HIPERTENSI

Dr. Zainal Safri, SpPD, SpJP

Dr. Dede Moeswir, SpPD
Departemen Penyakit Dalam
 B P = CO x SVR

SV x HR
BP-blood pressure-tekanan darah.
SVR-systemic vascular-resistance-tahanan perifer.
SV-stroke volume-isi sekuncup.
HR-heart rate-denyut jantung.
 Framingham – Study
Blood pressure and Age
160 Women
150 Men
Systolic BP
140
130
120
90

80 Men
Diastolic BP Women
70
36 41 46 51 56 61 66 71 76 81 Years age
Kannel et al 1978
Definisi dan klasifikasi/kriteria
menurut WHO, ISH, JNC.
 HIPERTENSI
• Tekanan darah sistolik lebih besar
atau sama dengan 140 mmHg, dan /
atau
• Tekanan darah diastolik lebih besar
atau sama dengan 90 mmHg, atau
• Pasien dalam pengobatan anti
hipertensi.
The JNC VI classification of blood pressure
for adults ³18 years old1
Category Systolic blood Diastolic blood
pressure (mmHg) pressure (mmHg)

Optimal2 <120 and <80

Normal <130 and <85
High normal 130–139 or 85–89
Hypertension3
Stage 1 140–159 or 90–99
Stage 2 160–179 or 100–109
Stage 3 180 or 110

1Not taking antihypertensives and not acutely ill

2Optimal blood pressure with respect to cardiovascular risk is <120 mmHg

systolic and <80 mmHg diastolic.

3Based on the average of two or more readings taken at each of two or more

visits after an initial screening.

Based on JNC VI, National Institutes of Health, Nov. 1997

 Definitions and classification of blood pressure levels
(mmHg), 1999 WHO-ISH guidelines

Category Systolic Diastolic

Optimal < 120 < 80
Normal <130 < 85
High-normal 130-139 85-89
Grade 1 hypertension (mild) 140-159 90-99
Subgroup: borderline 140-149 90-94

Grade 2 hypertension (moderate) 160-179 100-109

Grade 3 hypertension (severe) > 180 > 110
Isolated systolic hypertension > 140 < 90
Subgroup: borderline 140-149 < 90
When a patient’s systolic and diastolic blood pressures fall into different categories, the higher
category should apply.

Guidelines Subcommittee. 1999. WHO-Int’l Society of Hypertension. Guidelines for Management of Hypertension. J Hypertens 1999;17:151-83.
JNC VII
 Prevalence of Hypertension
Hypertension is one of the most frequent clinical discorders.
prevalence of hypertension (%)

70
SBP > 140 mm Hg 65
60 64
DBP > 90 mm Hg
50 54

40 44

30
20 21
10 4 11
0
age (yrs) 18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

 Secondary
hypertension
 Renal
Primary 10 %
 Parenchymal

hypertension 90 %  Vascular

 Others
No underlying cause
 Endocrine
 Neurogenic
 Miscellaneous
 Unknown
Fase Hipertensi
 Early or Hyperkinetic
hypertension
 Clinical signs : systolic blood
pressure higher than normal,
diastolic blood pressure normal.
 Pathophysiology : high cardiac
output or tachycardia.
 Young adult patients.
 Chronic or Established
Hypertension
 Clinical signs : systolic and diastolic
blood pressure elevated.
 Pathophysiogy : higher vascular
resistance, but cardiac output
normal or little lower than normal.
Aortic compliance normal.
Isolated Systolic Hypertension
(ISH)
 Clinical signs : high systolic blood
pressure, diastolic blood pressure
normal or low.
 Pathophysiology : Decreased aortic
compliance caused by atherosclerotic
in aortic and artery vascular system.
 Elderly patients
Isolated Systolic Hypertension
(ISH)
diastolic blood pressure

Stiffness (atherosclerotic) of aortic and artery

organ damage (morbidity / mortality)

 Crisis Hypertensive
Hypertensive emergency Hypertensive urgency
• Hypertensive • Hypertension associated
with CAD.
encephalopathy.
• Accelerated and malignant
• Acute aortic dissection. hypertension.
• Pulmonary edema. • Severe hypertension in the
kidney transplant patient.
• Pheochromocytoma crisis. • Postoperative hypertension.
• MAO inhibitor + tyramine • Uncontrolled hypertension
interaction. in the patient with
emergency surgery.
• Eclampsia.
Hemodynamic changes in
Hypertension
Consequences of hypertension
 Consequences
 Left Ventricular Hypertrophy
-angina
-arrythmias
-myocardial infarction
-contributes to congestive heart failure
 Consequences cont…
 Coronary Artery Disease
-accelerated atherosclerosis
-decrease in oxygen supply
-in addition to high stystolic work load also
contributes to risk of myocardial infarction
 Consequences cont…
 Stroke
-Hypertension induced strokes result from
hemorragic (rupture of microaneurysms in
cerebral vessels) or atherothrombotic (plaques in
carotids or major cerebral arteries break off and
embolize in smaller vessels conditions.)
 Target Organ Damage in
Hypertension
Organ System Manifestations
Heart -Left
ventricular hypertrophy
-Heart failure

-Myocardial ischemia and infarction

Cerebrovascular Stroke
Aorta and peripheral vascular -Aortic aneurysm and/or dissection
-Arteriosclerosis

Kidney -Nephrosclerosis

-Renal failure
Retina -Arterialnarrowing
-Hemorrhages, exudates,
papilledema
TARGET ORGAN
DAMAGE
 Rekomendasi pengobatan hipertensi

Pemilihan obat anti

hipertensi berkaitan
dengan kerusakan target
organ, penyakit
kardiovaskuler dan
ada/tidak ada DM.
RULE OF HALVES

Only HALF of all hypertensive patients are AWARE

Only HALF of those aware are TREATED
Only HALF of those treated have their BP CONTROLLED

= 50% x 50% x 50%

 Classes of antihypertensive agents

 Diuretics  Vasodilators
 thiazides and related agents  arterial dilators
 loop diuretics  arterial and venous dilators
 K+-sparing diuretics
 Ca2+ channel blockers
 Sympatholytic drugs
 centrally acting agents
 adrenergic neurone-blocking  ACE inhibitors
agents
  adrenergic antagonists  Angiotensin II receptor
 1 adrenergic antagonists
antagonists
 multiple-action neurohormonal
antagonists

Goodman and Gilman (1996)

 Guidelines for Selecting Drug Treatment of
Class of Drug Compelling
Hypertension
Possible Compelling Possible
indication indication contraindication contraindication

Diuretic Heart failure Diabetes Gout Dyslipidaemia

Elderly patients Sexually active males
Systolic hypertension

Beta Blockers Angina Heart failure Asthma and COPD Dyslipidaemia

After myocardial infarct Pregnancy Heart block a Athletes and
Tachyarrhytmias Diabetes physically patients
Peripheral vascular
disease
ACE inhibitors Heart failure Pregnancy
Left ventricular Hyperkalaemia
dysfunction
After myocardial Bilateral renal artery
infarct stenosis
Diabetic nephropathy
Calcium Angina Peripheral Heart block b Congestive heart
antagonists Elderly patients vascular
Systolic hypertension disease
Alfa Blockers Prostatic hypertrophy Glucose Orthostatic
intolerance
Dyslipidaemia hypotension
Angiotensine II ACE inhibitors cough Heart failure Pregnancy
antagonists Bilateral renal
artery stenosis
Hyperkalaemia
 Ideal Hypertension Agent :

• Once Daily
• Smooth anti HT effect
• Well tolerated, minimal SE
• Beneficial CV effect independent of BP lowering

Int’l Forum on Angiotensin Receptor Antagonism, Monte

Carlo 1999
 GOALS OF
TREATMENT
“Is to achieve the maximum reduction in the
total risk of Cardiovascular morbidity and
mortality”

 Reduce CVD and renal morbidity and mortality.

 Treat to BP <140/90 mmHg or BP <130/80 mmHg in
patients with diabetes or chronic kidney disease.
 Achieve SBP goal especially in persons >50 years of
age.
 JNC VI - NEW BP GOALS
 <140/<90 and lower if tolerated
 <130/<85 in diabetics (types 1 &2)
 <130/<85 in cardiac failure
 <130/<85 in renal failure
 <125/<75 in renal failure with proteinuria >
1.0 gm/24 hr
WHO-ISH new BP Goals
 < 140/90 in elderly
 < 130/85 in young, middle-aged
 < 130/85 in diabetic
Adapted from JNC VI.1997
JNC VI
 ALGORITHM FOR THE TREATMENT OF HYPERTENSION
Begin or Continue Lifestyle Modification

Not at Goal Blood Pressure (< 140/90 mm Hg)

Lower goals for patients with diabetes or renal disease

Initial Drugs Choices*

Uncomplicated Hypertension Compelling Indication
Diuretics Diabetes mellitus (type 1) with proteinuria
Beta-blockers * ACE Inhibitors
Heart failure
Specific indications for the * ACE inhibitors
Following Drugs * Diuretics
ACE inhibitors Isolated systolic hypertension (older persons)
Angiotensine II receptors blockers * diuretics preferred
Alpha - blockers * Long acting dihydropyridine
Alpha-beta-blockers * calcium antagonists
Beta-blockers Myocardial infaction
Calcium Antagonists * Beta-blockers (non ISA)
Diuretics * ACE inhibitors (with systolic dysfunction)

* Start with a low dose of a long acting once daily drug, and titrate dose
* Low-dose combinations may be appropriate
JNC 7 Report on the Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure
Systolic Diastolic Initial Drug Therapy
BP BP Lifestyle Without Compelling With Compelling
BP Classification mm Hg mm Hg Modification Indication Indications
Normal <120 and <80 Encourage
Prehypertension 120–139 or 80–89 Yes No antihypertensive Drug(s) for
drug indicated compelling
indications
Stage 1 140–159 or 90–99 Yes Thiazide-type
hypertension diuretics for most. Drug(s) for the
May consider ACEi, compelling
ARB, BB, CCB, or indications
combination
Stage 2 >160 or >100 Yes Two-drug Other
hypertension combination for most antihypertensive
(usually thiazide-type drugs (diuretics,
diuretic and ACEi or ACEi, ARB, BB,
ARB or BB or CCB) CCB) as needed

ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin II type 1-receptor blocker; BB, beta-blocker; CCB, calcium
channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.
 Stratification of Risk to Quantify
Prognosis
Blood Pressure (mmHg)

Grade 1 Grade 2 Grade 3

Other Risk Factors (mild hypertension) (moderate hypertension) (severe hypertension)
& Disease History SBP 140-159 SBP 160-179 SBP > 180
or DBP 90-99 or DBP 100-109 or DBP > 110

I no other risk factors

LOW RISK MED RISK HIGH RISK

II 1-2 risk factors

MED RISK MED RISK VERY HIGH RISK

III 3 or more risk factors

or TOD or diabetes HIGH RISK HIGH RISK VERY HIGH RISK

IV ACC VERY HIGH RISK VERY HIGH RISK VERY HIGH RISK

TOD = Target Organ Damage

Guidelines Subcommittee. 1999. WHO-Int’l Society of Hypertension. Guidelines for Management of Hypertension. J Hypertens 1999;17:151-83
 Initiation of Treatment
SBP 140-180 mmHg or DBP 90-110 mmHg
on several occasions (Grades 1 & 2 hypertension)

Assess other risk factors, TOD and CCD

Initate Lifestyle Measures

Stratify Absolute Risk

Very High High Medium Low

Begin Begin Monitor BP and Monitor BP and

drug drug other risk factors other risk factors
treatment treatment for 3 - 6 months for 6 - 12 months

SBP > 140 or SBP < 140 or SBP > 140 SBP < 140
DBP > 90 DBP < 90 or DBP > 90 or DBP < 90
Begin drug Continue to Begin drug Continue to
treatment monitor treatment monitor

1. TOD - Taeget Organ Damage (precious WHO Stage 2 hypertension) [6]

2. ACC - Associated Clinical Condition including clinical cardiovascular disease and renal disease
(previous WHO Stage 3 hypertension) [6]
 The lifestyle modifications
• Lose weight if overweight.
• Limit alcohol intake to no more than 1-2 drinks per day
(equivalent to approximately 15-30 mL ethanol per day).
• Increase aerobic physical activity to 30 - 45 minutes on
most days.
• Reduce sodium intake to no more than 100 mmol per day
(2.4 g sodium or 6 g sodium chloride per day).
• Maintain adequate intake of dietary potassium
(approximately 90 mmol per day). Inadequate intake may
increase blood pressure.
• Maintain adequate intake of dietary calcium and magnesium
for general health. Inadequate intake may increase blood
pressure.
• Stop smoking and reduce intake of dietary saturated fat and
cholesterol for overall cardiovascular health.
Hypertensive Heart Diseases
 Target Organ Damage in
Hypertension
Organ System Manifestations
Heart -Left
ventricular hypertrophy
-Heart failure

-Myocardial ischemia and infarction

Cerebrovascular Stroke
Aorta and peripheral vascular -Aortic aneurysm and/or dissection
-Arteriosclerosis

Kidney -Nephrosclerosis

-Renal failure
Retina -Arterialnarrowing
-Hemorrhages, exudates,
papilledema
ECG of a 47-year-old man with a long-standing history of
uncontrolled hypertension showing left atrial enlargement
and left ventricular hypertrophy.
 ECG of a 46-year-old man with long-standing
hypertension showing left atrial abnormality and left
ventricular hypertrophy with strain.
 Two-dimensional echocardiogram of a 70-year-old
woman (parasternal long axis view) showing concentric
left ventricular hypertrophy.
Short axis view : concentric left ventricular
hypertrophic
Gross specimen of the heart with concentric
left ventricular hypertrophy.
 Guidelines for Selecting Drug Treatment of
Class of Drug Compelling
Hypertension
Possible Compelling Possible
indication indication contraindication contraindication

Diuretic Heart failure Diabetes Gout Dyslipidaemia

Elderly patients Sexually active males
Systolic hypertension

Beta Blockers Angina Heart failure Asthma and COPD Dyslipidaemia

After myocardial infarct Pregnancy Heart block a Athletes and
Tachyarrhytmias Diabetes physically patients
Peripheral vascular
disease
ACE inhibitors Heart failure Pregnancy
Left ventricular Hyperkalaemia
dysfunction
After myocardial Bilateral renal artery
infarct stenosis
Diabetic nephropathy
Calcium Angina Peripheral Heart block b Congestive heart
antagonists Elderly patients vascular
Systolic hypertension disease
Alfa Blockers Prostatic hypertrophy Glucose Orthostatic
intolerance
Dyslipidaemia hypotension
Angiotensine II ACE inhibitors cough Heart failure Pregnancy
antagonists Bilateral renal
artery stenosis
Hyperkalaemia
THANK YOU