HIPERTENSI

HENI PURWANTI
16710372
 HIPERTENSI
peningkatan tekanan darah sistolik ≥ 140 mmHg
dan atau tekanan darah diastolik ≥ 90 mmHg, pada
pemeriksaan yang berulang. Tekanan darah sistolik
merupakan pengukuran utama yang menjadi dasar
penentuan diagnosis hipertensi (Perki, 2015).
• Epidemiologi :
• Jumlah penderita hipertensi di seluruh dunia :
1 milyar
• USA : 58-65 juta
• Indonesia: 25,8%
 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 120–129 and/or 80–84

High normal 130–139 and/or 85–89

Grade 1 hypertension 140–159 and/or 90–99

Grade 2 hypertension 160–179 and/or 100–109

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
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 CLASSIFICATIO BP SBP DBP
N Optimal <120 and <80
BP SBP HYPERTENSION
DBP
Normal
Normal 120-129and./or 80-84
<120 nd <80
High Normal 130-139 85-89

a HT stg 1 140-159 90-99

HT stg 2 160-179 100-109
Pre HT 120-139 o r 80-89
HT stg 3 ≥180 ≥110
Stg 1 140-159 o r 90-99 ISH ≥140 <90
Stg 2 ≥160 and
r ≥100
BP SBP DBP
o
Optimal <120 and <80
JNC 8
Normal <85
<130 and
High Nml
130-139
r 85-89 No definition of HT
HT stg 1
140-159 r 90-99
HT stg 2 o
160-179 r 100-109
HT stg 3 o ≥180 or ≥110
o
 Prevalensi hipertensi dunia

60 55
Prevalence of hypertension (%)
47 49 49
45 42
38 38

30 28

15

0
US Italy Sweden England Spain Finland Japan* Germany

Adults aged 35–64 years (data are age- and sex-adjusted), except* (adults aged ≥ 30 years)
Hypertension defined as BP ≥ 140/90 mmHg or on treatment

Wolf-Maier et al. JAMA. 2003;289:2363≥2369; Sekikawa, Hayakawa. J Hum Hypertens. 2004; 2004;18:911–912.
 Prevalensi hipertensi meningkat dengan
pertambahan usia
Prevalence of hypertension (%) 100
Men 80
80 Women 71
60 61
60
45 42
40 33
21 23
20 14
10
6
0
20-29 30-39 40-49 50-59 60-69 70
Age (Years)
Data for established market economies:
Australia, Canada, England, Germany, Greece, Italy, Japan, Spain, Sweden, USA
Kearney et al. Lancet. 2005;365:217≥223.
Faktor Resiko
Patofisiologi
Gejala Klinis
•Sakit kepala
•Kelelahan
•Mual-muntah
•Sesak napas
•Gelisah
•Pandangan menjadi kabur yang terjadi karena adanya kerusakan pada otak,
mata, jantung, dan ginjal
•Kadang penderita hipertensi berat mengalami penurunan kesadaran dan
bahkan koma karena terjadi pembengkakan otak disebut ensefalopati
hipertensif yang memerlukan penanganan segera
TATALAKSANA
HIPERTENSI
 Strength of
Recommendatio Recommendation
n
Recommendation
P
1opulasi berusia ≥60 yrs,mulai Grade
terapi farmakologi SBP≥150 mmHg, DBP≥90 A
mmHg HYVET, Sys-Eur, SHEP, JATOS, VALISH,
CARDIO-SIS
Corollary Recommendation
Populasi usia ≥60 yrs, jika terapi farmakologi
mengakibatkan penurunan TD lebih Grade
(<140/90) dan pengobatan ditoleransi dengan
rendah
baik tanpa efek samping, teruskan
E
pengobatan. Usia ini TD <140 tidak lebih baik
disbanding 140-160
Recommendation 2
Populasi usia <60 yrs, terapi farmacologi bila Grade A (30-59
DBP≥90 mmHg . Target DBP<90 mmHg yrs) Grade E (18-
29 yrs)
 Strength of
Recommendation Recommendati
on
Recommendation 3
Populasi usia <60 yrs, terapi farmacologi bila Grade E
SBP ≥140 mmHg.Target SBP<140 mmHg
Recommendation 4
Populasi usia ≥18 yrs dengan CKD, terapi
farmacologi bila SBP ≥140 mmHg or DBP ≥90 Grade E
mmHg . Target SBP <140 mmHg dan DBP
<90
mmHg AASK, MDRD, REIN-2
Recommendation 5
Populasi usia ≥18 dengan DM, terapi Grade E
farmacologi bila SBP ≥140 mmHg atau DBP ≥ 90
mmHg. Target SBP<140 and DBP <90 SHEP, Syst-Eur, UKPDS, ACCORD,
ADVANCE, HOT
 Strength of
Recommendation Recommendati
on
Recommendation 6
Pada populasi non black , termasuk dg DM, Grade B
initial anti HTN treatment : a thiazide type
diuretic, CCB, ACEI or ARB VA-cooperative, HDFP, SHEP

Recommendation 7
Populasi kulit hitam, termasuk dg DM, initial Grade B ( No DM)
anti HT: thiazide-type diuretic or CCB Grade C ( DM)
ALLHAT

Recommendation 8
Populasi usia ≥18 dg CKD dan HTN, initial (or Grade B
add on) anti HTN : ACEI or ARB utk
memperbaiki kidney outcomes. Tanpa melihat
ras atau status DM IDNT, AASK
 Recommendation Strength of
Recommendati
Recommendation 9 on

• Tujuan treatment HTN adalah untik mencapai

dan mempertahankan target BP
• Jika target BP tidak tercapai dlm 1 bl, naikkan
atau
dosis tambahkan 2nd 1 obat dr rekomendasi
(thiazide-type diuretic, CCB, ACEI, or ARB)
6
• Jika target BP tidak tercapai dg 2 obat, tambah dan Grade
titrasi obat 3rd . Do not use an ACEI and an ARB E
together
• Jika target BP tidak dapat tercapai dg obat-obat pada
recommendasi 6 krn kontraindikasi atau butuh >3
obat, obat antiHT dari kelas lain bias digunakan.
• Referral kepada hypertension specialist jika BP tidak
tercapai atau untuk management komplikasi.
 Strategies to Dose Antihypertensive Drugs
Strategies Description Details
A Mulai 1 obat naikan sp Jika target BP blm tercapai naikkan dosis
dosis obat 1 sp dosis maksimum sblm
maksimum,kemudian menambahkan obat ke-2 dan ke-3.
tambahkan obat ke-2
B Mulai 1 obat Tambahkan obat ke-2 sblm obat 1
kemudian tambahkan mencapai dosis maks.Jk Target BP blm
obat ke-2 sblm dosis tercapai,tambahkan obat ke-3 dan
maksimum titrasi sp dosis maks.

C Mulai dengan 2 • Mulai dg 2 obat

obat (separate or • Bbrp committee merekomendasi:
single combination)  ≥2 obat SBP >160 dan/atau DBP
>100, atau SBP >20 mmHg
diatas target dan/atau DBP >10
mmHg
 Jika target BP tdk tercapai (2
drugs),
tambahkan obat ke-3 dan titrasi.
 CHS January 2004
Considerations for individualization of anti-hypertensive therapy
Indication Initial Therapy Second line Rx Notes/Cautions
DM with nephropathy ACE-i or ARB addition thiazide, * *Cardioselective
-blockers , LA-CCB,  -blockers
ACE/ARB combo If CR >150 mmol/l use
loop diuretic for volume
DM without ACE-i or ARB Combo1st line Rx or *- control
nephropathy or thiazide blockers, LA-CCB
Angina  -blockers + strongly LA-CCB Avoid short acting
consider ACE-i nifedipine
Prior MI  -blockers + ACE-i Combine additional Rx
CHF  -blockers + ACE-i + Hydralazine /ISDN: Avoid non DHP-CCB
spironolactone (ARB if thiazide or loop diuretics (diltiazem, verapamil)
ACE-i intolerant ) as additive therapy
Prior CVA or TIA ACE-i/diuretic BP reduction  recurrent
combination events
Renal Disease ACE-i/diuretic as ARB if ACE-i intolerant Avoid ACE-i if bilateral
additive Rx Combo other agents Renal artery stenosis
LVH ACE-I, ARBs, DHP- Avoid hydralazine and
CCB, thiazide,  minoxidil
-blockers < 55 yr
Lifestyle Modification
 Komplikasi hipertensi

Eyes Brain Target Organ damage!!

retinopathy stroke

Damages depend on:

Hear
ischaemic heart disease
t
• How high of the blood
Kidneys left ventricular hypertrophy pressures
renal failure heart failure
• How long the
uncontrolled and
untreated high blood
presure
Peripheral arterial
disease
What is the goal BP?
 Guideline Population Goal BP Initial drugs
G
2014 HT General ≥60 y <150/90 Non Black: thiazide type diuretic, ACEI,
U ARB or ARB
I
Guideline
General <60 y <140/90 Black: thiazide type-diuretic or CCB
DM <140/90 Thiazide type diuretic, ACEI, ARB
D or CCB
CKD <140/90 ACEI or ARB
E
L ESH/ESC • General (non <140/90 βBocker, diuretic, CCB, ACEI, ARB
I elderly)
• General elderly <150/90
<80 y
N • General ≥ 80 y
• DM <150/90
• CKD (no <140/85 ACEI or ARB
E proteinemia) <140/90 ACEI or ARB
• CKD +
C proteinemia
<130/90
0
M
P
CHEP General <80 y <140/90 Thiazide, βBlocker (<60y), ACEI (nonblack) or
ARB
A General >80 y <150/90
R DM <130/80 Add CVD risk: ACEI or ARB
I No CVD risk: ACEI/ARB/Thiazide/DHPCCB
S ACEI or ARB
O CKD <140/90
 Guideline Population Goal BP Initial drugs
ADA DM <140/80 ACEI or ARB

KDIGO • DM and CKD ≤140/90 ACEI or ARB

alb exc <30
mg/d
• DM and CKD
alb exc >30 ≤130/80
mg/d

NICE General <80 y <140/90 <55 y; ACEI or ARB

General ≥80 <150/90 ≥55 y or black; CCB
y
ISHIB Black, lower risk <135/85 Diuretic or CCB
TOD or CVD <130/80
risk
JNC 7 General <140/90
CKD <130/80 ACEI or ARB
DM <130/80