HIPERTENSI

Sahala Panggabean

BAGIAN
ILMU PENYAKIT DALAM
FKUKI
Jakarta, 1 Oktober 2014
PATOFISIOLOGI HIPERTENSI
Autoregulation

BLOOD PRESSURE = CARDIAC OUTPUT x PERIPHERAL RESISTANCE

Hypertension = Increased CO and/or Increaced PR

 Preload  Contractility Functional Structural

Constriction hypertrophy
 Fluid Volume
Volume Redistribution
Sympathetic Renin- Cell Hyper
nervous over- Angiostensin Membran Insulinemia
Renal Decreased activity Excess Alteration
Sodium filtration
Retension surface

Stress Obesity

Excess Genetic Genetic Endothelium

Sodium Alteration Alteration derived
Intake factors
 Classification and managemen of
blood pressure for adults (JNC VII)
INITIAL GRUG THERAPY

BP SBp* DBp* Lifestyle Without Compelling With Compelling

Classification mmHg mmHg MODIFICATION Indication indication
Normal <120 And <80 Encourage

No Antihypertension Drug(s) for comppelling

Prehypertension 120-139 Or 80-89 Yes
Drug indicated indication
Stage 1 140-159 Or 90-99 Yes Thiazide-type diuretics Drug(s) for the
hypertension for most. May consider compelling indications
ACEI,ARB,BB, CCB or Other antihypertensive
combination drugs (diuratics, ACEI,
ARB, BB, CCB) as
Stage 2 <160 Or <210 Yes Two drug combination
needed
hypertension for most (usually
Thiazide-type diuretics an
ACEI or ARB or BB or
CCB)

DBP* diagnostic blood pressure, SBP, systotic blood pressure

Drug abbreviations :ACEL, angiotension converting enxyme inhibitor. ARBN, Angiotension receptor blocker. BB beta-blocker.
CCB, calcium chanel blocker.
*
….
….
 Evaluation Objectives

 To identify know causes

 To assess presence or absence of target
organ damage and cardiovascular disease
 To identify other risk factors or disorders
that might guide treatment
Evaluation Components

 Medical history
 Physical examination
 Routine laboratory tests
 Optional tests
MEDICAL HISTORY
 Duration and classification of
hypertension
 Patient history of cardiovascular
disease
 Family history
 Symptoms suggesting causes of
hypertension
 Lifestyle factors
 Current and previous medications
Physical Examination

 Blood pressure readings (two or more)

 Verification in contralateral arm.
 Height, weight, and waist circumference
 Funduscopic examination
 Examination of the neck, heart, lungs,
abdomen, and extremities
 Neurological assessment
Laboratory Tests Recommended
Before Initiating Therapy

 Urinalysis
 Complete blood count
 Blood chemistry (potassium, sodium,
creatinine, and fasting glucose)
 Lipid profile (total cholesterol and HDL
cholesterol)
 12-lead electrocardiogram
 Optional Tests and Procedures
 Creatinine clearance
 Microalbuminuria
 24-hour urinary protein
 Serum calcium
 Serum uric acid
 Fasting triglycerides
 LDL cholesterol
 Glycosolated
hemoglobin
 Thyroid-Stimulating
hormone
 Plasma rennin
activity/urinary sodium
determination
 Limited echocardiography
 Ultrasonography
 Measurement of ankle/arm
index
 Examples of Identifiable
Causes of Hypertension
 Renovascular disease  Primary aldosteronism
 Renal parenchymal disease  Cushing syndrome
 Polycystic kidneys  Hyperparathyroidism
 Aortic coarction  Exogenous causes
 Pheochromocytoma
Components of Cardiovascular
Risk in Patients With Hypertension

Major Risk Factors :

 Smoking
 Dyslipidemia
 Diabetes mellitus
 Age older than 60 years
 Sex (men or postmenopausal women)
 Family history of cardiovascular disease
Clinical Risk Factors for Stratification
Of Patients With Hypertension

 Heart diseases
 Stroke or transient ischemic attack
 Nephropathy
 Peripheral arterial disease
 Retinopathy
Types of Hypertension
 Primary HTN:
also known as essential HTN.
accounts for 95% cases of HTN.
no universally established cause known.

 Secondary HTN:
less common cause of HTN ( 5%).
secondary to other potentially rectifiable causes
Causes of Secondary HTN
 Common
 Intrinsic renal disease
 Renovascular disease
 Mineralocorticoid excess
 Sleep Breathing disorder
 Risk Stratification

Risk Group A No risk factors

No target organ disease/clinical cardiovascular disease

Risk Group B At least one risk factor, not including diabetes

No target organ disease/clinical cardiovascular disease

Risk Group C Target organ disease /clinical cardiovascular disease and/or

diabetes.
With or without other risk factors
 Treatment Strategies and
Risk Stratification
Blood Pressure
Stages (mmHg) Risk Group A Risk Group B Risk Group C
High-normal Lifestyle modification Lifestyle modification Drug therapy
(130-139/85-89) Lifestyle modification

Stage 1 Lifestyle modification Lifestyle modification Drug therapy

(140-159/90-99) (up to 12 months) (up to 6 months)** Lifestyle modification

Stages 2 and 3 Drug therapy Drug therapy Drug therapy

(≥160/ ≥ 100) Lifestyle modification Lifestyle modification Lifestyle modification

Or those with heart failure, renal insufficiency, or diabetes

For those with multiple risk factors, clinicians should consider drugs as initial Therapy plus lifestyle
modification
 Goal of Hypertension
Prevention and Management

 To reduce morbidity and mortality by the least

intrusive means possible. This may be
accomplished by
- Achieving and maintaining SBP < 140 Hg
and DBP < 90 mm Hg.
- Controlling other cardiovascular risk factors.
 Lifestyle Modifications

For Prevention and For Overall and

Management
 Lose weight if overweight
 Limit alcohol intake
 Increase aerobic physical activity
 Reduce sodium intake
 Maintain adequate intake of
Potassium
Cardiovascular Health
 Maintain adequate intake of
calcium and magnesium
 Stop Smoking
 Reduce dietary saturated fat and
cholesterol
Pharmacologic Treatment

 Decreases cardiovascular morbidity and mortality

based on randomised controlled trials
 Protects against stroke, coronary events, heart
failure, progression of renal disease, progression
to more severe hypertension, and all-cause
mortality
Special Considerations
In Selecting Drug Therapy

 Demographics
Coexisting diseases and Therapies
 Quality of life
 Physiological and biochemical measurements
 Drug interactions
 Economic considerations
Drug Therapy

 A low dose of initial drug should be used slowly

titrating upward.
 Optimal formulation should provide 24-hour
efficacy with once-daily dose with at least 50% of
peak effect remaining at end of 24 hours
 Combination therapies may provide additional
efficacy with fewer adverse effects
Classes of
Antihypertensive Drugs
 ACE inhibitors
 Adrenergic inhibitors
 Angiotensin II receptor blockers
 Calcium antagonists
 Direct vasodilators
 Diuretics
Combination Therapies

 β – adrenergic blockers and diuretics

 ACE inhibitors and diuretics
 Angiotensin II receptor antagonists and diuiretics
 Calcium antagonists and ACE inhibitors
 Other combinations
Followup
 Follow up within 1 to 2 months after initiating therapy
 Recognize that high-risk patients often require high
dose or combination therapies and shorter intervals
between changes in medications
 Consider reasons for lack of responsiveness if blood
pressure is uncontrolled after reaching full dose
 Consider reducing dose and number of agents after 1
year at or below goal.
Causes for inadequate
Response to drug Therapy
 Pseudo resistance
 Non adherence to therapy
 Volume overload
 Drug-related causes
 Associated conditions
 Identifiable cause of hypertension
Hypertensive Emergencies
And Urgencies
 Emergencies require immediate blood
pressure reduction to prevent or limit
target organ damage
 Urgencies benefit from reducing blood
pressure within a few hours
 Elevated blood pressure alone rarely
requires emergency therapy
 Fast-acting drugs are available.
Drugs Avaiblable for
Hypertensive Emergencies
Vasodilators Adrenergic Inhibitors
 Nitroprusside  Labetalol
 Nicardipine  Esmolol
 Fenoldopam  Phentolamine
 Nitroglycerin
 Enalaprilat
 Hydralazine
Algorithm For Treatment of
Hypertension
( JNC VII)
 Lifestyle Modifications
(JNC VII)
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for patiens with diabetes or chronic kidney disease

Initial Drug Choices

Without Compelling With Compelling Indication

Indication

Stage 1 Stage 2 Drug(S) for the

compelling indications
Hypertension Hypertension (se table *
(SBP 140-159 or DBP (SBP >=160 or DBP
90-99 mmHg >=100 mmHg
Other antihypertensive
drugs ( diuretics, ACEI,
Thiazide -type diuretc To-drug combination for ARB, BB, CCB) as
for most. May consider most (usually thiazide - needed
ACEI, ARB, BB, CCB, type diuretic and ACEI
or combination or ARB or BB or CCB)

NOT AT GOAL BLOOD PRESSURE

Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider
consultation with hypertension specialist

DBP, diastolic blood pressure, SBP, systolic blood pressure

Drug abbreviations: ACEI= angiotensin converting enzyme inhibitor; ARB=,angiotensin
receptor blocker; BB= beta-blocker; CCB= calcium channel blocker.
 Algorithm for Treatment of
Hypertension (continued)

Begin or Continue Lifestyle Modifications

 Lose weight  Maintain potassium

 Limit alcohol  Maintain calsium and magnesium
 Increase physical activity  Stop Smoking
 Reduce sodium  Reduce saturated fat cholesterol

Not at Goal Blood Pressure

 Specific Drug Indications

Some antihypertensive drugs may have

favourable affects on co-morbid conditions :

Angina Heart failure

- -blockers - Carvedilol
- Calcium antagonists - Losartan
Atrial tachycardia and • Myocardial infarction
fibrillation - Diltiazem
- -blockers - Verapamil
- Nondihydropyridine Calcium antagonists
 Specific Indications (continued)

Some antihypertensive drugs may have favourable affects

on co-morbid conditions :
Cyclorsporine-induced
hypertension
- Calcium antagonists
Diabetes mellitus (1 and 2)
with proteinuria
- ACE Inhibitos (preferred)
- Calcium antagonists
Diabetes mellitus (type 2)
- Low-dose diuretics
Dyslipidemia
- α -blockers
Prostatism (benign prostatic
hyperplasia)
- α -blockers
Renal insufficiency (caution
in renovascular hypertensio
and creatinine > 3 mg/dl [>
265. Ųmol/L])
- ACE inhibitors
SELAMAT BELAJAR