Hypertension

dr. Isbandiyah, SpPD

FK UMM
Blood Pressure
Classification(JNC7)
BP Classification SBP mmHg DBP mmHg

Normal <120 and <80

Prehypertension 120–139 or 80–89
Stage 1 140–159 or 90–99
Hypertension
Stage 2 >160 or >100
Hypertension
Etiology
• Essential (95%)
• Secondary – about 5%-10% of cases
- Renal : renal artery stenosis ; parenchymal disease
- Endocrine : Pheochromocytoma;
Hyperaldosteronism; hyperthyroidsm ; Cushing syndr;
Exogenous agent
- Vascular: Coarctation of aorta, Aortic insufficiency
- Toxemia of pregnancy
Causes of secundary hypertension
• Primary renal disease
• Oral contraceptives
• Pheochromocytoma (about one-half of px have
paroxysmal hypertension)
• Primary hyperaldosteronism (triad of hypertension,
unexplained hypokalemia, metabolic alkalosis)
• Renovascular disease
• Chusing syndrome
• Hyperthyroid, hyperparathyroid
• Sleep apnea syndrome
• Coartation of the aorta
Risk factors
• Race (more common and more severe in blacks)
• Age > 60 years
• Sex (men and postmenopausal women)
• Family history of CVD
• Smoking
• High cholesterol diet
• Co-existing disorders such as DM, obesity, and
hyperlipidemia
• Sodium intake
• High intake of alcohol
 Bahan-
Asupan Jumlah
Perubahan bahan yang
garam nefron Stress Obesitas
genetis berasal dari
berlebih berkurang
endotel

Aktivitas
Retensi Penurunan Renin Perubahan
berlebih Hiper-
natrium permukaan angiotensin membran
saraf insulinesmia
ginjal filtrasi berlebih sel
simpatis

↑ Volume Konstriksi
cairan vena

Konstriksi Hipertrofi
↑ Preload ↑ Kontraktilitas struktural
fungsionil

TEKANAN TAHANAN
=
CURAH
DARAH JANTUNG X PERIFER

Hipertensi ↑ curah jantung ↑ tahanan perifer

Autoregulasi
Standard work-up

Conformation of real hypertension

Identify Etiology of H/T
Access of End-organ damage
Identify cardiovascular risk
History
Onset of hypertension; Drug history; Family
History; Other major cardiovascular risk factors;
major target organ complications; Exogenous
agents
(e.g. oral pills, Licorice)
History
Hisory of flank pain, hematuria, history of renal trauma
-> Renovascular hyprertension;
History of proteinuria, pyelitis of pregnancy, renal
stones, dysuria, fever, or chill -> Parenchymal
renal disease as a cause of hypertension;
History of headache, sweating, palpitations, tachycardia,
thoracic and epigastric distress, and weight loss ….
Pheochromocytoma;
Heat intolerance and loss of weight ……
Hyperthyroidism,
History of weakness, paralysis, tetany, paresthesia,
polyuria… primary aldosteronism.
Physical Examination
General apperance : eg .Cushing syndrome
Serial blood pressure determinations
Blood pressure in both arms
Funduscopic examination :arteriovenous nicking , hemorrhage,
Exudates
Palpation of thyroid
Auscultation
Lungs for wheezing and rales
Cardiac: heart beat; S3 ,S4 murmur , PMI , thrill ….
Abdominal and cervical ( check bruit )
Palpation of pulses, especially femoral artery :delayed pulse and
decrease pressure -> coarctation
Laboratory test
Routine screen ,including CBC ,biochemistry
Urinalysis : albumin , microalbumin
Serum potassium , Calcium ,Creatinine
Thyroid function , Cortisol level
Cholesterol , TG
EKG
Chest X-Ray
Catecholamines only in presence of diastolic pressure >110 mmHg in
patient younger than 30
Echocardiography
Target organ damage
• Heart
– Left ventricular hypertrophy
– Angina or prior myocardial infarction
– Prior coronary revasculariztion
• Brain
– Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy
CVD Risk Factors

• HTN • Inactivity
• Obesity • Age:
• Hyperlipidemia >55 in men
>65 in women
• Diabetes
• Fam history of
• Cigarette premature CVD
Smoking
Complications

• Cerebrovascular disease: tromboembolic,

intracranial bleeding, TIA
• Cardiovascular disease: MI, HF, CAD
• LVH: enhanced incidence of HF,
ventricular arrythmia, sudden cardiac
death
• Periveral vascular disease
• Renal failure
Goals of Therapy

• Reduce CVD and renal morbidity and

mortality

 Treat to BP <140/90 mmHg or BP

<130/80 mmHg in patients
with diabetes or chronic kidney disease.
• Achieve SBP goal especially in persons 50
years of age
 JNC 7: Treatment Algorithm for Hypertension
Lifestyle modifications

Not at goal blood pressure (<140/90 mm Hg)

(<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial drug choices

Without compelling indications With compelling indications

Stage 1 hypertension Stage 2 hypertension Drugs for compelling indications

(SBP 140–159 or DBP 90–99 mm Hg) (SBP 160 or DBP 100 mm Hg) Other antihypertensive drugs
Thiazide-type diuretic for most. Two-drug combination for most (diuretic, ACEI, ARB, BB, CCB) as
May consider ACEI, ARB, BB, CCB, (usually thiazide-type diuretic and needed.
or combination. 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.

SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin-

converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=b-blocker;
CCB=calcium channel blocker
JNC 7. May 2003. NIH publication 03-5233.
 JNC 7: Classification and Management
of Blood Pressure for Adults
Initial Drug Therapy
BP SBP* DBP* Lifestyle Without With
Classificatio (mm (mm Modificati Compelling Compelling
n Hg) Hg) on Indications Indications
Normal <120 and <80 Encourage Drug(s) for
Prehypertens or 80– No antihypertensive compelling
120–139 Yes
ion 89 drug indicated. indications.
Thiazide-type
diuretic Drug(s) for
Stage 1 or 90– for most. May compelling
140–159 Yes indications.
hypertension 99 consider ACEI, ARB,
BB, CCB,
or combination.
Two-drug Other
combination antihypertensive
Stage 2 for most (usually drugs (diuretic,
160 or 100 Yes
hypertension thiazide-type diuretic ACEI, ARB, BB,
and ACEI or ARB or CCB) as needed.
BB or CCB).

JNC 7. May 2003. NIH publication 03-5233.

Compelling Indications
• Heart Failure:  Thiazide/loop, BB, ACEi, ARB,
Aldosterone antagonist
• Post- MI:  BB, ACE, Aldosterone antagonist
• High CVD risk:  Thiazide, BB, ACE, Ca channel
• DM: blocker
 Thiazide, BB, ACE, ARB, CCB
• CRF
– Cr > 1.5 in men  ACE, ARB. For creatinine 2-3 try
loop diuretic
– Cr > 1.3 in women
• S/P CVA
 Thiazide, ACE inhibitor
 Lifestyle Modifications to Manage HTN
Modification Recommendations Approximate Systolic
Blood Pressure
Reduction
Weight Reduction Maintain normal body 5-20 mm Hg for each
weight (BMI 18.5-24.9) 10 kg weight loss

Adapt eating plan Consume diets rich in fruits, 8-14 mm Hg

vegetables, low fat dairy
and low saturated fat
Dietary sodium reduction Reduce sodium to no more 2-8 mm Hg
than 2.4 g/day sodium or
6 g/day NaCl
Increase physical activity Engage in regular aerobic 4-9 mm Hg
activity such as walking
(30 min/day on most days)
Moderate alcohol consumption Limit alcohol to no more 2-4 mm Hg
than 2 drinks/d for men and
1 drinks/day for women.
Source: The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.
Factors affecting choice of
antihypertensive drug

• The cardiovascular risk profile

• Coexisting disorders
• Target organ damage
• Interactions with other drugs
• Tolerability of the drug
• Cost of the drug
Antihypertensive drug strategies
• Reduce cardiac output
– β-adrenergic blockers
– Ca-channel blockers
• Dilate resistance vessels
– Ca-channel blockers
– Renin-angiotensin system blockers
– Α1 adrenoreceptor blockers
– Nitrates
• Reduce vascular volume
– Diuretics
– Direct vasodilators
TIPS on drugs for HT
• CCB OK for isolated systolic hypertension
(ISH)
• For DM: ACEi or ARB with or without
diuretic, then add BB or CCB
• When ACEi causes cough, substitute ARB
• Don’t use short acting CCB (increases
deaths due to arrhythmias).
• Alpha blockers (e.g. clonidine) only as
second line (more side effects).
 Thiazides

• Chlorothiazide (Diuril)
• Chlorthalidone
• Hydrochlorthiazide(Microzide,
Hydrodiuril)
• Polythiazide (Renese)
• Indapamide (Lozol)
• Metolazone (Mykrox,
Zaroxolyn)

*All trade / brand / generic names are specific to the USA

 Loop Diuretics

• Bumetanide (Bumex)
• Furosemide (Lasix)
• Torsemide (Demadex)

Potassium-sparing Diuretics
•Amiloride (Midamor)
•Triamterene (Dyrenium)
*All trade / brand / generic names are specific to the USA
 Aldosterone Receptor Blockers

• Eplerone (Inspra)
• Spironolactone (Aldactone)

Combined alpha- and beta- blockers

•Carvedilol (Coreg)
•Labetalol (Normodyne, Trandate)

*All trade / brand / generic names are specific to the USA

 Beta-blockers
• Atenolol (Tenormin)
• Betaxolol (Kerlone)
• Bisoprolol (Zebeta)
• Metoprolol (Lopressor,
Toprol
XL)
• Nadolol (Corgard)
• Propranolol (Inderal/XL)
• Timolol (Blocadren)
*All trade / brand / generic names are specific to the USA
 ACE inhibitors
• Benzapril (Lotensin)
• Captopril (Capoten)
• Enalpril (Vasotec)
• Fosinopril (Monopril)
• Lisinopril (Prinivil, Zestril)
• Moexipril (Univasc)
• Perindopril (Aceon)
• Quinapril (Accupril)
• Ramipril (Altace)
• Trandolapril (Mavik)

*All trade / brand / generic names are specific to the USA

 Angiotensin II Receptor Blockers

• Candesartan (Atacand)
• Eprosartan (Tevetan)
• Irbesartan (Avapro)
• Losartan (Cozaar)
• Olmesartan (Benicar)
• Telmisartan (Micardis)
• Valsartan (Diovan)

*All trade / brand / generic names are specific to the USA

 Calcium channel blockers
• Dihydropyridines
– Amlodipine (Norvasc)
– Felodipine
(Plendil)
– Isradipine
(Dynacirc CR)
– Nicardipine (Cardene
SR)
– Nifedipine (Adalat
CC, Procardia XL)
– Nisoldipine (Sular)
• DHPs can have negative inotropic effects, unlike non-DHPs,
so use with caution in pts with impaired cardiac function
 Calcium channel blockers
• non-Dihydropyridines:
– Diltiazem (Cardizem
CD, Dilacor XR, Tiazac,
Cardizem LA)
– Verapamil (Calan SR,
Isoptin SR)

*All trade / brand / generic names are specific to the USA

• DHPs can have negative inotropic effects, unlike non-DHPs,

so use with caution in pts with impaired cardiac function
 Alpha1 blockers
• Doxazosin (Cardura)
• Prazosin (Minipress)
• Terazosin (Hytrin)

*All trade / brand / generic names are specific to the USA

 Direct Vasodilators

• Hydralazine (Apresoline)
• Minoxidil (Loniten)

*All trade / brand / generic names are specific to the USA

 Centrally acting drugs

• Clonidine (Catapres)
• Methyldopa (Aldomet)
• Reserpine (generic)
• Guanfacine (generic)

*All trade / brand / generic names are specific to the USA

 Again: Treatment Algorithm

Lifestyle Modification

Not at goal BP

Initial Drug Choices

W/O Compelling Indications With Compelling Indications

Stage 1 Stage 2 Drug for Indication

Thiaz, ACE, ARB, BB, CCB 2 Drug Combo Not at Goal BP

Adjust Dose or add additional agents

KRISIS HIPERTENSI
Tabel I : Hipertensi emergensi ( darurat ) Tabel II : Hipertensi urgensi (
mendesak )
TD Diastolik > 120 mmHg disertai dengan satu
atau lebih kondisi akut. Hipertensi berat dengan TD Diastolik
• Pendarahan intra cranial, trombotik CVA atau > 120 mmHg, tetapi dengan
pendarahan subarakhnoid. minimal atau tanpa kerusakan organ
•Hipertensi ensefalopati. sasaran dan tidak dijumpai keadaan
• Aorta diseksi akut. pada tabel I.
• Oedema paru akut. 􀂙 Hipertensi post operasi.
• Eklampsi. 􀂙 Hipertensi tak terkontrol /
• Insufisiensi ginjal akut. tanpa diobati pada perioperatif.
• Infark miokard akut, angina unstable.
• Sindroma kelebihan Katekholamin
- Sindrome withdrawal obat anti hipertensi.
- Cedera kepala.
- Luka bakar.
- Interaksi obat.
 Klasifikasi
Kelompok Biasa Mendesak Darurat
Tekanan darah >180/110 >180/110 >220/140
Gejala -, kadang2 sakit Sakit kepala Sesak nafas, nyeri
kepala dan gelisah hebat, dan sesak dada, kacau gangguan
nafas kesadaran

Pmx fisik Organ target (-) Gangguan organ Ensefalopati, edema

target minimal paru, gangguan fungsi
ginjal, CVA, iskemia
jantung

Pengobatan Awasi 1-3 jam Awasi 3-6 jam Pasang IV, Pmx Lab,
mulai/teruskan obat obat oral dg terapi lewat IV
oral, naikkan dosis jangka kerja
pendek
Rencana Periksa ulang dalam Periksa ulang Rawat ruangan /ICU
3 hari dalam waktu 24
jam
Buku Ajar Ilmu Penyakit Dalan jilid II
 Obat hipertensi oral yang sering digunakan di
Indonesia
Obat Dosisi Efek Lama Efek
kerja samping
Nifedipin 5- Diulang 15 5-15 4-6 jam Gangguan koroner
10 mg menit menit

Kaptopril Diulang ½ 15-30 6-8 jam Stenosis a.renalis

12,5-25mg jam menit

Klonidin 75- Diulang/jam 30-60 8-16 jam Mulut kering.

150 mg menit Ngantuk

Propanolol Diulang 15-30 3-6 jam Bronkokonstriksi,

10-40 mg setiap ½ jam menit Blok jantung.

Buku Ajar Ilmu Penyakit Dalan jilid II