Diagnosis &

Penatalaksanaan
Hipertensi

OUTLINE

OUTCOME HYPERTENSION
WHY TO TREAT
HOW TO DIAGNOSE
MANAGING HYPERTENSION
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINED ?
COMBINATION STRATEGIES

Hypertension:
a major CV risk factor

Hypertension is an important
public health challenge worldwide
In 2000,
> quarter of
global
population
with
hypertension

introduction

earney PM, et al. Lancet. 2005;365:217-223.

Population (in millions)

with hypertension
globally

BP control is particularly poor in hypertensive patients at high risk

Hypertension controlled (%)
Total n=4,646

CAD, coronary artery disease; CHF, congestive heart failure; CKD, chronic kidney disease;
DM, diabetes mellitus; HTN, hypertension; PAD, peripheral arterial disease.
* Based on BP target <130/80 mmHg

Wong ND,et al. Arch Intern Med 2007;167:2431-2436

Uncontrolled hypertension carries the same

CV risk as untreated hypertension
Third National Health and Nutrition Examination Survey (NHANES III)

Not treated

BP
uncontrolled
BP controlled

48%
(n = 2,458)

Both are at equally

increased risk compared
with controlled BP
(p>0.05)

35%
(n = 1,756)
17%
(n = 872)
Gu Q, et al. Am J Hypertens 2010;23(1):38-45

Hypertension Risk for

ESRD

Compared with BP < 120/80 mmHg, the

adjusted relative risks for developing ESRD
in subject without baseline renal disease:
RR

CI

BP

1,62

95% CI (1,27 - 2,07)

120-129 / 80- 84

1,98

95% CI (1,55 2,52)

130-139 / 85-89

2,59

95% CI (2,07-3,25)

140-159 / 90-99

3,86

95% CI (3,00 4,96)

160-179 / 100-109

3,88

95% CI (2,82- 5,34)

180-209 / 110-119

4,25

95% CI (2,63-6,86)

210 / 120
Hsu, et al. Arch Intern Med. 2005

OUTLINE

OUTCOME HYPERTENSION
WHY TO TREAT
HOW TO DIAGNOSE
MANAGING HYPERTENSION
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINED ?
COMBINATION STRATEGIES

Millimetres matter
A 2-mmHg reduction in DBP
would
result in a 6% reduction in the
risk of
CHD and a 15% reduction in the
risk of
stroke and TIAs

DBP, diastolic blood pressure; CHD, coronary heart disease;

TIA, transient ischaemic attack

Cook NR, et al. Arch Intern Med 1995;155:701-709

Hypertension Awareness,
Treatment,
and Control In US 2009 -2012

Source:CDC/NHNS, National Health and Nutrition Examination

Survey, 2011-2012
Available at http://www.cdc.gov. Accessed 8/24/14.

Global Hypertension Awareness, Treatment, & Control In The

In Treated Hypertensive Patients Population
Individuals (%)
Low treatment & control rates could contribute to a
higher burden of CV Risk

*
* Threshold of SBP/DBP 140/90 mm Hg
Wolf-Maier K,et al. Hypertension 2004;43:1017

WHO Age-standardized Estimates of the

Prevalence of Hypertension in Sout East
Asia Region
Estimates of age-standardized prevalence (%) of raised blood
pressure in adults aged 25+ years in countries of the SEA Region,
2008
Country
Men
Women
Both
44.3
39.8
42.0
Myanmar
(37.7-50.5)
(33.1-46.5)
(37.2-46.8)
42.7
39.2
41.0
Indonesia
(35.3-49.9)
(32.5-46.0)
(35.9-45.8)
36
34.2
35.2
India
(29.7-41.8)
(28.6-39.9)
(30.9-35.2)
37.0
31.6
34.2
Thailand
(31.3-42.5)
(26.0-37.1)
(30.0-38.1)
37.6
35.4
36.6
Asia Tenggara
(32.6-42.4)
(30.9-39.8)
(33.1-39.8)
40.8
36.0
38.4
Global
(37.7-43.7)
(33.3-38.6)
(36.3-40.5)

Krishnan A. Regional Health Forum. Vol 17, Number 1;2013

More Than 80% Of hypertensive Patients have

additional Co-morbidities

Sumut
(-)

Adult Population with

Hypertension

Percentage of Adult Population

with Hypertension in Indonesia

Only 24%
Aware of
Hypertensi
ve Status

Krishnan A. Regional Health Forum. Vol 17, Number 1;2013;7-11

OUTLINE

OUTCOME HYPERTENSION
WHY TO TREAT
HOW TO DIAGNOSE
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINED ?
COMBINATION STRATEGIES

JANGAN ASAL TUDUH YA !!!!!!!

HYPERTENSION
Diagnosis
DEFINITION:

WHO-ISH: Because blood pressure is characterized by large spontaneous

(2004)

variations, the diagnosis of hypertension should be based on

multiple blood pressure measurements,
taken on several separate occasions.

JNC VII: .. Is based on two or more properly measured, seated BP

(2003)

readings on each of two or more office visits.

INDONESIA: Metode pengukuran tekanan darah. dilakukan sesuai

dengan standar WHO dengan alat standar manometer air
(2007)
raksa. Untuk menegakkan diagnosis hipertensi, perlu
dilakukan pengukuran minimal 2 kali dengan jarak 1
minggu bila tekanan darah <160/100 mmHg.

PERSIAPAN SEBELUM PENGUKURAN

Standardized Preparation:

Patient
1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the
preceding 30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before
measurement
8. Patient should stay silent prior and during the
procedure.

PERSIAPAN SEBELUM PENGUKURAN

Tehnik yang standard
Postur
Pasien harus duduk tegak dan posisi
lengan setentang letak jantung
Kedua telapak kaki harus menyentuh
lantai dan kedua kaki lurus (tdk boleh
disilangkan

OUTLINE

OUTCOME HYPERTENSION
WHY TO TREAT
HOW TO DIAGNOSE
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINED ?
COMBINATION STRATEGIES

Decisions on management of the

hypertensive patient
depend on the initial level of total
cardiovascular risk

TINGKATAN RESIKO KV (WHO/ESC/ESH

2013)

Rekomendasi Awal terapi Hipertensi ( WHO/ESC/ESH 2013)

The Newest
Guideline!!!

Algoritme Managemen Hipertensi JNC

8 2014

Algoritme Managemen Hipertensi JNC 8

2014 (cont)

From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

Date of download: 3/5/2014

Copyright 2014 American Medical

Association. All rights reserved.

OUTLINE

OUTCOME HYPERTENSION
WHY TO TREAT
HOW TO DIAGNOSE
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINE ?
COMBINATION STRATEGIES

OUTLINE

OUTCOME HYPERTENSION
WHY TO TREAT
HOW TO DIAGNOSE
TIME TO START DRUG THERAPY
WHICH ONE DRUG?
WHEN TO COMBINE ?
COMBINATION STRATEGIES

COMPARISONS BP TARGET
BASE ON GUIDELINES
BP Goal

JNC-7

JNC-8

ASH/ISH

ESC/ESH

CHEP

Age < 60

<140/90

<140/90

<140/90

<140/90

<140/90

Age 6079
Age 80+

<140/90

<150/90

<140/90

<140/90

<140/90

<140/90

<150/90

<150/90

<150/90

<150/90

Diabetes

<130/80

<140/90

<140/90

<140/85

<130/80

CKD

<130/80

<140/90

<140/90

<130/90

<140/90

Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.

Approach To Mono or Combination Therapy

Mancia et al. Jounal of Hypertension 2013.

31:1281-1357

ARB+CCB is one of the preffered

antihypertensive combination

UNDER VS OVER TREATMENT

Take Home Message

Hipertensi masih menjadi masalah global
Peningkatan TD sedikit saja akan meningkatkan
resiko morbiditas dan mortalitas KV
Pengurangan TD 2 mmhg saja akan menurunkan
resiko morbiditas dan mortalitas KV
Tatalaksana Hipertensi harus dimulai sedini mungkin
Dokter sebagai motor pelayanan kesehatan Tingkat
Pertama memegang peranan penting dalam usaha
menurunkan angka morbiditas dan mortalitas
hipertensi melalui tatalaksana yang tepat sesuai
tingkat resikonya

Thank You

Case Presentation 1

Ny K, 61 th TB 160 cm/BB 55 kg (IMT

21.4=normoweight),hipertensi

tahun

(OAH tdk teratur ,saat ini komsumsi

Captopril 2x12.5 mg),DM 2 tahun

tdk

minum obat teratur, Creatinine 2.48 (Cr

Cl 20.7),EKG dbn, prot urine +3 .
saat ini datang dengan TD 150/90 mmhg

1. Tatalaksana awal yang dipilih :

a. Re evaluasi lagi diagnosis hipertensi
b. Re evaluasi derajat resiko KV
c. teruskan captopril dengan dosis
yang sama
d. Lanjut Captopril dengan dosis
menjadi 3x25 mg
e. Mulai terapi kombinasi

2.

Target tekanan darah yang diinginkan pada

pasien tersebut :
a. Sistolik < 150/90 mmhg
b. Sistolik < 140/90 mmhg
c. Sistolik < 130/80 mmhg
d. Sistolik <120 /80mmhg
e. The lower, The better