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Essential Hypertension
and
Hypertensive Heart Disease
MASRUL SYAFRI
Refferences
Perhatian
Bahan ajar ini hanya sebagai panduan dan rangkuman
dasar dari materi kuliah pakar. Sebagai sumber
pengetahuan dan bahan untuk ujian silahkan membaca
referensi tersebut diatas.
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Introduction
• Hypertension :
– Prevalence up to 1 billion
individuals world wide
– 7.1 million deaths per year
– 62 % of cerebrovascular disease
and 49 % of ischemic heart
disease
– Riskerdas 2013 : Indonesian
prevalence ± 25%, West Sumatera
22,6%
– Overall prevalence of worldwide
population 30-45%
– Most common, readily
identifiable, and reversible risk
factor for cardiovascular disease
Checklist for Accurate Measurement of BP
Step 3: Take the proper measurements needed for diagnosis and treatment
of elevated BP/hypertension.
Definition
• Hypertension :
– BP 140/90 mmHg or higher (for every age!)
– JNC VII :
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*Factors that can be changed and, if changed, may reduce CVD risk.
†Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive
sleep apnea, cannot be changed (family history, increased age, male sex), or, if changed through
the use of current intervention techniques, may not reduce CVD risk (psychosocial stress).
CKD indicates chronic kidney disease; and CVD, cardiovascular disease.
BP Patterns Based on Office and Out-of-Office Measurements
Office/Clinic/Healthcare Home/Nonhealthcare/AB
Setting PM Setting
Normotensive No hypertension No hypertension
Sustained
Hypertension Hypertension
hypertension
Masked
No hypertension Hypertension
hypertension
White coat
Hypertension No hypertension
hypertension
ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.
Corresponding Values of SBP/DBP for Clinic, HBPM, Daytime,
Nighttime, and 24-Hour ABPM Measurements
Cardiovascular Continuum
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Pathophysiology of Hypertension
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Essential Hypertension
• A high blood pressure for which an obvious
secondary cause cannot be determined (AKA
idiopathic)
• Account for 95% of all hypertension
• Several factors contributed to essential
(primary) hypertension are obesity, excess
alcohol and salt intake, sedentary lifestyle, and
diabetes
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Neurohormonal mechanism
• Sympathetic nervous system is a major
long and short term BP controller
• Renal sympathetic nerves plays important
role in long term regulation of BP and
pathogenesis of hypertension
• Excessive renal sympathetic nerves
activation leads to sodium retention,
increased RAAS, and impaired
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Neurohormonal mechanism
• Baroreceptor reflexes buffering moment-to-
-moment changes in BP that varies during
daily activities.
• Baroreceptor detect sudden increase or
decrease of BP and causing reflex mechanism
through vagal stimulation and sympathetic
or parasympathetic activation.
Baroreceptor reflex
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Neurohormonal mechanism
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•
Vascular mechanism
Endothelial cells of vascular vessel
have expresses nitric oxide
synthase which produce NO and
possess vasodilatation properties
• Several condition (i.e diabetes,
vascular inflammation, and
hypertension) cause dysfunctional
endothelium characterized by
impaired release of NO and
enhanced release of endothelium-
derived constricting,
proinflammatory, prothrombotic,
and growth factor
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Vascular mechanism
• Endothelial dysfunction and hypertension
caused vascular remodeling over time, which
perpetuates further hypertension
• Remodeling marked by an increase in the
medial thickness relative to lumen diameter in
arteries
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RAAS
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RAAS
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RAAS
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Diagnostic of Essential
Hypertension
• ABPM • HBPM
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ABPM
Investigation of hypertension
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Treatment of Hypertension
• Strategies :
– Life styles changes
– Monotherapy or combination antihypertension drugs
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Lifestyles changes
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Complication of hypertension
Complication of hypertension
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Ventricular hypertrophy
Diagnostic modality
• ECG
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Diagnostic modality
• Chest X ray
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Diagnostic modality
• Echocardiography
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Management
• Regression of LV Mass and reversing LV systolic
and diastolic dysfunction
• Several drugs are proven to reduce the
hypertensive heart disease progression
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Management
• Current Medication :
– ACE-I / ARB
– CCB
– β –blocker and α-blocker
– Diuretics
• Future perspectives
– cyclosporin
– HMG CoA reductase inhibitor
– Recombinant human B-type natriuretic peptide
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BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension
According to Clinical Conditions
BP Threshold, BP Goal,
Clinical Condition(s)
mm Hg mm Hg
General
Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80
No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80
Older persons (≥65 years of age; noninstitutionalized, ≥130 (SBP) <130 (SBP)
ambulatory, community-living adults)
Specific comorbidities
Diabetes mellitus ≥130/80 <130/80
Chronic kidney disease ≥130/80 <130/80
Chronic kidney disease after renal transplantation ≥130/80 <130/80
Heart failure ≥130/80 <130/80
Stable ischemic heart disease ≥130/80 <130/80
Secondary stroke prevention ≥140/90 <130/80
Secondary stroke prevention (lacunar) ≥130/80 <130/80
Peripheral arterial disease ≥130/80 <130/80
Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAHA§ Randall S. Stafford, MD, PhD‡‡
Sondra M. DePalma, MHS, PA-C, CLS, AACC║ Sandra J. Taler, MD, FAHA§§
Samuel Gidding, MD, FACC, FAHA¶ Randal J. Thomas, MD, MS, FACC, FAHA║║
Kenneth A. Jamerson, MD# Kim A. Williams, Sr, MD, MACC, FAHA†
Daniel W. Jones, MD, FAHA† Jeff D. Williamson, MD, MHS¶¶
Eric J. MacLaughlin, PharmD** Jackson T. Wright, Jr, MD, PhD, FAHA##
Paul Muntner, PhD, FAHA†
BP Measurement Definition
*Factors that can be changed and, if changed, may reduce CVD risk.
†Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive
sleep apnea, cannot be changed (family history, increased age, male sex), or, if changed through
the use of current intervention techniques, may not reduce CVD risk (psychosocial stress).
CKD indicates chronic kidney disease; and CVD, cardiovascular disease.
2017 Hypertension Guideline
Classification of BP
Definition of High BP
Measurement of BP
Accurate Measurement of BP in the Office
Step 3: Take the proper measurements needed for diagnosis and treatment
of elevated BP/hypertension.
27–34 cm Adult
Office/Clinic/Healthcare Home/Nonhealthcare/AB
Setting PM Setting
Normotensive No hypertension No hypertension
Sustained
Hypertension Hypertension
hypertension
Masked
No hypertension Hypertension
hypertension
White coat
Hypertension No hypertension
hypertension
ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.
Detection of White Coat Hypertension or Masked Hypertension
in Patients Not on Drug Therapy
Office BP
at goal
Yes No
Increased Office BP
CVD risk or ≥5–10 mm Hg
target organ above goal on
damage ≥3 agents
Yes No Yes No
Screen for Screen for
Screening Screening
masked uncontrolled white coat effect with
not necessary not necessary
hypertension with HBPM HBPM
(No Benefit) (No Benefit)
(Class IIb) (Class IIb)
HBPM BP HBPM BP
above goal at goal
Yes No
ABPM BP
above goal
White coat effect:
Continue titrating
Yes No Confirm with ABPM
therapy
(Class IIa)
Masked uncontrolled
Continue current
hypertension:
therapy
Intensify therapy
(Class IIa)
(Class IIb)
Colors correspond to Class of Recommendation in Table 1.
ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM,
home blood pressure monitoring.
2017 Hypertension Guideline
Causes of Hypertension
Secondary Forms of Hypertension
Recommendations for Secondary Forms of
COR LOE
Hypertension
Screening for specific form(s) of secondary hypertension
is recommended when the clinical indications and
I C-EO physical examination findings are present or in adults
with resistant hypertension.
Conditions
• Drug-resistant/induced hypertension
• Abrupt onset of hypertension
• Onset of hypertension at <30 y
• Exacerbation of previously controlled hypertension
• Disproportionate TOD for degree of hypertension
• Accelerated/malignant hypertension
• Onset of diastolic hypertension in older adults (age ≥65 y)
• Unprovoked or excessive hypokalemia
Yes No
Positive
screening test
Yes No
Common causes
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Uncommon causes
Pheochromocytoma/paraganglioma
Cushing’s syndrome
Hypothyroidism
Hyperthyroidism
Aortic coarctation (undiagnosed or repaired)
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary aldosteronism
Acromegaly
Primary Aldosteronism
COR LOE Recommendations for Primary Aldosteronism
In adults with hypertension, screening for primary aldosteronism
is recommended in the presence of any of the following
concurrent conditions: resistant hypertension, hypokalemia
(spontaneous or substantial, if diuretic induced), incidentally
I C-EO
discovered adrenal mass, family history of early-onset
hypertension, or stroke at a young age (<40 years).
Nonpharmacological Interventions
Nonpharmacological Interventions
Patient Evaluation
Basic and Optional Laboratory Tests for Primary Hypertension
Treatment of High BP
BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug
Treatment of Hypertension
Clinical ASCVD
Nonpharmacologic
Promote optimal or estimated 10-y CVD risk
therapy
lifestyle habits ≥10%*
(Class I)
No Yes
Reassess in Reassess in
3–6 mo 1 mo
(Class I) (Class I)
1y 3–6 mo therapy
BP-lowering medication BP-lowering medication†
(Class IIa) (Class I) (Class I)
(Class I) (Class I)
Reassess in Reassess in
3–6 mo 1 mo
(Class I) (Class I)
BP goal met
No Yes
Consider
intensification of
therapy
Angina
pectoris
Yes No
Add
Add
dihydropyridine CCBs,
dihydropyridine CCBs
thiazide-type diuretics,
if needed
and/or MRAs as needed
(Class I)
(Class I)
BP goal <130/80 mm Hg
(Class I)
Albuminuria
(≥300 mg/d or ≥300 mg/g
creatinine)
Yes No
ACE inhibitor
intolerant
Yes No
Patient
qualifies for IV
thrombolysis
therapy
Yes No
And
For adults with a lacunar stroke, a target SBP goal of less than
IIb B-R 130 mm Hg may be reasonable.
Previous
diagnosed or treated
hypertension
Yes No
Restart
antihypertensive
Established Established
treatment
SBP ≥140 mm Hg or SBP <140 mm Hg and
(Class I)
DBP ≥90 mm Hg DBP <90 mm Hg
Aim for
BP <140/90 mm Hg
(Class IIb) Initiate Usefulness of starting
antihypertensive antihypertensive
treatment treatment is not
(Class I) well established
(Class IIb)
Aim for
BP <130/80 mm Hg
(Class IIb)
Other Considerations
Resistant Hypertension: Diagnosis, Evaluation, and Treatment
.
BP indicates blood pressure; CKD, chronic kidney disease; DBP, diastolic blood pressure;
eGFR, estimated glomerular filtration rate; NSAIDs, nonsteroidal anti-inflammatory drugs;
and SBP, systolic blood pressure.
Adapted with permission from Calhoun et al.
Hypertensive Crises: Emergencies and Urgencies
Yes No
Hypertensive
Markedly elevated BP
emergency
Admit to ICU
(Class I) Reinstitute/intensify oral
antihypertensive drug therapy
and arrange follow-up
Conditions:
• Aortic dissection
• Severe preeclampsia or eclampsia
• Pheochromocytoma crisis
Yes No
Reduce SBP to <140 mm Hg Reduce BP by max 25% over first h†, then
during first h* and to <120 mm Hg to 160/100–110 mm Hg over next 2–6 h,
in aortic dissection† then to normal over next 24–48 h
(Class I) (Class I)
Use of the EHR and patient registries is beneficial for guiding quality
improvement efforts designed to improve hypertension control.
I B-NR
Telehealth Interventions to Improve Hypertension Control
BP Threshold, BP Goal,
Clinical Condition(s)
mm Hg mm Hg
General
Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80
No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80
Older persons (≥65 years of age; noninstitutionalized, ≥130 (SBP) <130 (SBP)
ambulatory, community-living adults)
Specific comorbidities
Diabetes mellitus ≥130/80 <130/80
Chronic kidney disease ≥130/80 <130/80
Chronic kidney disease after renal transplantation ≥130/80 <130/80
Heart failure ≥130/80 <130/80
Stable ischemic heart disease ≥130/80 <130/80
Secondary stroke prevention ≥140/90 <130/80
Secondary stroke prevention (lacunar) ≥130/80 <130/80
Peripheral arterial disease ≥130/80 <130/80