HIPERTEN

SI
Kepaniteraan Klinik Ilmu Penyakit Dalam
Fakultas Kedokteran Universitas Kristen Indonesia
25 Februari – 4 Mei 2019
Jakarta
FAKTOR KOMPLIKASI PENYAKIT KARDIOVASKULAR

• Hipertensi
• Usia (laki-laki >55 tahun, wanita > 65 tahun)
• Diabetes mellitus
• Kolestrol total/LDL meningkat atau HDL rendah
• LFG <60 mL/menit
• Riwayat keluarga dengan kematian
kardiovaskular premature
• Mikroalbuminuria
• Obesitas (IMT lebih dari sama dengan 30 kg/m2)
• Inaktivitas fisik
• Merokok
HIPERTENSI ?
DEFINISI HIPERTENSI
“Hipertensi atau tekanan darah tinggi adalah
peningkatan tekanan darah sistolik lebih dari 140 mmHg
dan tekanan darah diastolik lebih dari 90 mmHg pada
dua kali pengukuran dengan selang waktu lima menit
dalam keadaan cukup istirahat/tenang.”
Departemen Kesehatan

“High blood pressure (also referred to as HBP, or

hypertension) is when your blood pressure, the force of
blood flowing through your blood vessels, is consistently too
high.”
American Heart Association
DEFINISI HIPERTENSI
Tekanan darah harus persisten diatas atau sama dengan
140/90 mmHg –> bukan siklus sirkardian!

Isolated systolic hypertension?

Isolated diastolic hypertension?
White coat hypertension?
Sustained hypertension?
Hipertensi resisten?
KLASIFIKASI HIPERTENSI
FAKTOR RISIKO HIPERTENSI

• Obesitas
• Sindroma metabolik (dislipidemia, diabetes
mellitus)
• Kenaikan berat badan
• Usia lebih dari 60 tahun
• Lifestyle (merokok, asupan garam, alcohol, stress,
kurang olahraga)
• Seks (pria atau wanita pascamenopause)
• Riwayat keluarga dengan penyakit kardiovaskular
PATOFISIOLOGI HIPERTENSI
SISTEM RENIN -
ANGIOTENSIN -
ALDOSTERON
PERAN DINDING VASKULAR PEMBULUH
DARAH
Faktor risiko Kerusakan Remodelling
+ Faktor vaskular vaskular
genetik

Inflamasi Ruptur
plak/erosi

Vasokosntriksi Trombosis
 PENCEGAHAN
Pencegahan primer: mengobati faktor risiko
Pencegahan sekunder
 Mengobati kelainan hemodinamik dengan bantuan antihipertensi
dengan monoterapi maupun kombinasi yang disesuaikan dengan
indikasi sebagai berikut:
 1. Penurunan tekanan darah sampai 140/90 mmHg pada semua
penderita hipertensi yang tidak berkomplikasi
 2. Penurunan tekanan darah sampai 130/80 mmHg pada penderita
diabetes dan PGK
 3. Penurunan tekanan darah sampai 125/75 mmHg pada penderita
proteinuria >1 g/hari
Pencegahan tersier: mengobati kerusakan target organ
JENIS HIPERTENSI
Primary Hypertension:
juga dikenal sebagai hipertensi esensial. Hipertensi disebut
primer bila penyebabnya tidak diketahui (90%).

Secondary Hypertension:
Hipertensi yang terjadi akibat penyebab yang jelas (10%).
Penyebabnya adalah penyakit, obat obatan, serta makanan.
DIAGNOSIS
ANAMNESIS
1. Lama menderita hipertensi dan derajat tekanan darah
2. Indikasi hipertensi sekunder
Penyakit ginjal, ISK, hematuria, pemakaian obat-obat analgesik,
feokromositoma, aldosteronisme
3. Faktor-faktor risiko
Riwayat hipertensi atau kardiovaskular, riwayat hyperlipidemia,
riwayat DM, kebiasaan merokok, pola makanan, kegemukan,
intensitas olahraga
4. Gejala kerusakan organ
5. Pengobatan anti hipertensi sebelumnya
6. Faktor pribadi, keluarga dan lingkungan
DIAGNOSIS

 Riwayat penyakit dahulu

 Pemeriksaan fisik
 Pemeriksaan laboratorium
rutin
 Pemeriksaan penunjang
lainnya
RIWAYAT PENYAKIT
· Durasi dan klasifikasi hipertensi
· Riwayat penyakit kardiovaskular
· Riwayat penyakit keluarga
· Gejala yang menunjukkan penyebab hipertensi
· Faktor gaya hidup
· Obat-obatan saat ini dan sebelumnya
 PEMERIKSAAN FISIK
· Pembacaan tekanan darah (dua kali atau lebih)
· Verifikasi di lengan kontralateral
· Tinggi badan, berat badan, dan lingkar pinggang
· Pemeriksaan funduskopi
· Pemeriksaan leher, jantung, paru-paru, perut, dan ekstremitas
· Penilaian neurologis
PEMERIKSAAN LABORATORIUM

· Hitung darah lengkap

· Kimia darah (kalium, natrium, kreatinin, dan glukosa
puasa)
· Profil lipid (kolesterol total dan kolesterol HDL)
· Elektrokardiogram 12-lead
 PENYEBAB HIPERTENSI

 Renovascular disease  Primary aldosteronism

 Renal parenchymal disease  Cushing syndrome
 Polycystic kidneys  Hyperparathyroidism
 Aortic coarction  Exogenous causes
 Pheochromocytoma
 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
 TARGET PENGOBATAN

Blood Pressure
Stages (mmHg) Risk Group A Risk Group B Risk Group C
High-normal Lifestyle modification Lifestyle modification Drug therapy
(130-139/85-89) Lifestyle modification

Stage 1 Lifestyle modification Lifestyle modification Drug therapy

(140-159/90-99) (up to 12 months) (up to 6 months)** Lifestyle modification

Stages 2 and 3 Drug therapy Drug therapy Drug therapy

(≥160/ ≥ 100) Lifestyle modification Lifestyle modification Lifestyle modification

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 and

Management
 Lose weight if overweight
 Limit alcohol intake
 Increase aerobic physical activity
 Reduce sodium intake
 Maintain adequate intake of
Potassium
Cardiovascular Health
 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

 β – 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 Adrenergic Inhibitors
Nitroprusside  Labetalol
Nicardipine  Esmolol
Fenoldopam  Phentolamine
Nitroglycerin
Enalaprilat
Hydralazine
ALGORITHM FOR TREATMENT OF
HYPERTENSION
( JNC VII)
 Lifestyle Modifications
(JNC VII)
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for patiens with diabetes or chronic kidney disease

Initial Drug Choices

Without Compelling With Compelling Indication

Indication

Stage 1 Stage 2 Drug(S) for the

compelling indications
Hypertension Hypertension (se table *
(SBP 140-159 or DBP (SBP >=160 or DBP
90-99 mmHg >=100 mmHg
Other antihypertensive
drugs ( diuretics, ACEI,
Thiazide -type diuretc To-drug combination for ARB, BB, CCB) as
for most. May consider most (usually thiazide - needed
ACEI, ARB, BB, CCB, type diuretic and ACEI
or combination 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

DBP, diastolic blood pressure, SBP, systolic blood pressure

Drug abbreviations: ACEI= angiotensin converting enzyme inhibitor; ARB=,angiotensin
receptor blocker; BB= beta-blocker; CCB= calcium channel blocker.
 ALGORITHM FOR TREATMENT OF
HYPERTENSION (CONTINUED)

Begin or Continue Lifestyle Modifications

Lose weight  Maintain potassium

Limit alcohol  Maintain calsium and magnesium
Increase physical activity  Stop Smoking
Reduce sodium  Reduce saturated fat cholesterol

Not at Goal Blood Pressure

 SPECIFIC DRUG INDICATIONS

Some antihypertensive drugs may have favourable

affects on co-morbid conditions :
Heart failure
Angina - Carvedilol
- -blockers - Losartan
- Calcium antagonists • Myocardial infarction
- Diltiazem
Atrial tachycardia and
- Verapamil
fibrillation
- -blockers
- 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
Prostatism (benign prostatic
hyperplasia)
- α -blockers
Renal insufficiency (caution
in renovascular hypertensio
and creatinine > 3 mg/dl [>
265. Ųmol/L])
- ACE inhibitors

Dyslipidemia
- α -blockers
TERIMA
KASIH