HIPERTENSI

DEFINISI

Blood pressure:

is the pressure of the blood against the walls of the

arteries.

results from two forces.

One is created by the heart as it pumps blood into the arteries

and through the circulatory system.
The other is the force of the arteries as they resist the blood
flow.

Tekanan darah

Systolic blood pressure is a measure of blood

pressure while the heart is beating

Diastolic pressure is a measure of blood pressure

while the heart is relaxed, between heartbeats.

TEKANAN DARAH

CARDIAC OUTPUT

RESISTENSI PERIFER

HIPERTENSI

Hypertension is defined by persistent elevation of

arterial blood pressure (BP).

The Seventh Report of the Joint National Committee
on the Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 7) classifies adult BP

isolated systolic hypertension: Patients with diastolic
blood pressure (DBP) values <90 mm Hg and
systolic blood pressure (SBP) values 140 mm Hg

A hypertensive crisis (BP >180/120 mm Hg) may be

categorized as either :

a hypertensive emergency (extreme BP elevation
with acute or progressing target organ damage) or

a hypertensive urgency (severe BP elevation without
acute or progressing target organ injury)

PREVALENSI DAN EPIDEMIOLOGI

Prevalensi nasional Hipertensi Pada Penduduk

Umur > 18 Tahun adalah sebesar 29,8%

31% penduduk Amerika mengalami hipertensi
140/90 mmHg

Tekanan darah akan meningkat dengan
bertambahnya usia (hipertensi banyak terjadi pada
lansia)

menurut WHO prevalensi hipertensi di dunia
33.6% pd thn 2006

ETIOLOGI

Hipertensi primer (90%): tidak diketahui

penyebabnya, hanya bisa dikontrol (faktor genetik)

Hipertensi sekunder (10%):

disfungsi ginjal, gagal ginjal kronis, penyakit thyroid, Cushing
syndrome

Obat: dekongestan, steroid, NSAID

Makanan: Natrium, etanol, tiramin

Multiple factors may contribute to the development

of primary hypertension, including:

Humoral abnormalities involving the renin-angiotensin-

aldosterone system, natriuretic Hormone, or

hyperinsulinemia;

A pathologic disturbance in the CNS, autonomic nerve
fibers, adrenergic receptors, or baroreceptors;

Abnormalities in either the renal or tissue autoregulatory
processes for sodium excretion, plasma volume, and
arteriolar constriction;

A deficiency in the local synthesis of vasodilating
substances in the vascular endothelium, such as
prostacyclin, bradykinin, and nitric oxide, or an increase in
production of vasoconstricting substances such as
angiotensin II and endothelin I;


A high sodium intake and increased circulating

natriuretic hormone inhibition of intracellular

sodium transport, resulting in increased vascular
reactivity and a rise in BP; and

Increased intracellular concentration of calcium,
leading to altered vascular smooth muscle function
and increased peripheral vascular resistance.

PATOFISIOLOGI

Malfungsi sistem renin-angiotensin-aldosteron

PATOPHYSIOLOGY

Renin is an enzyme secreted into the blood from

the kidneys

sensitive to changes in blood flow and blood
pressure

The primary stimulus for increased renin secretion
is decreased blood flow to the kidneys, which may
be caused by loss of sodium and water (as a result
of diarrhea, persistent vomiting, or excessive
perspiration)

Renin catalyzes the conversion of angiotensinogen
into angiotensin I

PATOPHYSIOLOGY

An enzyme in the serum called angiotensin-

converting enzyme (ACE) then converts

angiotensin I into angiotensin II

Angiotensin II acts via receptors in the adrenal
glands to stimulate the secretion of aldosterone:
which stimulates salt and water reabsorption by the
kidneys,

and the constriction of small arteries (arterioles), which
causes an increase in blood pressure.

Angiotensin II further constricts blood vessels

through its inhibitory actions on the reuptake into

nerve terminals of the hormone norepinephrine

JNC VII: Classification of blood pressure

Blood pressure
classification
Normal

Systolic BP
(mm Hg)

Diastolic BP
(mm Hg)

<120

or

<80

Prehypertension

120-139

or

80-89

Stage 1
hypertension

140-159

or

90-99

Stage 2
hypertension

160

or

100

The JNC VII. JAMA 2003;289:2560-72

JNC VII and ESH

ESC summary:
target blood pressure goals

Type of hypertension

BP goal (mmHg)

Uncomplicated

<140/90

Complicated
Diabetes mellitus

<130/80

Kidney disease

<130/80

Kaplan (Clinical Hypertension, 9th ed.,2006)

BP target is to lower BP below the threshold for
starting therapy

Chobanian et al. JAMA 2003;289:256072

Guidelines Committee. J Hypertens 2003;21:101153

KOMPLIKASI HIPERTENSI

Otak: stroke

Jantung: penyakit jantung koroner, gagal jantung

Mata: hipertensif retinopati

Ginjal : gagal ginjal (kreatinin tinggi, proteinuria)

Penyakit vaskular perifer: aneurisma

KOMPLIKASI

Risk of CV disease doubles with every 20/10 mm Hg

increase.

Even patients with prehypertension have an
increased risk of CV disease.

DIAGNOSIS

Silent killer

Pengukuran tekanan darah (sesuaikan dgn

klasifikasi tekanan darah JNC VII)

Evaluasi hipertensi

TERAPI

Nonfarmakologi

Farmakologi:

Tujuan: menurunkan mortalitas dan morbiditas yang
berhubungan dengan kerusakan hipertensi

Mortalitas dan morbiditas berkaitan dgn organ target spt:
kejadian kardiovaskular/serebrovaskular, gagal jantung,
penyakit ginjal

Terapi nonfarmakologi

Terapi Farmakologi

first-line options: Diuretic, ACE inhibitor, ARB,

and CCB

-Blockers may be used either to treat a
specific compelling indication or as combination
therapy with a primary antihypertensive agent for
patients without a compelling indication.

1-Blockers, direct renin inhibitors, central
2-agonists, peripheral adrenergic
antagonists, and direct arterial vasodilators
are alternatives that may be used in select patients
after primary agents.

Terapi farmakologi

Indikasi khusus

Gagal jantung: ACEI, diuretik, beta blocker, ARB

Pasca IM: beta blocker, ACEI

Penyakit iskemia jantung: beta blocker, CCB

Penyakit ginjal kronis: ACEI, ARB, diuretik loop

Penyakit serebrovaskular: ACEI dan diuretik tiazid


Wanita hamil: metil dopa, beta blocker, vasodilator

Preeklamsia: hidralazin iv, metil dopa

Hipertensi urgensi

Hipertensi emergensi

Algoritma terapi hipertensi

Oral antihypertensive drugs*

Class Drug (Trade Name) Usual dose range in mg/day (Daily Frequency)
ACE inhibitors
benazepril
captopril
enalapril
fosinopril
lisinopril
moexipril
perindopril
quinapril
ramipril
trandolapril

(Lotensin)
(Capoten)
(Vasotec)
(Monopril)
(Prinivil, Zestril)
(Univasc)
(Aceon)
(Accupril)
(Altace)
(Mavik)

Angiotensin II antagonists
candesartan
(Atacand)
eprosartan
(Tevetan)
irbesartan
(Avapro)
losartan
(Cozaar)
olmesartan
(Benicar)
telmisartan
(Micardis)
valsartan
(Diovan)

1040
25100
2.540
1040
1040
7.530
48
1040
2.520
14

832
400800
150300
25100
2040
2080
80320

(12)
(2)
(12)
(1)
(1)
(1)
(12)
(1)
(1)
(1)

(1)
(12)
(1)
(12)
(1)
(1)
(1)

Classification
Calcium Antagonists
Generation:
First
Second
Verapamil
Nifedipine
Diltiazem

Felodipine RTD
Isradipine CR
Verapamil SR
Nifedipine GITS
Diltiazem CD

J Clin Basic Cardiol 1999;2:155

Third

Latest

Amlodipine Lercanidipine
(hydrophilic) (lipophilic)

DIURETIK

Tiazid: HCT

Loop: furosemid

Hemat kalium: amilorid, triamteren

Antagonis aldosteron: spironolakton

ES diuretik tiazid, loop:

hipokalemia, hipomagnesia, hiperkalsemia,
hiperuriemia, hiperglikemia, hiperlipidemia, dan
disfungsi seksual

ACE Inhibitor

Menghambat angiotensin I menjadi angiotensin II

Angiotensin II adalah vasokonstriktor kuat dan jg

merangsang sekresi aldosteron

ACEI memblok degradasi bradikinin--
meningkatkan efek penurunan tekanan darah dan
ES batuk kering

Penyekat reseptor angiotensin II (ARB)

Efek angiotensin II: vasokonstriksi, pelepasan

aldosteron, aktivasi simpatik, pelepasan hormon

antidiuretik

Beta blocker

Adrenoseptor beta-1 dan beta-2 terdistribusi di seluruh tubuh

Beta -1:

terdapat banyak di jantung dan ginjal

Menaikkan denyut jantung, kotraktilits, pelepasan renin

Beta-2:

terdapat di paru-paru, liver, pankreas dan otot halus rteri

Sekresi insulin dan glikogenolisis

Bronkodilatasi dan vasodilatasi

Beta blocker:

Kardioselektif kecil kemungkinan terjadi spasme bronkus dan
vasokonstriksi (beta-1 blocker)

Beta-2 blocker: Vasokonstriksi dan spasme bronkus, hiperglikemia

Antihipertensi alternatif

Alfa 1 blocker

Prazosin, terazosin, doxazosin

Bekerja pada pembuluh darah perifr, menghambat

ambilan katekolamin pd sel otot halus menyebabkan

vasodilatasi dan menurunkan tekanan darah.

Menguntungkan utk laki-laki dgn BPH (benign
prostatic hyperplasia)--- memblok reseptor
postsinaptik alfa-1 adrenergik di tempat kapsul
prostat, menyebabkan relaksasi dan berkurang
hambatan keluarnya aliran urin.

Agonis alfa 2 central

Klonidin dan metil dopa

Menurunkan tekanan darah dengan merangsang

reseptor alfa- adrenergik di otak--menurunkan

aliran simpatetik dari pusat vasomotor di otak
(meningkatkan akt parasimpatetik) dan
menurunkan tonus vagal--- menurunkan denyut
jantung, cardiac output, resistensi perifer total, akt
plasma renin, dan reflex baroreseptor.

Klonidin utk hipertensi yang resisten obat pilihan
utama pada kehamilan

Reserpin
Mekanisme kerja:

Reserpin menurunkan tekanan darah dgn
mengosongkan norefinefrin dari ujung saraf
simpatetik dan memblok perjalanan NE ke granul
penyimpanannya.

Mengosongkan katekolamin dari otak dan
miokardium: sedasi, depresi dan berkurangnya
curah jantung

Reserpin

Mulai kerja dan waktu paruh lambat: dosis

pemberian 1x/hari.

Perlu 2-6 minggu efek antihipertensi terlihat

Dapat menyebabkan retensi natrium dan air perlu
kombinasi dgn diuretik (tiazid)

Hambatan akt simpatetik (meningkatkan akt
parasimpatetik) terlihat ES: hidung tersumbat,
sekresi asam lambung meningkat, diare, bradikardia

Vasodilator arteri langsung

Hidralazin, minoksidil

Mekanisme kerja:

relaksasi langsung otot polos arteriolar tetapi tdk
menyebabkan vasodilatasi ke pembuluh darah vena.

Penurunn tekanan perfusi yg kuat mengaktifkan
refleks baroreseptor menyebabkan aliran simpatetik
meningkat -- meningkatkan denyut jantung, curah
jantung dan pelepasan renin ---takifilaksis, efek
hipotensi akan hilang dgn pemakaian seterusnya.
Efek ini dpt diatasi dgn penggunaan beta blocker
bersamaan.

Interaksi obat

Studi kasus

L.N. is a 49-year-old white woman with a history of type 2 diabetes, obesity,

hypertension, and migraine headaches. The patient was diagnosed with type 2
diabetes 9 years ago when she presented with mild polyuria and polydipsia.
L.N. is 54 and has always been on the large side, with her weight fluctuating
between 165 and 185 lb.

Initial treatment for her diabetes consisted of an oral sulfonylurea with the
rapid addition of metformin. Her diabetes has been under fair control with a
most recent hemoglobin A1c of 7.4%.

Hypertension was diagnosed 5 years ago when blood pressure (BP) measured
in the office was noted to be consistently elevated in the range of 160/90
mmHg on three occasions. L.N. was initially treated with lisinopril, starting at
10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated.

One year ago, microalbuminuria was detected on an annual urine screen, with
1,943 mg/dl of microalbumin identified on a spot urine sample. L.N. comes into
the office today for her usual follow-up visit for diabetes. Physical examination
reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm.

Pertanyaan

Apa pengaruh mengontrol tekanan darah pada

pasien DM

Berapa target tekanan darah pd pasien DM

Obat antihipertensi yg mana yg direkomendasikan
utk pasien tsb

JELASKAN ISTILAH BERIKUT

Pheochromocytoma

Ortostatik hipotensi

Chushing syndrome

Atherosklerosis

Hirsutisme

Morbiditas

Mortalitas

Infark miokard

Stroke iskemia

Intrinsic sympathomimetic activity