DAFTAR RIWAYAT HIDUP

1. Nama : Dr.H.Trisulo Wasyanto, Sp JP (K), FIHA

2. Tempat & tanggal lahir : Poso , 8 2 - 1956

3. Pangkat / Golongan : Pembina Utama Muda / IV C

4. Perguruan Tinggi Strata I : Fak.Kedokteran UNDIP , lulus 1982
Strata II : Program Pendidikan Dokter Spesialis I
Jantung dan Pembuluh Darah FK UNAIR ,
lulus 1995

5. 1983 - 1990 Kepala Puskesmas Kec. Mojolaban Kab. Sukoharjo Jateng
6. 1990 - 1995 PPDS I Jantung di FK UNAIR / RSUD Dr. Soetomo Surabaya
7. 1996 - Sekarang SMF / Lab. Kardiologi RSUD Dr.Moewardi / FK UNS
8. 1998 - 2006 Wakil Kepala Instalasi Perawatan Intensive RSUD Dr.
Moewardi Surakarta
9. 2004 - Sekarang Ketua Panitia Kredensial Komite Medik RSUD
Dr. Moewardi Surakarta
10. 2006 - Sekarang Ketua PERKI Cabang Surakarta
THE ROLE OF ANTIHYPERTENSIVE AGENT
IN HYPERTENSION PATIENTS WITH METABOLIC SYNDROME
Dr.TRISULO WASYANTO,Sp JP (K),FIHA
DEPT OF CARDIOLOGY & VASCULAR MEDICINE
UNIV OF SEBELAS MARET / Dr MOEWARDI HOSPITAL
S U R A K A R T A
The Metabolic Syndrome
The metabolic syndrome is characterized by
the variable combination of visceral obesity
and alterations in glucose metabolism, lipid
metabolism, and BP. It has a high prevalence
in the middle age and elderly population.
Subjects with the metabolic syndrome also
have a higher prevalence of microalbuminuria,
LVH and arterial stiffness than those without
metabolic syndrome. Their CV risk is high and
the chance of developing diabetes markedly
increased.
Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.
Eur Heart J 2007;28:1462-1536
Vascular Damage
The presence of the Metabolic Syndrome is associated
with increased CAD and Total mortality
Definition and Classification of
Hypertension : JNC VII
Hypertension is defined as blood pressure 140/90 mmHg
Category Systolic
(mmHg)
Diastolic
(mmHg)
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 hypertension 160 or 100
JNC VII. J AMA 2003;289:2560-2572
JNC VII : Management of Hypertension by
JNC VII : Management of Hypertension by
Blood Pressure Classification
Blood Pressure Classification
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker;
CCB = calcium channel blocker.
Chobanian Chobanian AV et al. AV et al. J AMA. J AMA. 2003;289:2560 2003;289:2560- -2572. 2572.
Drug(s) for the compelling
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB,
BB, CCB) as needed
Drug(s) for the compelling
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB, BB,
CCB) as needed
BP Classification
Lifestyle
Modification
Initial Drug Therapy
Without Compelling
Indication
With Compelling
Indication
Normal
<120/80 mm Hg
Prehypertension
120-139/80-89 mm Hg
Stage 1 hypertension
140-159/90-99 mm Hg
Stage 2 hypertension
160/100 mm Hg
Encourage
Yes
Yes
Yes
No drug indicated Drug(s) for the compelling
indications
Thiazide-type diuretics
for most; may consider
ACE-I, ARB, BB, CCB, or
combination
2-drug combination for most
(usually thiazide-type diuretic
and ACE-I, ARB, BB, or
CCB)
Hypertension treatment strategy : JNC VII
Lifestyle modifications
Not at goal blood pressure (<140/90 mmHg)
(<130/80 mmHg for patients with diabetes or chronic kidney disease)
Initial drug choices
Without compelling
indications
With compelling
indications
Stage 1 hypertension
(SBP 140-159 or DBP
90-99 mmHg)
Thiazide-type diuretics
for most. May consider
ACE-I, ARB, BB, CCB
or combination
Stage 2 hypertension
(SBP 160 or DBP 100 mmHg)
Two-drug combination for
most (usually thiazide-type
diuretic and ACE-I or
ARB, or BB, or CCB)
Drug(s) for the
compelling indications

Other antihypertensive
Drugs (diuretics, ACE- I,
ARB, BB, CCB) as needed
Not at blood pressure goal
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
JNC VII. J AMA 2003;289:2560-2572
SBP, systolic blood pressure; DBP, diastolic blood pressure; ACE-I,
angiotensin-converting enzyme inhibitor; ARB, angiotensin II
receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker
JNC VII & ESH/ESC 2003:
Treatment Considerations
Most patients with hypertension will require 2 or
more antihypertensive drugs to achieve BP goals
According to baseline BP and presence or absence
of complications, therapy can be initiated either with
a low dose of a single agent or with a low-dose
combination of 2 agents
When BP is >20/10 mm Hg above goal,
consideration should be given to initiating 2 drugs,
either as separate prescriptions or in fixed-dose
combinations, one of which should be a thiazide-
type diuretic

Chobanian AV et al. J AMA. 2003;289:2560-2572.
Guidelines Committee. J Hypertens. 2003;21:1011-1053.
Definitions and Classifications of
Blood Pressure : ESH/ESC 2007
Category Systolic Diastolic
Optimal
< 120 and < 80
Normal
120-129 and/or 80-84
High normal
130-139 and/or 85-89
Grade 1
hypertension
140-159 and/or 90-99
Grade 2
hypertension
160-179 and/or 100-109
Grade 3
hypertension
180 and/or 110
Isolated
systolic
hypertension
and < 90
140
Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.
Eur Heart J 2007;28:1462-1536
Initiation of Antihypertensive treatment : ESC 2OO7
Other risk
factors, OD, or
disease
Normal SBP
120-129 or DBP
80-84
High normal
SBP 130-139 or
DBP 85-89
Grade 1 HT
SBP 140-159 or
DBP 90-99
Grade 2 HT
SBP 160-179 or
DBP 100-109
Grade 3 HT
SBP 180 or
DBP 110
No other risk
factors
No BP
intervention
No BP
intervention
Lifestyle
changes for
several months
then drug
treatment if BP
uncontrolled
Lifestyle
changes for
several weeks
then drug
treatment if BP
uncontrolled
Lifestyle
changes +
immediate drug
treatment
1-2 risk factors Lifestyle
changes
Lifestyle
changes

Lifestyle
changes for
several weeks
then drug
treatment if BP
uncontrolled
Lifestyle
changes for
several weeks
then drug
treatment if BP
uncontrolled
Lifestyle
changes +
immediate drug
treatment
3 risk factors,
MS or OD
Lifestyle
changes
Lifestyle
changes and
consider drug
treatment
Lifestyle
changes + drug
treatment
Lifestyle
changes + drug
treatment

Lifestyle
changes +
immediate drug
treatment
Diabetes Lifestyle
changes
Lifestyle
changes + drug
treatment
Lifestyle
changes + drug
treatment
Lifestyle
changes + drug
treatment
Lifestyle
changes +
immediate drug
treatment
Established CV
or renal
disease
Lifestyle
changes +
immediate drug
treatment
Lifestyle
changes +
immediate drug
treatment
Lifestyle
changes +
immediate drug
treatment
Lifestyle
changes +
immediate drug
treatment
Lifestyle
changes +
immediate drug
treatment
Conditions favouring the use of some
Antihypertensive drugs versus other
SUBCLINICAL ORGAN DAMAGE
LVH ACEI, CA, ARB
Asymptomatic atherosclerosis CA, ACEI
Microalbuminuria ACEI, ARB
Renal Dysfunction ACEI, ARB
CLINICAL EVENT
Previous stroke Any BP lowering agent
Previous MI BB, ACEI, ARB
Angina pectoris BB, CA
Heart failure Diuretics, BB, ACEI, ARB,
Anti - aldosterone agents
Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.
Eur Heart J 2007;28:1462-1536
Continued..
Atrial fibrillation
Recurrent ARB, ACEI
Permanent BB, non - dihydropiridine CA
Tachyarrhytmias BB
ESRD / proteinuria ACEI, ARB, loop diuretics
Peripheral artery disease CA
LV dysfunction ACEI
Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension
Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.
Eur Heart J 2007;28:1462-1536
Continued..
CONDITION
ISH (elderly) Diuretics, CA
Metabolic syndrome ACEI, ARB, CA
Diabetes mellitus ACEI, ARB
Pregnancy CA, methyldopa, BB
Black people Diuretics, CA
Glaucoma
ACEI induced cough
BB
ARB
Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.
Eur Heart J 2007;28:1462-1536
Contra-indications to use certain
Antihypertensive drugs
Compelling contra-
indications
Possible contra-
indications
Thiazide diuretics Gout -Metabolic syndrome
-Glucose intolerance
-Pregnancy
Beta-blockers Asthma

A-V block (grade 2 or 3)
-Peripheral artery disease
-Metabolic syndrome
-Athletes and physically
active patients
-Chronic obstructive
pulmonary disease
Calcium antagonists
(dihydropiridine)
-Tachyarrhytmias
-Heart failure
Calcium antagonists
(verapamil, diltiazem)
A-V block (grade 2 or 3)
Heart failure
Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.
Eur Heart J 2007;28:1462-1536
Continued..
Compelling contra-
indications

Possible contra-
indications
ACE-inhibitors Pregnancy
Angioneurotic edema
Hyperkalaemia
Bilateral renal artery
stenosis
Angiotensin receptor
blockers
Pregnancy
Hyperkalaemia
Bilateral renal artery
stenosis
Diuretics
(antialdosterone)
Renal failure
hyperkalaemia
Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension.
Eur Heart J 2007;28:1462-1536
Diuretics
ARBs
CCBs
ACE-Inhibitors
-Blockers
-Blockers
European Society
of Hypertension
2007
Possible Combination of
Different Classes of Anti
Hypertension Drugs
Preferred
combinations
Proven bene-
ficial in trials

Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension
Mild BP elevation
Low/Moderate CV risk
Conventional
BP Target
Marked BP elevation
High/very high CV Risk
Lower BP target
Choose between
Single Agent at
low Dose
Two Drugs Combination
at low Dose
Previous Agent
at Full Dose
Two Three drug combination
at full dose
Switch to different
agent
at low dose
Two-to
Three drug
Combination
at full dose
Full Dose
Monotherapy
Monotherapy versus combination therapy strategies
Previous
combination
at full dose
Add a Third drug
at low dose
If Goal BP
Not Achieved
If Goal BP
Not Achieved
Adapted From 2007 ESH-ESC Guidelines for the Management of Arterial Hypertension
Comparison of tight BP vs tight Glucose control
in UKPDS
5
-50
-40
-30
-20
-10
0
Tight glucose control
Tight BP control
Microvascular
endpoints
*
Stroke
Any diabetes-
related endpoint
Diabetes-related
deaths
*
*
*
* p<0.02, tight BP control (achieved BP 144/82 mmHg) vs less tight control (achieved BP 154/87 mmHg).

p<0.03, intensive glucose control (achieved HbA

1c
7.0%) vs less intensive control (achieved HbA
1c
7.9%).
R
i
s
k

r
e
d
u
c
t
i
o
n

(
%
)



UKPDS 38. BMJ 1998;317:703-713;
UKPDS 33. Lancet 1998;352:837-853
BP, blood pressure; UKPDS, United Kingdom Prospective Diabetes Study
44
12
24
10
32
32
37
Gaede P, et al. N Engl J Med 2003;348:383-393
Steno-2: Patients who reached intensive-
treatment goals at a mean of 7.8 years
HbA
1c
<6.5%
P
a
t
i
e
n
t
s

(
%
)

20
30
40
50
60
70
10
80
Cholesterol
<175 mg/dL
Triglycerides
<150 mg/dL
Systolic BP
<130 mmHg
Diastolic BP
<80 mmHg
p=0.06
p<0.001
p=0.19
p=0.001
p=0.21
Intensive
therapy
Conventional
therapy
0
Good BP control
reduces risk of
cardiovascular events
BP, blood pressure
Steno-2: Composite CV endpoints
P
r
i
m
a
r
y

c
o
m
p
o
s
i
t
e


e
n
d
p
o
i
n
t
*

(
%
)

0
0 36 12 96 60 48 84 72 24
60
30
40
20
10
50
Intensive therapy
BP 132/73 mmHg
Conventional therapy
BP 146/78 mmHg
Months of follow-up
p=0.007
Hazard ratio=0.47
(95% CI, 0.24 to 0.73; p=0.008)
Gaede P, et al. N Engl J Med 2003;348:383-393
* Primary composite endpoint = composite of death from cardiovascular causes,
nonfatal myocardial infarction, nonfatal stroke, revascularization and amputation
Treatment of Hypertension in MS
Some anti-hypertensives (diuretics, beta-
blockers) worsen glycemic control and may
not be suitable for long-term use in MS
Drugs of choice in MS may be ACE-inhibitors,
and possibly ARBs
ACE-inhibitors (and ARBs) are free of potentially
diabetogenic side-effects and seem to have
pleiotropic antidiabetic properties
Use of ACE-inhibitors with beta-blockers and/or
diuretics may cancel out the diabetogenic effects
of the latter
Adapted from www.biophoenic.com
In patients with metabolic syndrome diagnostic
procedures should include a more in-depth
assessment of subclinical organ damage.
In all individuals with metabolic syndrome intense
lifestyle measures should be adopted.
When there is hypertension drug treatment should
start with a drug unlikely to facilitate onset to
diabetes. Therefore a blocker of the renin-
angiotensin system should be used and followed, if
needed, by the addition of a calcium antagonists or
a low-doze thiazide diuretics. It appears desirable
to bring BP to the normal range.
CONCLUTIONS (1)
Lack of evidence from specific clinical trials
prevents firm recommendations on use of
antihypertensive drugs in all metabolic
syndrome subjects with a high normal BP.
There is some evidence that blocking the renin-
angiotensin system may also delay incident
hypertension.
CONCLUTIONS ( 2 )