Definisi Hipertensi

• is defined as the level of BP at which the benefits of treatment (either

with lifestyle interventions or drugs) unequivocally outweigh the risks
of treatment, as documented by clinical trials
• Hypertension is defined as office SBP values >_140 mmHg and/or
diastolic BP (DBP) values >_90 mmHg. This is based on evidence from
multiple RCTs that treatment of patients with these BP values is
beneficial
Klasifikasi hipertensi
Prevalensi
• Berdasarkan Office BP, Prevalensi dunia untuk hipertensi
diestimasikan sebanyak 1.13 milyar pada tahun 2015.
• The overall prevalence of hypertension in adults is around 30 - 45%
• Hypertension becomes progressively more common with advancing
age, with a prevalence of >60% in people aged >60 years.
• people with hypertension will increase by 15–20% by 2025, reaching
close to 1.5 billion.
• Elevated BP was the leading global contributor to premature death in
2015, accounting for almost 10 million deaths and over 200 million
disability-adjusted life years
• SBP >_140 mmHg accounts for most of the mortality and disability
burden (70%), and the largest number of SBP-related deaths per year
are due to ischaemic heart disease (4.9 million), haemorrhagic stroke
(2.0 million), and ischaemic stroke (1.5 million)
HMOD
• HMOD more accurately describes hypertension-induced structural
and/or functional changes in major organs (i.e. the heart, brain,
retina, kidney, and vasculature)
HMOD
• There are three important considerations related to HMOD
(i) not all features of HMOD are included in the SCORE system (CKD and established vascular
disease are included) and several hypertensive HMODs (e.g. cardiac, vascular, and retinal) have
well-established adverse prognostic significance (see section 5) and may, especially if HMOD is
pronounced, lead to a high CV risk even in the absence of classical CV risk factors;
(ii) (ii) the presence of HMOD is common and often goes undetected;38 and
(iii) (iii) the presence of multiple HMODs in the same patient is also common, and further increases
CV risk.39–4
Blood pressure measurement
• Conventional office blood pressure measurement
• Unattended office blood pressure measurement
• Out-of-office blood pressure measurement
• Home blood pressure monitoring
• Ambulatory blood pressure monitoring
• Advantages and disadvantages of ambulatory blood pressure
monitoring and home blood pressure monitoring
• White-coat hypertension and masked hypertension
• available prospective studies have further indicated that HBPM better
predicts cardiovascular morbidity and mortality than office BP.59
WHITE-COAT HYPERTENSION
• White-coat hypertension refers to the untreated condition in which
BP is elevated in the office, but is normal when measured by ABPM,
HBPM, or both.
• ‘masked hypertension’ refers to untreated patients in whom the BP is
normal in the office, but iselevated when measured by HBPM or
ABPM.
• The term ‘true normotension’ is used when both office and out-of-
office BP measurements are normal, and ‘sustained hypertension’ is
used when both are abnormal
Konfirmasi diagnosis dari hipertensi
Evaluasi dan penilaian klinis HMOD pada pasien dengan hipertensi
Medical History
• Time of the first diagnosis of hypertension, including records of any previous
medical screening, hospitalization, etc.
• Record any current and past BP values
• Record current and past antihypertensive medications
• Record other medications
• Family history of hypertension, CVD, stroke, or renal disease
• Lifestyle evaluation, including exercise levels, body weight changes, diet
history, smoking history, alcohol use, recreational drug use, sleep history, and
impact of any treatments on sexual function
• History of any concomitant CV risk factors
• Details and symptoms of past and present comorbidities
• Specific history of potential secondary causes of hypertension
• History of past pregnancies and oral contraceptive use
• History of menopause and hormone replacement therapy
• Use of liquorice
• Use of drugs that may have a pressor effect.
Penilaian HMOD
Tatalaksana Hipertensi
When to initiate antihypertensive treatment ?
• All guidelines agree that patients with grade 2 or 3 hypertension should receive
antihypertensive drug treatment alongside lifestyle interventions.
• Guidelines are also consistent in recommending that patients with grade 1 hypertension
and high CV risk or HMOD should be treated with BP-lowering drugs
Tatalaksana Hipertensi
Non Farmakologi
• Lifestyle changes
• Dietary sodium restriction
• Moderation of alcohol consumption
• Other dietary changes
• Weight reduction
• Regular physical activity
• Smoking cessation
Tatalaksana Hipertensi

Farmakologi
Five major drug classes were recommended for the treatment of hypertension:
• ACE inhibitors
• ARBs
• Beta-blockers
• CCBs
• Diuretics.
Angiotensin converting enzyme inhibitors and angiotensin receptor blockers

• Both ACE inhibitors and ARBs are among the most widely used classes of antihypertensive drugs. They have
similar effectiveness.

• ACE inhibitors and ARBs should not be combined for the treatment of hypertension because there is no added
benefit on outcomes and an excess of renal adverse events.

• ACE inhibitors and ARBs also appear effective in preventing or regressing HMOD, such as LVH and small artery
remodelling, for an equivalent reduction in BP.

• Both ACE inhibitors and ARBs reduce albuminuria more than other BP-lowering drugs and are effective at
delaying the progression of diabetic and non-diabetic CKD
Beta blockers

• When compared with other BP-lowering drugs, beta-blockers are usually equivalent in preventing major CV
events, except for less effective prevention of stroke, which has been a consistent finding.
Calcium Channel Blockers

• CCBs are widely used for the treatment of hypertension and have similar effectiveness as other major drug
classes on BP, major CV events, and mortality outcomes.

• CCBs have also been compared with other antihypertensive agents in HMOD-based trials, and are reported to
be more effective than beta-blockers in slowing the progression of carotid atherosclerosis, and in reducing
LVH and proteinuria.
Resistant Hypertension
• Hypertension is defined as resistant to treatment when the recommended treatment strategy fails to lower
office SBP and DBP values to <140 mmHg and/or <90mmHg, respectively, and the inadequate control of BP is
confirmed by ABPM or HBPM in patients whose adherence to therapy has been confirmed.

• Treatment with optimal or best-tolerated doses of three or more drugs, which should include a diuretic,
typically an ACE inhibitor or an ARB, and a CCB
Diagnostic approach to resistant hypertension
• Diagnosis of resistant hypertension requires detailed information about:
1. The patient’s history, including lifestyle characteristics, alcohol and dietary
sodium intake, interfering drugs or substances, and sleep history.

2. Dosing of the antihypertensive treatment.

3. A physical examination, with a particular focus on determining the

presence of HMOD and signs of secondary hypertension.
4. Confirmation of treatment resistance by out-of-office BP
measurements (i.e. ABPM or HBPM).

5. Laboratory tests to detect electrolyte abnormalities (hypokalaemia),

associated risk factors (diabetes), organ damage (advanced renal
dysfunction), and secondary hypertension.

6. Confirmation of adherence to BP-lowering therapy.