PENATALAKSANAAN HIPERTENSI

TERKINI :
FOKUS PADA JNC 8

WACHID PUTRANTO
Divisi Ginjal Hipertensi
Fakultas Kedokteran UNS/RS.Dr. Moewardi
Surakarta
 HIPERTENSI

Suatu keadaan klinis dimana tekanan

darah seseorang lebih tinggi
daripada tekanan darah normal

Epidemiologi :
Jumlah penderita hipertensi di seluruh
dunia :
1 milyar
USA : 65 juta
Indonesia ? : belum ada data resmi
Conlin PR, Int J Clin Pract 2005; 59(2):214-
24
Prevalensi Hipertensi

prevalence of hypertension (%)

70
SBP > 140 mm Hg 65
60DBP > 90 mm Hg 64

50 54
44
40

30
21
20
4 11
10

0
age (yrs)18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

 Hypertension complication

Eyes Brain Target Organ damage!!

retinopathy stroke

Damages depend on:

Heart
ischaemic heart disease
How high of the blood
Kidneys left ventricular hypertrophy pressures
renal failure heart failure
How long the
uncontrolled and
untreated high blood
presure
Peripheral arterial disease
Blood Pressure Reduction Of 2
mmHg Reduces The Risk Of CV
Events by 710%
Meta-analysis of 61 prospective, observational
studies
1 million adults
12.7 million person-years 7% reduction
2 mmHg in risk of
ischaemic
decrease heart disease
in mean mortality
SBP 10% reduction
in risk of stroke
mortality

Lewington et al. Lancet 2002;360:190313

 JNC A A /
D
A AH C

NI
AC

C
ASH/I

E
SH
NH
LBI HYPERTENSION
GUIDELINES IS
H IB

ES C
JS H TN da NKF
H a
a n
C
 CLASSIFICATION BP SBP DBP
HYPERTENSION Optimal <120 and <80
BP SBP DBP Normal 120-129
and./o80-84
Norma <120 and <80 High r
130-139 85-89
l
ES 90-99
or Normal
Pre HT 120- or 80-89 HT stg 1 140-159
139 C100-109
Stg J1N
or HT stg 2 160-179
C7 140-
159
90-99
HT stg 3 180 110

Stg 2 160 100 ISH 140 and <90

BP SBP DBP
Optimal <120 and <80
JNC 8
Normal
C 6<130 and <85
High JN
Nml 130-139 or 85-89 No definition of HT
HT stg 1 140-159 or 90-99
HT stg 2 160-179 or 100-109
HT stg 3 180 or 110
Topic JNC 7
2014 Hypertension Guidelin
Methodology Non systematic literature review by Critical questions and review
criteria defined by expert
expert committee including a range panel with input from
methodology team
of study design Initial systematic review by
methodologist restricted to
Recommendation based on consensus RCT evidence
Subsequent review of RCT
evidence and recommendations
by the panel according to
a standardized protocol
Definitions Defined hypertension and prehypertension Definision of hypertension and
prehypertension not
addressed, but tresholds
for pharmacologic treatment
were defined
Treatments Separate treatmen goals defined for Similar treatment goals defined
for all hypertensive
Goals uncomplicated hypertension and for populations except when
evidence review supports
subsets with various comorbid condition different goals for a particular
subpopulation
Lifestyle Recommended lifestyle modifications Lifestyle recommendations
 Included a comprehensive table oral
Antihypertensive drugs including names
and usual dose ranges
Scope of topics Addressed multiple issues ( blood pressure Evidence review
of RCTS addressed a limited
measurements methods,patients evaluation number of
questions,those judge by the panel
components,secondary hypertension, to be of highest
priority
adherence to regimens,resistant hypertension,
and hypertension in special populations) based
on literature review and expert opinion
Review process Reviewed by the National High Blood pressure Reviewed by
experts including those affiliated
Prior to Education Program Coordinating Committee, with professional
and public organizations and
Publication a coalition of 39 major professional,public, and federal agencies;
no official sponsorship by any
voluntary organizations and 7 federal agencies organization
should be inferred
The Process
Literature review 1/1/1966
12/31/2009

Inclusion Criteria
(1) HTN
(2) 2000 participants
(3) multisenter
(4)Kriteria inklusi/eksklusi.

9
Recommendatio
ns
 Stron
g
Reco A
m-
mend
ation
Moderate
Recommendation
B

Weak Recommendation C

D
Recommendation against

E
Expert Opinion

No Recommendation for or against N

 Strength of
Recommendation Recommendation
Recommendation 1
Populasi berusia 60 yrs,mulai Grade A
terapi farmakologi SBP150 mmHg,
DBP90 mmHg HYVET, Sys-Eur, SHEP,
JATOS, VALISH, CARDIO-
SIS
Corollary Recommendation
Populasi usia 60 yrs, jika terapi
farmakologi mengakibatkan Grade E
penurunan TD lebih rendah (<140/90)
dan pengobatan ditoleransi dengan
baik tanpa efek samping, teruskan
pengobatan. Usia ini TD <140 tidak
lebih baik disbanding 140-160
Recommendation 2
Populasi usia <60 yrs, terapi Grade A (30-59 yrs)
farmacologi bila DBP90 mmHg . Grade E (18-29 yrs)
Target DBP<90 mmHg HDFP, HT-Stroke
 Strength of
Recommendation Recommendation
Recommendation 3
Populasi usia <60 yrs, terapi Grade E
farmacologi bila SBP 140
mmHg.Target SBP<140 mmHg

Recommendation 4
Populasi usia 18 yrs dengan CKD,
terapi farmacologi bila SBP 140 Grade E
mmHg or DBP 90 mmHg . Target
SBP <140 mmHg dan DBP <90 AASK, MDRD, REIN-2
mmHg
Recommendation 5
Populasi usia 18 dengan DM, terapi Grade E
farmacologi bila SBP 140 mmHg
atau DBP 90 mmHg. Target SHEP, Syst-Eur, UKPDS,
SBP<140 and DBP <90 ACCORD, ADVANCE,
HOT
 Strength of
Recommendation Recommendation
Recommendation 6
Pada populasi non black , termasuk dg Grade B
DM, initial anti HTN treatment : a
thiazide type diuretic, CCB, ACEI or VA-cooperative, HDFP,
ARB SHEP

Recommendation 7
Populasi kulit hitam, termasuk dg DM, Grade B ( No DM)
initial anti HT: thiazide-type diuretic Grade C ( DM)
or CCB
ALLHAT
Recommendation 8
Populasi usia 18 dg CKD dan HTN, Grade B
initial (or add on) anti HTN : ACEI or
ARB utk memperbaiki kidney
outcomes. Tanpa melihat ras atau IDNT, AASK
status DM
 Recommendation Strength of
Recommendatio
n
Recommendation 9

Tujuan treatment HTN adalah untik

mencapai dan mempertahankan target BP
Jika target BP tidak tercapai dlm 1 bl,
naikkan dosis atau tambahkan 2nd 1 obat
dr rekomendasi 6 (thiazide-type diuretic,
CCB, ACEI, or ARB) Grade E
Jika target BP tidak tercapai dg 2 obat,
tambah dan titrasi obat 3rd . Do not use
an ACEI and an ARB together
Jika target BP tidak dapat tercapai dg obat-
obat pada recommendasi 6 krn
kontraindikasi atau butuh >3 obat, obat
antiHT dari kelas lain bias digunakan.
Referral kepada hypertension specialist
jika BP tidak tercapai atau untuk
 Strategies to Dose Antihypertensive Drugs
Strategie Description Details
s
A Mulai 1 obat naikan Jika target BP blm tercapai
sp dosis naikkan dosis obat 1 sp dosis
maksimum,kemudia maksimum sblm menambahkan
n tambahkan obat obat ke-2 dan ke-3.
ke-2
B Mulai 1 obat Tambahkan obat ke-2 sblm obat
kemudian 1 mencapai dosis maks.Jk Target
tambahkan obat ke- BP blm tercapai,tambahkan obat
2 sblm dosis ke-3 dan titrasi sp dosis maks.
maksimum
C Mulai dengan 2 obat Mulai dg 2 obat
(separate or single Bbrp committee
combination) merekomendasi:
2 obat SBP >160
dan/atau DBP >100, atau SBP
>20 mmHg diatas target
dan/atau DBP >10 mmHg
Lifestyle Modification
JNC
8
JNC
7
 Guideli Populatio Goal Initial drugs
G
U ne n BP
I 2014 HT General 60 <150/90 Non Black: thiazide type
D y diuretic, ACEI, ARB or ARB
E Guidelin
<140/90 Black: thiazide type-diuretic or
L e General <60 <140/90 CCB
I
y Thiazide type diuretic, ACEI,
N
E DM <140/90 ARB or CCB
ACEI or ARB
C CKD
0 ESH/ESC General (non <140/90 Bocker, diuretic, CCB, ACEI, ARB
M elderly)
P General <150/90
A elderly <80
y <150/90
R General 80 <140/85 ACEI or ARB
I y <140/90 ACEI or ARB
S DM
O CKD (no <130/90
N proteinemia)
CKD +
proteinemia
GOAL BP
INITIAL TX CHEP General <80 y <140/90 Thiazide, Blocker (<60y), ACEI
(nonblack) or ARB
Guidelin Population Goal BP Initial drugs
e
ADA DM <140/80 ACEI or ARB
KDIGO DM and 140/90 ACEI or ARB
CKD alb exc
<30 mg/d
DM and 130/80
CKD alb
exc >30
mg/d
NICE General <80 y <140/90 <55 y; ACEI or ARB
General 80 y <150/90 55 y or black; CCB
ISHIB Black, lower <135/85 Diuretic or CCB
risk <130/80
TOD or CVD
risk
JNC 7 General <140/90
CKD <130/80 ACEI or ARB
DM <130/80
 Important Variables For HTN
Recommendations
BP NICE ESC/ES ASH/I AHA/A JNC 7 JNC 8
H SH CC/CD
C
Definitio 140/90 140/90 140/9 140/9 Pre HT Not
120-139 or
n HTN and 0 0 80-89
addresse
daytime Stg 1 HT d
ABPM 140-159 or
135/85 90-99
Stg 2 HT
160 or
100

Drug th/ 160/10 140/90 140/9 140/9 140/90 <60 y,

in low 0 or 0 0 140/9
risk pts daytime 0
after ABPM 60 y,
non 150/95 150/9
pharm 0
th/
Blocker No Yes No No No No
st
 NICE ESH/ESC ASH/IS AHA/A JNC 7 JNC 8
H CC/CD
C
Diureti Chorthal Thiazides THZ THZ THZ THZ
c i-done (THZ), CTD CTD
(CTD) CTD IND IDP
Indapam ND
i-
de (IND)
Initiate Not Pts w/ 160/90 160/10 160/10 Not
th/ mentio- markedly 0 0 mention
with 2 ned elevated ed
drugs BP
BP <140/90 <140/90 <140/90 <140/90 <140/90 <160/90
target 80 y, Elderly 80 y, (<60 y)
<150/90 <80 SBP <150/90
140-150, 60 y,
in fit pts <150/90
SBP
<140
Elderly
80 y
SBP 140-
Under JNC 8, in all cases, targets BP should be
reached within a month of starting treatment either
by increasing the dose or by using a combination
drugs
In patients 60 yrs who do not have DM or CKD,
the goal BP level is <150/90 mm Hg

In pts 18 - 59 yrs without major comorbidities

target BP <140/90, and in patient 60 yrs without
DM, CKD, or both, the new goal BP is <150/90 mm
Hg

JNC 8 panel recommended thiazide-type diuretics

as initial therapy for most patients (include newly
diagnosed HTN)
 JNC 8 also recommend lifestyle interventions
include use of the DASH eating plan, weight loss,
reduction in sodium intake to <2.4 gr/day, and at
least 30 minutes of aerobic activity most days of the
week
Under the JNC 8 guidelines, patients would receive a
dosage adjustment and combinations of the 4 first-
line & later line therapies ACEI/ARB, CCB, and
thiazide-type diuretic
The JNC 8 does not recommend -blockers and -
blockers as 1st therapy due to 1 trial that showed a
higher rate of CV events with use of B compared
with use of an ARB, and another trial in which B
resulted in inferior CV outcomes compared with use
of a diuretic
When initiating therapy, patients of
African descent without CKD should use
CCBs and thiazides instead of ACE
inhibitors

ACE inhibitors and ARBs should not be used in

the same patient simultaneously
TERIMA KASIH