HIPERTENSI

Dr. Sahala Panggabean, SpPD

Bagian Ilmu Penyakit Dalam
FK UKI

Autoregulation
BLOOD PRESSURE
Hypertension

= CARDIAC OUTPUT
= Increased CO

Preload

x
and/or

Contractility

PERIPHERAL RESISTANCE
Increaced PR

Functional
Constriction

Fluid
Volume

hypertrophy

Volume
Redistribution

Renal
Sodium
Retension

Decreased
filtration
surface

Sympathetic
nervous overactivity

ReninAngiostensin
Excess

Cell
Membran
Alteration

Stress
Excess
Sodium
Intake

Structural

Hyper
Insulinemia

Obesity

Genetic
Alteration

Genetic
Alteration
factors

Endothelium
derived

Classification of
Blood Pressure for Adults (JNC VI)
Category

Optimal
Normal
High-normal
Hypertension
Stage 1
Stage 2
Stage 3

SBP
(mm Hg)

DBP
(mm Hg)

< 120
<130
130-139

And
And
Or

< 80
< 85
85-89

140-159
160-179
180

Or
Or
Or

90-99
100-109
110

When SBP and DBP fall into different categories, use the higher
category

Classification and management

of blood pressure for adults
(JNC VII)
INITIAL GRUG THERAPY

BP
Classification

SBp*
mmHg

DBp*
mmHg

Lifestyle
MODIFICATION

Without Compelling
Indication

With Compelling
indication

Normal

<120

And
<80

Encourage

Prehypertension

120139

Or 8089

Yes

No Antihypertension
Drug indicated

Drug(s) for comppelling

indication

Stage 1
Prehypertension

140159

Or 9099

Yes

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

Or
>100

Yes

Two drug
combination for most
(usually Thiazidetype diuretics an
ACEI or ARB or BB
or CCB)

Drug(s) for the

compelling indications
Other antihypertensive
drugs (diuratics, ACEI,
ARB, BB, CCB) as
needed

Stage 2
Prehypertension

>160

DBP* diagnostic blood pressure, SBP* systotic blood pressure

Drug abbreviations :ACEL, angiotension converting enxyme inhibitor. ARBN, Angiotension receptor blocker. BB beta-blocker.
CCB, calcium chanel blocker.

Evaluation Objectives
To identify know causes
To assess presence or absence of
target organ damage and cardiovascular
disease
To identify other risk factors or disorders
that might guide treatment

Evaluation Components

Medical history
Physical examination
Routine laboratory tests
Optional tests

MEDICAL HISTORY

Duration and classification of hypertension

Patient history of cardiovascular disease
Family history
Symptoms suggesting causes of hypertension
Lifestyle factors
Current and previous medications

Physical Examination
Blood pressure readings (two or more)
Verification in contralateral arm.
Height, weight, and waist circumference
Funduscopic examination
Examination of the neck, heart, lungs,
abdomen, and extremities
Neurological assessment

Laboratory Tests and Other

Diagnostic Procedure
Determine presence of target organ
damage and other risk factors
Seek specific causes of hypertension

Laboratory Tests Recommended

Before Initiating Therapy
Urinalysis
Complete blood count
Blood chemistry: potassium, sodium,
creatinine, and fasting glucose
Lipid profile: total cholesterol and HDL
cholesterol
12-lead electrocardiogram

Examples of Identifiable
Causes of Hypertension
Renovascular disease
Renal parenchymal
disease
Polycystic kidneys
Aortic coarction
Pheochromocytoma

Primary aldosteronism
Cushing syndrome
Hyperparathyroidism
Exogenous causes

Stratification of Risk Factors

on Patients with Hypertension
Major Risk Factors:
Smoking
Dyslipidemia
Diabetes mellitus
Age older than 60 years
Sex (men or
postmenopausal women)
Family history of
cardiovascular disease

Clinical Risk Factors:

* Heart diseases
* Stroke or TIA
* Nephropathy
* Peripheral arterial disease
* Retinopathy

Risk Stratification
Risk Group A

No risk factors
No target organ disease/clinical cardiovascular disease

Risk Group B

At least one risk factor, not including diabetes

No target organ disease/clinical cardiovascular disease

Risk Group C

Target organ disease /clinical cardiovascular disease and/or

diabetes.
With or without other risk factors

Treatment Strategies and

Risk Stratification
Blood Pressure
Stages (mmHg) Risk Group A

Risk Group B

High-normal
(130-139/85-89)

Lifestyle modification

Lifestyle modification Drug therapy

Lifestyle modification

Stage 1
(140-159/90-99)

Lifestyle modification
(up to 12 months)

Lifestyle modification Drug therapy

(up to 6 months)**
Lifestyle modification

Stages 2 and 3
(160/ 100)

Drug therapy
Lifestyle modification

Drug therapy
Drug therapy
Lifestyle modification Lifestyle modification

Risk Group C

Or those with heart failure, renal insufficiency, or diabetes

For those with multiple risk factors, clinicians should consider drugs as initial Therapy plus lifestyle
modification

Goal of Hypertension
Prevention and Management

To reduce morbidity and mortality by the least

intrusive means possible. This may be
accomplished by :
- Achieving and maintaining SBP < 140 Hg
and DBP < 90 mm Hg.
- Controlling other cardiovascular risk factors.

Lifestyle Modifications
For Prevention and for Overall Cardiovascular
Health and Management

Lose weight if overweight

Limit alcohol intake
Increase aerobic physical
activity
Reduce sodium intake
Maintain adequate intake of
Potassium

Maintain adequate intake of

calcium and magnesium
Stop Smoking
Reduce dietary saturated fat
and cholesterol

Pharmacologic Treatment
Decreases cardiovascular morbidity and
mortality based on randomised controlled
trials
Protects against stroke, coronary events,
heart failure, progression of renal disease,
progression to more severe hypertension,
and all-cause mortality

Special Considerations
In Selecting Drug Therapy

Demographics
Coexisting diseases and Therapies
Quality of life
Physiological and biochemical measurements
Drug interactions
Economic considerations

Drug Therapy
A low dose of initial drug should be used
slowly titrating upward.
Optimal formulation should provide 24-hour
efficacy with once-daily dose with at least
50% of peak effect remaining at end of 24
hours
Combination therapies may provide additional
efficacy with fewer adverse effects

Classes of
Antihypertensive Drugs

ACE inhibitors
Adrenergic inhibitors
Angiotensin II receptor blockers
Calcium antagonists
Direct vasodilators
Diuretics

Combination Therapies

adrenergic blockers and diuretics

ACE inhibitors and diuretics
Angiotensin II receptor antagonists and diuiretics
Calcium antagonists and ACE inhibitors
Other combinations

Followup
Follow up within 1 to 2 months after initiating therapy
Recognize that high-risk patients often require high
dose or combination therapies and shorter intervals
between changes in medications
Consider reasons for lack of responsiveness if blood
pressure is uncontrolled after reaching full dose
Consider reducing dose and number of agents after 1
year at or below goal.

Causes for inadequate Response

to Drug therapy

Pseudo resistance
Non adherence to therapy
Volume overload
Drug-related causes
Associated conditions
Identifiable cause of hypertension

Hypertensive Emergencies
and Urgencies
Emergencies require immediate blood pressure
reduction to prevent or limit target organ
damage
Urgencies benefit from reducing blood pressure
within a few hours
Elevated blood pressure alone rarely requires
emergency therapy
Fast-acting drugs are available.

Drugs avaiblable for

hypertensive emergencies
Vasodilators :
Nitroprusside
Nicardipine
Fenoldopam
Nitroglycerin
Enalaprilat
Hydralazine

Adrenergic Inhibitors :

Labetalol
Esmolol
Phentolamine

Algorithm for Treatment of

Hypertension (continued)
Initial Drug Choices *
Compelling Indications
* Heart failure
- ACE inhibitors
- Diuretics
* Mycardial infarction
- -blockrs (non-ISA)
- ACE inhibitors (with systolic dysfunction)
* Diabetes Mellitus (Type 1) with proteinuria
- ACE inhibitors
* Isolated systolic hypertension (older persons)
- Diuretics preffered
- Long-acting dihydropyridine calcium antagonists

* Based on randomizet controlled trials

Specific Drug Indications

Some antihypertensive drugs may have
favourable affects on co-morbid conditions :
Heart failure

Angina
- Carvedilol
- -blockers
- Losartan
- Calcium antagonists
Atrial tachycardia and fibrillation Myocardial infarction
- Diltiazem
- -blockers
- Verapamil
- Nondihydropyridine Calcium
antagonists

Specific Indications (continued)

Some antihypertensive drugs may have favourable
affects on co-morbid conditions :
Cyclorsporine-induced
hypertension
- Calcium antagonists

Diabetes mellitus (1 and 2)

with proteinuria
- ACE Inhibitos (preferred)
- Calcium antagonists

Diabetes mellitus (type 2)

- Low-dose diuretics

Dyslipidemia
- -blockers

Prostatism (benign prostatic

hyperplasia)
- -blockers
Renal insufficiency (caution
in renovascular hypertensio
and creatinine > 3 mg/dl [>
265. mol/L])
- ACE inhibitors