Professional Documents
Culture Documents
Pekerjaan
SMF Penyakit Dalam RSUD Gunung Jati Cirebon SMF Penyakit Dalam RS Putra Bahagia Cirebon
SpPD (Internist)
FK Univ Andalas, 2001
Pendidikan Tambahan
Fellowship Hemodialisa (RSCM/FKUI, 2006) Fellowship Endoscopi (RSHS/FK Unpad, 2008)
Riw Pekerjaan
Puskesmas Danau Sembuluh. Kotim. Kalteng RSUD Purwakarta RSUP M Djamil Padang RSUD Pekanbaru Riau Caltex Hospital (Duri.Riau) RSUD Batusangkar
Organisasi :
PAPDI Cabang Cirebon (Sekretaris)
IDI Cabang Cirebon (Bid Org & Kesra) Bulan Sabit Merah Indonesia (BSMI) Kota Cirebon (Ketua) PERNEFRI, PUSKI, InaSH, PEGI (Anggota)
Gu DF, et al. Hypertension 2002;40:920-927; Singh RB, et al. J Hum Hypertens 2000;14:749-763; Janus ED. Clin Exp Pharmacol Physiol 1997;24:987-988; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al. Singapore Med J 2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27:405-409; Muhilal H. Asia Pacific J Clin Nutr 1996;5:132-134; Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48:827-836 [in Japanese]
Prevalence (%)
Prevalence of Hypertension
Hypertension is one of the most frequent clinical discorders.
prevalence of hypertension (%)
70
60
50
64
65
40
30
20
10 0
age (yrs) 4 11
21
18-29
30-39
40-49
50-59
60-69
70-79
80+
Measure
Total number worldwide in 2000 Total number in economically developed countries in 2000 Total number in economically developing countries in 2000 Total number worldwide in 2025
N (95% CI)
972 million (957-987) 333 million (329-336) 639 million (625-654) 1056 billion (1.54-1.58)
Hypertension complication
Eyes retinopathy Brain stroke ( 2,7)
ischaemic heart disease left ventricular hypertrophy heart failure
Heart
Kidneys
renal failure
( 2,8)
( 1,5)
Systolic BP (mmHg)
Diastolic BP (mmHg)
<120 120-139
or
<80 80-89
or
Stage 1 hypertension
Stage 2 hypertension
140-159
>160
or
90-99
>100
or
Tools
Examiner
Patients
BP Measurement Techniques
Method In-office Brief Description Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.
Ambulatory BP monitoring
Self-measurement
Indicated for evaluation of whitecoat HTN. Absence of 1020% BP decrease during sleep may indicate increased CVD risk. Provides information on response to therapy. May help improve adherence to therapy and evaluate white-coat HTN.
Hypertension
A II
AT1 receptor
LV hypertrophy Fibrosis Remodeling Apoptosis GFR Proteinuria Aldosterone release Glomerular sclerosis
Heart failure MI
DEATH
Renal failure
*preclinical data LV = left ventricular; MI = myocardial infarction; GFR = glomerular filtration rate
Adapted from Willenheimer R et al Eur Heart J 1999; 20(14): 9971008, Dahlf B J Hum Hypertens 1995; 9(suppl 5): S37S44, Daugherty A et al J Clin Invest 2000; 105(11): 16051612, Fyhrquist F et al J Hum Hypertens 1995; 9(suppl 5): S19S24, Booz GW, Baker KM Heart Fail Rev 1998; 3: 125130, Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories 1999: 16821704, Anderson S Exp Nephrol 1996; 4(suppl 1): 3440, Fogo AB Am J Kidney Dis 2000; 35(2):179188
Management of Hypertension
The main objective in lowering BP is to reduce the patients absolute risk of premature death and disease, primarily by reducing their risk of cardiovascular diseases.
Stroke
CVD mortality
All-cause mortality
-20%
-30%
-21% P<0.0001
-25% P<0.001
-40%
-37% P<0.001
MI
Percent Reduction
-15%
-30%
-26%
-29%
-30%
-31%
-45%
-42%
*Fatal and nonfatal heart failure and nonfatal myocardial infarction and sudden death **Fatal and nonfatal heart failure and nonfatal myocardial infarction, sudden death and stroke
10% Reduction in BP
10% Reduction in TC
Less than 140/90 mm Hg or Less than 130/80 mm Hg (diabetes, chronic kidney disease) or Less than 125/75 mm Hg (protein uria >1g/day)
1999 WHO/ISH Hypertension Guidelines. J Hypertens 1999;17:151-183 ADA Position Statement. Diabetes Care 2002;25:S33-S49
Stage 1 Hypertension
(SBP 140159 or DBP 9099 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.
Stage 2 Hypertension
(SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and 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.
Lifestyle Modification
Modification Approximate SBP reduction (range)
Weight reduction
Adopt DASH eating Dietary sodium Physical activity
24 mmHg
Stage 1 Hypertension
140159 or 9099
Yes
Stage 2 Hypertension
>160
or >100
Yes
*Treatment determined by highest BP category. Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
Diabetes? Chronic kidney disease? Stroke? High coronary disease risk? Heart failure? Post myocardial infarction?
NO Treatment in the absence of specific indication YES
Individualized treatment
(compelling indication)
Diuretic
Alpha blocker
Possible combination of different classes of anti hypertension drugs
CCB
Most rational combination
ACE inhibitor
Journal Of Hypertension 2003
LONGACTING FORMULATIONS THAT PROVIDE 24-H EFFICACY ARE PREFERRED OVER SHORT-ACTING AGENTS FOR MANY REASONS :
1. ADHERENCE IS BETTER WITH ONCE-DAILY DOSING 2. FOR SOME AGENTS, FEWER TABLETS INCUR LOWER COST 3. CONTROL OF HYPERTENSION IS PERSISTENT AND SMOOTH RATHER THAN INTERMITTENT 4. PROTECTION IS PROVIDED AGAINTS WHATEVER RISK FOR SUDDEN DEATH, HEART ATTACK, AND STROKE THAT IS DUE TO TE ABRUPT INCREASE OF BP AFTER ARISING FROM OVERNIGHT SLEEP
Angiotensin I
BRADYKININ
Kininase II
Inactive Fragments
A.C.E. ANGIOTENSIN II
Inhibitor
Heart
Inhibition of hypercardia Inhibition of fetus type gene expression Inhibition of TGF- b1 expression Decrease of collagen Inhibition of fibrosis
Blood Vessel
Bradykinin increase NO increase Protection of endothelial function Vascular dilation Inhibition of smooth muscle proliferation
Inhibition of arteriosclerosis
Kidney
Decrease of interior pressure of glomeruli NO increase Preservation of size barrier and charge barrier of glomerular basal lamina Inhibition of mesangial proliferation
Anti-proteinuria
Inhibition of remodeling
Prevention of glomerulosclerosis
RENIN-ANGIOTENSIN CASCADE
ANGIOTENSINOGEN RENIN ANGIOTENSIN I ACE ANGIOTENSIN II
ACE Inhibitors
A2RBs
AT 1 Receptor AT 2 Receptor
Endothelial dysfunction
Sympathetic tone
Angiotensin II
Weight increase
IMIDAPRIL HCl as ACE-I improved fibrinolytic function and ventricular function in acute MI
High-Versus Low-Dose ACE Inhibition in Chronic Heart Failure a Double-Blind, PlaceboControlled Study of Imidapril. Dirk J van Veldhuisen et al. J am Coll Cardial 1998;32:1811-1818 - High dose ACE inhibition ( with imidapril ) is superior to low dose
Change in Exercise Duration after 12 weeks treatment with IMIDAPRIL 60 50 Exercise duration (soc) 40 30 20 10 0
p < 0.05 Vs placebo, p < 0.05 Vs Imidapril 2,5 mg
Change in Physical Working Capacity (PWC) after 12 weeks treatment with IMIDAPRIL 10
*
*
0 -5
-10
Placebo Imidapril Imidapril Imidapril 2,5 mg 5 mg 10 mg Placebo Imidapril Imidapril Imidapril 2,5 mg 5 mg 10 mg
1. 2. 3. 4.
Start ACEIs at a half of the usual dosage Determine serum creatinine and potassium levels within 2-4 wk Continue ACEIs if the serum creatinine level is slightly increase Stop ACEIs if the serum creatinine level is more than 1.5 times of the basal level.