Pendekatan Komprehensif

dalam
Tatalaksana Hipertensi

Rochmad Romdoni
Departemen Kardiologi dan Kedokteran Vaskuler FK Unair
RS Dr Soetomo Surabaya

Effects of blood pressure on the risk

of cardiovascular disease
Average annual incidence rate per 10.000
100

CHD

90
80
70
60
50

Stroke

40
30

CHF

20
10
0

<100

120

140

180

>180

Systolic blood pressure (mmHg)

Source : Framingham study (after Gorlin)

Staessen et al., (2001)

Metaanalysis 27 trials of 136,124 patients,
conclude :

Lowering blood pressure as much

as possible to achieve the greatest
reduction
in
cardiovascular
complications.

Norman M. Kaplan, Clinical Hypertension 8th ed. P.177, 2002

Benefits of Lowering BP
Average Percent Reduction
Stroke incidence

3540%

Myocardial infarction

2025%

Heart failure

50%

Percentages of Patients whose

Hypertension is Controlled
< 140/90 mmHg
USA
27

England

Canada
16

< 160/95 mmHg

Finland

Spain

20.5

20

France

Germany

24

22.5

Scotland
17.5

Australia
19

India
9

> 65 years

USA: JNC VI. Arch Intern Med 1997

Canada: Joffres et al. Am J Hypertens 1997
England: Colhoun et al. J Hypertens 1998
France: Chamontin et al. Am J Hypertens 1998

Marques-Vidal P et al. J Hum Hypertens 1997

Adapted from G. Mancia / L. Ruilope

Majority of US Hypertensive Patients Are Not at

SBP Goal of <140 mm Hg
14.0
12.0
10.0
Population 8.0
(millions)
6.0

Not meeting goal

4.0
2.0

SBP Range (mm Hg)

Adapted from Lapuerta P, LItalien GJ. Am J Hypertens. 1999;12:92A.

241 - 250

231 - 240

221 - 230

211 - 220

201 - 210

191 - 200

181 - 190

171 - 180

161 - 170

151 - 160

141 - 150

131 - 140

121 - 130

111 - 120

101 - 110

91 - 100

81 - 90

0.0

We can do a better job for

controlling hypertension
Marvin Moser
J.Clin.Hypertens. 1999 ;1:91

ESH ESC 2003

WHO-ISH Guidelines for Management of

Hypertension: Stratification of Cardiovascular Risk
Blood Pressure (mm Hg)
Grade 1

Grade 2

Grade 3

Mild
hypertension

Moderate
hypertension

Severe
hypertension

Other risk factors and

disease history

SBP 140159
or DBP 9099

SBP 160179
or DBP 100109

SBP 180
or DBP 110

I No other risk factors

Low risk

Med risk

High risk

II 12 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

Very high risk

Very high risk

Very high risk

IV ACC

TOD = Target-organ damage

ACC = Associated clinical conditions

Guidelines subcommittee. WHO-ISH

Guidelines. J Hypertens 1999;17:151-183.

JNC VII Guidelines

Amy P. Witte, Pharm.D.

University of the Incarnate Word Feik School of Pharmacy

Adapted from JNC VII Guidelines 2003

Changes in Blood Pressure

Classification
JNC 6 Category

JNC 7 Category
SBP/DBP (mm Hg)

Optimal

< 120/80

Normal

Normal

120-129/80-84

Borderline

130-139/85-89

Hypertension

Hypertension

Stage 1

140/90
140-159/90-99

Stage 2
Stage 3

160-179/100-109
180/110

Stage 2

Prehypertension

Stage 1

Blood Pressure Goals

Target Blood Pressure Goals

Most patients < 140/90 mm Hg
Patients with diabetes or chronic kidney
disease < 130/80 mm Hg
Patients with proteinuria < 125/75 mm Hg

Amy P. Witte, Pharm.D.

University of the Incarnate Word Feik School of Pharmacy

JNC VII Guidelines 2003

White Coat Hypertension

White coat hypertension

Office BP 140/90 mmHg, daytime ABPM < 135/85 mmHg
Clinical implications:

few clinical characteristics to assist diagnosis

considered in newly diagnosed HT before prescribe drug

placed in context of overall risk profile

common in the elderly and pregnancy

needed less drug prescribing, follow up & monitoring

Home/Ambulatory BP Monitoring

WCH in patients: manifest symptom of overmedication, or home

BP < office BP

Clinical indications for ABPM:

exclusion of WCH

decide diagnosis in borderline HT

elderly patients, pregnancy HT

identify nocturnal HT, diagnosis hypotension

resistant HT, as guide to treatment

Home Blood Pressure Monitoring

Mercury sphygmomanometer

Standard for BP monitoring

No calibration
Need a second person to use machine
May be difficult for hearing impaired or patients with arthritis

Home Blood Pressure Monitoring

z

Aneroid equipment

Inexpensive, lightweight and portable

Two person operation/need stethoscope
Delicate mechanism, easily damaged
Needs calibration with mercury sphygmomanometer

Home Blood Pressure Monitoring

z

Automatic equipment

Contained in one unit

Portable with easy-to-read digital display
Expensive, fragile
Must be calibrated
Requires careful cuff placement

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

With Compelling
Indications

Stage 1 Hypertension

Stage 2 Hypertension

(SBP 140159 or DBP 9099 mmHg)

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

(SBP >160 or DBP >100 mmHg)

2-drug combination for most (usually
thiazide-type diuretic and
ACEI, 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.

Drug(s) for the compelling

indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.

Lifestyle Modification
Modification

Weight reduction

Approximate SBP reduction

(range)
520 mmHg/10 kg weight loss

Adopt DASH eating plan

814 mmHg

Dietary sodium reduction

28 mmHg

Physical activity

49 mmHg

Moderation of alcohol
consumption

24 mmHg

Era of Antihypertensive Agents

50

Classic antihypertension

60

Diuretics

70

Adrenoceptor-Blockers

80

Calcium-Channel-Blockers

90

ACE-Inhibitors

2000

AIIRA (Angiotensin II Receptor

Antagonists) or ARB (Angiotensin II
Receptor Blocker)
Direct Renin Inhibitor

Development of Antihypertensive Therapies

Effectiveness
Tolerability
1940s

1950

Direct
vasodilators
Peripheral
sympatholytics
Ganglion
blockers
Veratrum
alkaloids

1957

1960s

1970s

-blockers
Thiazides
diuretics
Central 2
agonists
Calcium
antagonistsnon DHPs
-blockers

1980s

1990s

ARBs
ACE
inhibitors

Calcium
antagonistsDHPs

2001

Direct
Renin
Inhibitor

What is New?
Suitable first-line
drug therapy
Combination
therapy

1999 WHO-ISH

1993 WHO-ISH

JNC-VI / VII

6 drug
classes

5 drug
classes

2-3 drug
classes

Low dose
combinations
recommended if
monotherapy
inadequate

Low dose
combinations
may be used to
initiate therapy

1999 WHO-ISH HYPERTENSION PRACTICE GUIDELINES FOR PRIMARY CARE PHYSICIANS

10

Classification and Management

of BP for adults
Initial drug therapy

SBP* DBP*
BP
classification mmHg mmHg

Lifestyle
modification

Normal

<120

and
<80

Encourage

Prehypertensi
on

120
139

or 80
89

Yes

Stage 1
Hypertension

140
159

or 90
99

Yes

Without compelling
indication

No antihypertensive
drug indicated.

With compelling
indications

Drug(s) for
compelling
indications.

Thiazide-type diuretics
for most. May consider Drug(s) for the
ACEI, ARB, BB, CCB, or compelling
indications.
combination.
Other
Stage 2
>160 or >100
Yes
Two-drug combination
antihypertensive
Hypertension
for most (usually
drugs (diuretics,
thiazide-type diuretic
ACEI, ARB, BB,
*Treatment determined by highest BP category.
and
ACEI
or
ARB
or
BB

Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. CCB) as needed.

or goal
CCB).
Treat patients with chronic kidney disease or diabetes to BP
of <130/80 mmHg.

Prescription errors / inadequate therapy

Inadequate drug doses or failure to titrate medicine to reach the

goal.

Inappropriately low doses of drugs multiple drug regimens

compliance

Consequences of monotherapy dose titration:

Uncontrolled BP
Poor compliance
Increased incidence of
adverse effects

Increased dose

Antihypertensive Agents Combination

DIURETIC

AT-2 RB

-BLOCKER

Ca-ANTAGONIST

-BLOCKER

ACE INHIBITOR
ESC-ESH 2003

Therapy of Hypertension with Comorbid conditions

Specific Indication

Treatment

CHF

Diuretic, ACE I, AIIRA

Angina

Diuretic, blocker, CCB

MI

blocker

MI + LV dysfunction

ACE I

Diabetic nephropathy

ACE I

Dyslipidemia

ACE I, CCB, - blocker

ISH

Diuretic, CCB (DHP)

Conclusion
Detecting and Treating Hypertension cannot be
overestimated
Effective treatment of hypertension significantly
reduces the risk of stroke and cardiovascular
disease
Physician play a critical role in helping to
decrease this healthcare burden