypertensive medication

Wolf-Maier, et al. JAMA 2003

Hypertension is the number one risk

factor
for global attributable mortality

CVD = Cardiovascular Disease

World Health Organisation. Global atlas on cardiovascular disease prevention and control.
2011.
Available at:

Economic Burden of Hypertension

64.3 million disability-adjusted life years (DALYs) [4.4% of
the global total] were estimated to be due to non-optimal
BP1
HTN is ranked third as a cause of DALYs

Untreated HTN causes an average loss of 5.5 workdays per

person annually2
HTN represents one of the three leading causes of visits to
primary healthcare centres3
In France, Germany, Italy, Sweden and the UK, failure to
achieve BP targets result in 281,000 avoidable major CV
events, costing health systems 1.26 billion each year4
Lawes et al. J Hypertens 2006;24:42330; 2Rizzo et al. Health Econ 1996;5:24965; 3Pardell et
al. Drugs 2000;59:1320; 4Hansson et al. Blood Pressure 2002;11:3545

ETIOLOGY

HYPERTENSION
PRIMARY (90-95%)
Enviromental or genetic causes

SECONDARY (2-10%)
Renal
Vascular
Endocrine

Hypertensive emergencies are most

often precipitated by inadequate
medication or poor compliance

Penyebab Hipertensi
Sekunder
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings
syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
Pregnancy-induced hypertension

CLASSIFICATION

KLASIFIKASI HIPERTENSI
Klasifikasi Hipertensi pada orang dewasa :
JNC 7 (The 7th Report of The Joint National

Committee on Prevention Detection, Evaluation,

and Treatment of High Blood Pressure)

ESC/ESH (European Society of Hypertension)

WHO (World Health Organization)/ISH

(International Society of Hypertension)

BHS (British Hypertension Society)/NICE

CHEP (Canadian Hypertension Education
Program)

KLASIFIKASI HIPERTENSI
Dewasa usia > 18 tahun
Blood Pressure (mm Hg)

JNC 7 2003
Category

Systolic

Diastolic

<120

and <80

Normal

120-139

or 80-89

Prehypertension

140-159

or 90-99

Stage 1 hypertension

160

or 100

Stage 2 hypertension

Isolated hypertension : usia >55 tahun TDS 140 dan

TDD < 90 mmHg
Chobanian AV, et al. Hypertension 2003;42:1206-52

2013 ESH/ESC Guidelines for the management of arterial hypertension

Definitions and classification of office BP levels

(mmHg)*
Hypertension:
SBP >140 mmHg DBP >90 mmHg
Category

Systolic

Diastolic

Optimal

<120

and

<80

Normal

120129

and/or

8084

High normal

130139

and/or

8589

Grade 1 hypertension

140159

and/or

9099

Grade 2 hypertension

160179

and/or

100109

Grade 3 hypertension

180

and/or

110

Isolated systolic hypertension

140

and

<90

* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated
systolic hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over
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Criteria of measurement
in different methods
Systolic BP
Diastolic BP
mmHg
Clinic BP

Home BP
Ambulatory BP
24 hour
Day
Night

mmHg

140
135

90
85

130
135
120

80
85
70

Japan Society of Hypertension 2009

Home BP vs Ambulatory BP
Home BP

Ambulatory BP

Multiple measurements

day-to-day activities and

over several days, or even

BP data during routine,

longer periods

during sleep

in the individuals usual

Waking surge

environment

quantifies short-term BP

notes day-to-day BP

variability

variability

Correlation with symptoms

cheaper

Most accurate

more widely available and

more easily repeatable.

PATHOPHYSIOLOGY

Patofisiologi Hipertensi

MULTIFAKTORIAL

Primary Hypertension
Pathophysiology
Heredity interaction of genetic,
environmental, and demographic
factors
Water & Sodium Retention 20% of
pts with high Na+ diet develop HTN
Altered Renin-Angiotensin Mechanism
found in 20% of patients
Stress & Increased SNS Activity
Insulin Resistance & Hyperinsulinemia
Endothelial Cell Dysfunction

Secondary Hypertension
Pathophysiology
Specific cause of hypertension can be
identified
5+% of adult hypertension
Causes:
Coarctation or congenital narrowing of
the aorta
Renal disease renal artery disease /
parenchymal
Endocrine disorders: Pheochromocytoma,
Cushing Syndrome, Hyperaldosteronism
Neurology disorders brain tumors / head
injury
Sleep apnea

Renin Angiotensin Aldoterone

System
(RAAS)

INTERACTION OF FACTORS IN BLOOD PRESURE

Excess
Na intake

Nephron
number

Obesity

Genetic
alteration

Filtration Sympathetic
surface
Nervous
overactivity

Renal Na
retention

Fluid
volume

Stress

Renin
Cell
Angiotensin Membrane
release
alteration

Endothelium
derived
factors

Hyperinsulinemia

Venous
constriction

Preload

BLOOD PRESSURE =
Hypertension
=

Functional
Contractability constriction

CARDIAC OUTPUT
Increased CO

Structural
hypertrophy

PERIPHERAL RESISTANCE
Increased PR
and/or

autoregulation

Hypertension:
The Disease Continuum
Early Paradigm

Natural History of CVD Progression

Elevated BP Target Organ Damage
More Recent Paradigm

Vascular Dysfunction Elevated BP Target Organ Damage

A Proposed Future Paradigm

Endothelial
Dysfunction

Vascular
Dysfunction

Elevated BP

Target Organ
Damage

LVH
Renal
Damage

Angina
Pectoris

MI Stroke

MEASUREMENT

Scipione Riva rocci, 1896

menemukan sfignomanometer air raksa

 Continuing Medical Implementation

...bridging the care gap

Measurement device
Aneroid
sphygmomanometer

Simple mercury
sphygmomanometer

Automated bp device

RECOMMENDED BLOOD PRESSURE

MEASUREMENT TECHNIQUE
2.2.

The
Thecuff
cuffmust
mustbe
belevel
levelwith
withheart.
heart.
IfIfarm
circumference
e
xceeds
arm circumference exceeds 33
33cm,
cm,
aalarge
largecuff
cuff must
mustbe
beused.
used.
Place
Placestethoscope
stethoscopediaphragm
diaphragmover
over
brachial
artery.
brachial artery.

1.1.
The
Thepatient
patientshould
should
be
relaxed
and
be relaxed andthe
the
arm
must
b
e
arm mu st be
supported.
supported.
Ensure
Ensureno
notight
tight
clothing
constricts
clothing co nstricts
the
thearm.
arm.

Continuing Medical Implementation

3.3.

Stethoscope

Mercury
machine

The
Thecolumn
columnofof
mercury
mercurymust
mustbe
be
vertical
.
vertical.
Inflate
Inflatetotoocclude
occludethe
the
pulse.
pulse. Deflate
Deflateatat22toto
33mm/s.
re
mm/s.Measu
Measure
systolic
systolic(first
(firstsound)
sound)
and
anddiastolic
diastolic
(disappearance)
(disappearance)toto
nearest
nea rest 22mm
mmHg.
Hg.

...bridging the care gap

Blood Pressure (BP): Measurements

Figure 15-7: Measurement of arterial blood pressure

Korotkoff sounds and auscultatory gaps

Korotkoff sounds
200
180

No sound
Clear sound

Phase 1

Muffling

Phase 2

140

No sound

Auscultatory
gap

120

Clear sound

Phase 3

Muffled sound

Phase 4

No sound

Phase 5

160

100
80

Systolic BP
Phase 3
Phase 4
Diastolic BP

60
40
20
0
mmHg

2009 Canadian Hypertension Education Program Recommendations

Pentingnya akurasi pengukuran

tekanan darah
Ketidakakuratan pengukuran TD dapat
menimbulkan masalah perbedaan 5
mmHg membawa akibat yang besar
Overestimasi orang dengan prehipertensi
hipertensi
Underestimasi orang dengan hipertensi
normotensi/ klasifikasi HTN yang berbeda
Perlu diketahui faktor-faktor yang
mempengaruhi akurasi pengukuran TD

Critical issues
Choice of the blood pressure
measuring device
Posture of the subject and arm
during the measurement
Selection of correct cuff size
Standardization of the measurement
protocol

AHA Guidelines for In-Clinic Blood Pressure Measurement

Recommendation

Comments

Patient should be seated

comfortably, with back
supported, legs uncrossed,
and upper arm bared.

Diastolic pressure is higher in the seated

position, whereas systolic pressure is
higher in the supine position.An
unsupported back may increase diastolic
pressure; crossing the legs may increase
systolic pressure.

Patients arm should be

supported at heart level.

If the upper arm is below the level of the

right atrium, the readings will be too high;
if the upper arm is above heart level, the
readings will be too low.If the arm is
unsupported and held up by the patient,
pressure will be higher.

Cuff bladder should encircle An undersized cuff increases errors in

80 percent or more of the
measurement.
patients arm
circumference.

Recommendation

Comments

Mercury column should be

deflated at 2 to3 mm per
second.

Deflation rates greater than 2 mm per

second can cause the systolic pressure
to appear lower and the diastolic
pressure to appear higher.

The first and last audible sounds

should be recorded as systolic
and diastolic pressure,
respectively. Measurements
should be given to the nearest 2
mm Hg.
Neither the patient nor the
Talking during the procedure may
person taking the measurement cause deviations in the measurement.
should talk during the
procedure.
Information from Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, et al.; Subcommittee of Professional and
Public Education of the American Heart Association Council on High Blood Pressure Research. Recommendations for blood
pressure measurement in humans and experimental animals. Part 1: blood pressure measurement in humans.
Hypertension 2005;45:14261.

Recommended Cuff Sizes for Accurate

Measurement of Blood Pressure
Patient

Recommended cuff size

Adults (by arm circumference)

22 to 26 cm

12 x 22 cm (small adult)

27 to 34 cm

16 x 30 cm (adult)

35 to 44 cm

16 x 36 cm (large adult)

45 to 52 cm

16 x 42 cm (adult thigh)

Children (by age)*

Newborns and premature infants

4 x 8 cm

Infants

6 x 12 cm

Older children

9 x 18 cm

*A standard adult cuff, large adult cuff, and thigh cuff should
be available for use in measuring a childs leg blood pressure
and for children with larger arms

TARGET ORGAN DAMAGE

HYPERTENSION and
Target Organ Damage
Atherosclerosis*
Vasoconstriction
Vascular hypertrophy

HPN

LV hypertrophy
Fibrosis
Remodeling
Apoptosis
GFR
Proteinuria
Aldosterone release
Glomerular sclerosis

Stroke
Hypertension
DEATH
Heart failure
MI

Renal failure

*preclinical data
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.

Asymptomatic Target Organ

Damage (TOD)

Pulse pressure ( in the elderly) >= 60 mmHg

Electrocardiograhic LVH( Sokolow-Lyon index > 3.5 mV; RaVL >

1.` mV; Cornell voltage duration product> 244 mV* ms), or
Echocardiographic LVH [ LVM index: men > 115 g/m2; women
> 95 g/m2 (BSA)]a
Carotid wall thickening (IMT > 0.9 mm) or plaque
Carotid- femoral PWV > 10 m/s
Ankle- brachial index < 0.9

CKD with eGFR 30-60 ml/min/1.73 m2 (BSA)

Microalbuminuria (30-300 mg/24 h), or albumin- creatinine
ratio(30-300 mg/g; 3.4-34 mg/mmol) (preferentially on morning
spot urine)

WORKUP

Routine Clinical
Investigations
Anamnesis :
Family and Clinical History
Duration and previous level of high BP
Indications of secondary hypertension
Risk factors
Symptoms of organ damage
Previous antihypertensive therapy
Personal, family and environmental
factors

Physical Examination
In addition to BP, Heart rate should be
measured sympathetic ,
parasympathetic , heart failure
Search for signs suggesting secondary
hypertension, and for evidence of
organ damage
Waist circumference, Body weight &
height
BMI

Routine Laboratory Tests

Fasting plasma glucose
Serum total cholestero, LDL-C, HDL-C, Fasting
Triglycerides
Serum potassium
Serum uric acid
Serum creatinine
Estimated creatinine clearance (Cockroft-Gault
formula) or glomerular filtration rate (MDRD formula)
Haemoglobin and haematocrit
Urinalysis (complemented by microalbuminuria via
dipstick test and microscopic examination)
Electrocardiogram

DIAGNOSIS

Diagnosis Hypertension
If BP is only slightly elevated, repeated
measurements should be obtained over a period
of several months to define the patients usual
BP as accurately as possible
if BP is more marked elevation, evidence of
hypertension related organ damage or a high or
very high cardiovascular risk profile, repeated
measurements should be obtained over shorter
periods of time (weeks or days)
In general, the diagnosis of hypertension should
be based on at least 2 BP measurements per visit
and at least 2 to 3 visits, although in particularly

MANAGEMENT

2013 ESH/ESC Guidelines for the management of arterial hypertension

Blood pressure goals in hypertensive patients

Recommendations
SBP goal for most
Patients at lowmoderate CV risk
Patients with diabetes
Consider with previous stroke or TIA
Consider with CHD
Consider with diabetic or non-diabetic CKD

<140 mmHg

SBP goal for elderly

Ages <80 years
Initial SBP 160 mmHg

140-150 mmHg

SBP goal for fit elderly

Aged <80 years

<140 mmHg

SBP goal for elderly >80 years with SBP

160 mmHg

140-150 mmHg

DBP goal for most

<90 mmHg

DB goal for patients with diabetes

<85 mmHg

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over
Powered by
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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 HTN (SBP 140159 or

DBP 9099 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB,
CCB, or combination.

With Compelling
Indications

Stage 2 HTN (SBP >160 or DBP

>100 mmHg)
2-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)

Drug(s) 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.

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

Blood Pressure Classification and Management

BP Classification
Normal

SBP mmHg*

<120

DBP mmHg

Lifestyle
Modification

Drug
Therapy**

and <80 Encourage

No

Prehypertension

120-139 or 80-89

Yes

No

Stage 1
Hypertension

140-159 or 90-99

Yes

Single
Agent

Yes

Combo

Stage 2
Hypertension

160

or 100

*Treatment determined by highest BP category; **Consider treatment for compelling

indications regardless of BP
JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

HTN Classification

Table 1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older

Cardiovascular Risk Stratification

Blood pressure (mm Hg)
Other risk factor,
organ damage, or
disease

Normal

High
normal

No other risk
factors

Average
risk

Average
risk

1-2 risk factors

Low
added
risk

3 risk factors,
mets, organ
damage, or
diabetes
Established CV or
renal disease

Grade 1
HT

Grade 2
HT

Grade 3
HT

Low
added
risk

Low
added
risk
Moderate
added
risk

Moderate
added
risk
Moderate
added
risk

Moderate
added
risk

High
added
risk

High
added
risk

High
added
risk

Very high
added risk

Very high
added
risk

Very high
added
risk

Very high
added
risk

Very high
added
risk

Very high
added risk

High
added risk
Very high
added risk

HT: hypertension; mets: metabolic syndrome; CV: cardiovascular

Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187

Anti Hypertensive Agents

Classification

Anti Hypertensive Drug

Classification

BLOOD PRESSURE
VARIABILITY

24-Hour Blood Pressure Profile:

Two Patients with Hypertension

Blood pressure (mm Hg)

17
5
15
5
13
5
11
5
95

Slee
p

Non-dipper

Dipper

75
55
7:00
3:00

11:00
7:00

15:00
19:00
Time of day

23:00

Continuing Medical Implementation

...bridging
the care gap
Adaptedfrom:Redman,etal.1976;Mancia,etal.1983;Kobrin,etal.1984;Baumgart,etal.1989;Imai,etal.1990;Portaluppi,etal.1991.

24-Hour Blood Pressure Profile:

The Morning Blood Pressure Surge
Blood pressure (mm Hg) Time of awakening
18
Sleep
0
16
0
14
0
12
0
10
0
80
18:00
14:00

22:00
18:00

Adaptedfrom:MillarCraig,etal.1978;Mancia,

02:00
06:00
Time of day

Continuing Medical Implementation

...bridging the care gap

10:00

Circadian Incidence of Cardiovascular

Events: Myocardial Ischemia
n=24

Ischemia (min)
300
250
200
150
100
50
0

01:00

05:00

09:00

Continuing Medical Implementation

Adaptedfrom:Rocco,etal.1987.

13:00
Time of day

17:00
...bridging the care gap

21:00

PROGNOSIS

TERIMA KASIH