Hipertensi-Konsekwensi Dan Terapi

HYPERTENSION
HIGH BLOOD PRESSURE
ELEVATED BLOOD PRESSURE
RAISED BLOOD PRESSURE
HYPERTENSION
JNC VII
2010
Part 2:
Recommendations
for Hypertension
Treatment
Hypertension
as a Public Health Risk
2012 Canadian Hypertension
Education Program
Recommendations
Routine steps for accurate measurement
of blood pressure
• Rest the patient (seated) for at least 5 mins in a quiet
confortable room
. Use a calibrated sphygmomanometer (a validated and recently
calibrated electronic device may may also be used)
. Choose cuff with appropriate width of bladder
. Record with cuff at heart level
. Deflate cuff at 2 mmHg/sec
. First sound = systolic reading, disappearance = diastolic
reading
. Repeat measurement at least x2 (first visit: x3) & take average
value
. Take BP in both arms at least once; record which arm is used;
patient position ( seated, supine, standing) & pulse rate.
. Measure BP at + 1 & 5 mins after standing ( especially in older
patients and those with diabetes).
BP Measurement Techniques
Method Brief Description
In-office Two readings, 5 minutes apart, sitting
in chair. Confirm elevated reading in
contralateral arm.
Ambulatory BP Indicated for evaluation of “white-coat”
monitoring HTN. Absence of 10–20% BP decrease
during sleep may indicate increased
CVD risk.
Self-measurement Provides information on response to
therapy. May help improve adherence
to therapy and evaluate “white-coat”
HTN.
JNC 7 2003
Office BP Measurement
 Use auscultatory method with a properly calibrated and validated
instrument.
 Patient should be seated quietly for 5 minutes in a chair
(not on an exam table), feet on the floor, and arm supported at heart
level.
 Appropriate-sized cuff should be used to ensure accuracy.
 At least two measurements should be made.
 Clinicians should provide to patients, verbally and in writing,
specific BP numbers and BP goals.
JNC 7 2003
Arm supported
How to measure blood pressure accurately
 ……… sphygmomanometer
 Patient should be seated and relaxed, preferably for several minutes
prior to to the measurement and in a quiet room.
 Appropriate cuff size.
 Average the readings. If the first two readings differ by more than 10 mmHg
systolic or 6 mmHg diastolic or if the initial readings are high, take several
readings after five minutes of quiet rest, until consecutive readings do not
vary by greater than these amounts.
 Ideally, patients should not take caffeine-containing beverages or
smoke for at least two hours before blood pressure is measured,
…………………..
Australia, 2004
Measuring Blood Pressure
Slide 9-15
Using sthetoscope, 5 stages (NS Korotkoff, 1904)
WRONG
X
Home measurement: Doing it
right
EQUIPMENT
Validated device
Ensure the cuff size is appropriate

Ensure the device is accurate in the patient
at purchase and annually
2009 Canadian Hypertension Education Program Recommendations

Office and Home Blood Pressure
Assessment
Hypertension Diagnosis and Follow up

Education Program
Recommendations
Blood Pressure Assessment:
Patient preparation and posture
Standardized Preparation:
Patient
1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the preceding
30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before measurement
8. Patient should stay silent prior and during the
procedure.
Patient preparation and posture
Standardized technique:
Posture
• The patient should be
calmly seated with his or
her back well supported
and arm supported at the
level of the heart.
• His or her feet should
touch the floor and legs
should not be crossed.
Patient position
X
Diagnostic algorithm for high Blood Pressure including
Office, ABPM and Home Blood Pressure Measurement
Elevated Out of the Elevated Random
Office BP Office BP
measurement Measurement
Hypertension Visit 1 Hypertensive

BP Measurement, Urgency /
History and Physical examination Emergency
Diagnostic tests ordering

at visit 1 or 2
Hypertension Visit 2
within 1 month
BP ≥ 140/90 mmHg and

Target organ damage or Diagnosis
Yes of HTN
Diabetes or Chronic Kidney
Disease or BP ≥ 180/110?
No
BP: 140-179 / 90-109

HTN = hypertension
Hypertension Visit 1 Hypertensive
BP Measurement, Urgency /
History and Physical Emergency
examination
Hypertension Visit 2
Target Organ Damage Diagnosis
or Diabetes Yes
of HTN
or Chronic Kidney Disease
or BP ≥ 180/110?
No
BP: 140-179 / 90-109
Office BPM ABPM (If available) HBPM
HBPM = Home Blood

Pressure Measurement
BP: 140-179 / 90-109
Office BPM ABPM (If available) Home BPM
Hypertension visit 3
>160 SBP or Diagnosis
>100 DBP of HTN Awake BP Awake BP < 135/85 >135 SBP or
<135/85 >135 SBP or >85 DBP
<160 / 100 ABPM or HBPM and >85 DBP or
or Repeat
or 24-hour 24-hour
Home BPM
<130/80 >130 SBP or
>80 DBP If
Hypertension visit 4-5
< 135/85
>140 SBP or Diagnosis
>90 DBP of HTN
Continue to Diagnosis Continue to Diagnosis
follow-up of HTN follow-up of HTN
Continue to
< 140 / 90 follow-up
Patients with high normal blood pressure (office SBP
130-139 and/or DBP 85-89) should be followed annually.
© Continuing Medical Implementation …...bridging the care gap
Ambulatory blood pressure
measurement
© Continuing Medical Implementation …...bridging the care gap

HYPERTENSION
If blood pressure is only slightly elevated, repeated measurements should
be obtained over a period of several month to define the patient’s “usual”
blood pressure as accurately as possible. On the other hand if the patient
has a more marked blood pressure elevation, evidence of hypertension-
related target organ damage or a high or very high cardiovascular risk
profile, repeated measurements should be obtained over shorter period of
time (weeks or days).
In general a diagnosis of hypertension should be based

on at least 2 blood pressure measurements per visit on
at least 2 to 3 visit, although in particularly severe cases
the diagnosis can be based on measurements taken at a
single visit.
J Hypertens 2007 25:1113-4.

Burden of Hypertension in Asia.
45% 45%
40%
34%
35%
29%
30% 26% 27%
24% 25%
25% 23%
20% 20%
20%
15%
10%
5%
0%
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Sharma D et al: IHJ Feb 2006, Pakistan Med Research Council

Wolf-Meir et.al JAMA .2003 , WHO bulletin , Gu et al 35-74 yrs,China, Jo et.al Korea 18-92 yrs J Hyper 2001
Transisi pola penyakit (morbiditas)
PREVALENS (Riskesdas 2007)
Peny. Infeksi Peny. Non-infeksi
Filaria 1,10% Sakit sendi 30,30%
DBD 0,60% Hipertensi 31,70%
Malaria 2,90% Stroke (/1000) 8,30%
ISPA 25,50% Asma 3,50%

Pneumonia 2,10% Jantung 7,20%
Tbc 0,99% DM 1,10%
Campak 1,20% Tumor 4,30%
Tifoid 1,60% Psikotik 4,60%

Hepatitis 0,60% Mntl/Emsnl 11,60%
Diare 9,00% Glaukoma 4,60%
Thalasemia 1,50%
Hemofili 1,30%
Gizi Balita
* KG Berat 6,5 Cedera (12 bln) 7,50%
* KG sedang 8,2 KLL 25,90%
* Normal 76,7
* Obese 8,7
Gizi > 15 th
Obesitas 19,1 Ascobat Gani/ASKES/Jogya 2 12 2011
Transisi pola penyakit (mortalitas)
Penyebab Persen Penyebab Persen
1 Stroke 15,40% 12 Pneumonia 3,80%
2 Tb 7,50% 13 Diare 3,50%
3 Hipertensi 6,80% 14 Ulkus pencernaan 1,70%
4 Cedera 6,50% 15 Typhoid 1,60%
5 Perinatal 6,00% 16 Malaria 1,30%
6 DM 5,70% 17 Meningitis enceph 0,80%
7 Tumor parah 5,70% 18 Kelainan kongenital 0,60%
8 Liver 5,10% 19 Dengue 0,50%
9 IHD 5,10% 20 Tetanus 0,50%
10 Sal nafas 5,10% 21 Septicemia 0,30%
11 Jantung 4,60% 22 Malnutrisi 0,20%
Ascobat Gani/ASKES/Jogya 2 12 2011

90
76,4
80
Percent of Population
69,6
70 64,7 64,1
55,8
60 53,7
50
36,2 35,9
40
30 23,2
16,5
20 13,4
10 6,2
0
20-34 35-44 45-44 55-64 65-74 75+
Men Women
Prevalence of HBP in adults more than 20 years by age and sex (NHANES: 2005 to 2006). Adapted
from NCHS and NHLBI. Hypertension is defines as SBP  140 mmHg or DBP  90 mmHg, taking
antihypertensive medication, or being told twice by a physician or other professional that one has
hypertension. (From Lloyd-Jones D, Adam R. Carnethon M, et al. Heart disease and stroke statistics-
2009 update: A report from the American Heart Association statistics committee and stroke statistics
subcommitee. Circulation 2009; 119:e21-e181, with permission)
Kaplan’s Clinical Hypertension, 2010
Hypertension Has a High Prevalence That Is Expected To Rise
Over the Coming Decades
50
40.7
39.1 Men
37.4 37.2
40
with Hypertension
35.3 34.8 Women

% Population
28.3
30 26.9
23.7
2000 20.6 20.9
22 22.6
19.7
20 17
14.5
10
50 45.9
44.5
41.6 42.5 40.2
39.1
40
with Hypertension
% Population
27.7 28.2
30 27 27 27
22.9 23.6 24
2025 18.8
20 17.1
10
Hypertension is an important public health challenge worldwide.

Prevention, detection, treatment and control should receive high priority
Kearney PM, et al. Lancet. 2005;365:217–223
Awareness, Treatment, and Control of
Hypertension in the US
Hypertension, Awareness, Treatment, and Control: US 1976 to 2002
Awareness
80 71
Treatment
69 68 69 Control
70 61
58
60 51 52 52
Hypertensive Adults (%)
50
40 31 31 34
30 25 23
20
10
10
0
NHANES II NHANES III NHANES III NHANES NHANES
1976-1980 (Phase 1) (Phase 2) 1999-2000 2001-2002
1988-1991 1991-1994
Cheung et al. J Clin Hypertens. 2006;8:93–98.

63 - 14
36
Cardiovascular Mortality Risk
Increases as Blood Pressure Rises*
8x
8
7
Cardiovascular
6
Mortality Risk
5
4x
4
3
2x
2
1
0
115/75 135/85 155/95 175/105
Systolic/Diastolic Blood Pressure (mm Hg)
*Measurements taken in individuals aged 40–69 years, beginning with a blood
pressure of 115/75 mm Hg.
Lewington S, et al. Lancet. 2002;360:1903-1913; Slide Source
Hypertension Online
Chobanian AV, et al. JAMA. 2003;289:2560-2572. www.hypertensiononline.org
Complications of persistently untreated hypertension ( target organ damage )
Brain-
stroke
Heart
LVH Kidney
Heart failure End stage
AMI renal disease
Peripheral
LVH>2cm artery
10/2/2018 38
Penyulit pada 500 penderita hipertensi
yang tak diobati
PENYULIT % SURVIVAL
(thn)
JANTUNG
 Hipertrofi (x ray) 74 8
 Hipertrofi (ECG) 59 6
 Payah jantung 50 4
 Angina pectoris 16 5
CEREBRAL
 Ensepalopati 2 1
 Stroke 12 4
RENAL
 Proteinuria 42 5
18 1
 Insufisiensi
7 1
HIPERTENSI KRISIS
PERERA, 1950
Effect of SBP and DBP on
Age-Adjusted CAD Mortality: MRFIT
CAD Death Rate per 10,000 Person-years

80.6
48.3 43.8
37.4 34.7 38.1
31.0
25.8 24.6 25.3 25.2 24.9
23.8
160+
16.9 13.9 12.8 12.6 11.8
20.6 140-159
10.3 11.8 8.8 8.5 9.2 120-139
<120 Systolic BP
100+ 90-99 80-89 75-79 70-74 <70 (mmHg)
Diastolic BP (mmHg)
Neaton et al. Arch Intern Med 1992; 152:56-64
40
The left ventricle is markedly thickened in this
patient with severe hypertension that was
untreated for many years. The myocardial fibers
have undergone hypertrophy.
Kieran McGlade Nov 2001
Department of General Practice QUB
Coronary Heart Disease Rates by
SBP, DBP, and Age
Systolic Blood Pressure Diastolic Blood Pressure
Age at risk: Age at risk:
256 80-89 years 256 80-89 years
128 70-79 years 128 70-79 years
64 60-69 years 64 60-69 years
CHD 32 50-59 years 32
mortality 50-59 years
(floating 16 40-49 years 16
40-49 years
absolute 8 8
risk and
4 4
95% CI)
2 2
1 1
120 140 160 180 70 80 90 100 110

Usual SBP (mm Hg) Usual DBP (mm Hg)
CI, confidence interval; IHD, ischemic heart disease
Lewington S et al. Lancet. 2002;360(9349):1903-1913 42
Stroke and Ischemic Heart Disease (IHD) Mortality Rate in Each
Decade of Age, Versus Usual Systolic BP at the Start of that Decade
Stroke Age at risk IHD Age at risk
80–89 y 80–89 y
256 256
70–79 y 70–79 y
128 128
64 60–69 y 64 60–69 y
Mortality*
32 32 50–59 y
50–59 y
16 16
40–49 y
8 8
4 4
2 2
1 1
0 120 140 160 180 0 120 140 160 180
Usual SBP (mmHg) Usual SBP (mmHg)

Reproduced from The Lancet, 360, Lewington et al. pp. 1903–13
*Floating absolute risk and 95% CI Copyright © 2002, with permission from Elsevier
43
Gagal Ginjal Dalam Hipertensi
Optimal
Normal but not optimal
High Normal
End Stage Renal Disease
Stage 1 Hypertension
Due to Any Cause (%)
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Years since Screening
Hypertension Risk for ESRD
Compared with BP < 120/80 mmHg, the adjusted
relative risks for developing ESRD in subject
without baseline renal disease:
RR CI BP
1,62 95% CI (1,27 - 2,07) 120-129 / 80- 84
1,98 95% CI (1,55 – 2,52) 130-139 / 85-89
2,59 95% CI (2,07-3,25) 140-159 / 90-99
3,86 95% CI (3,00 – 4,96) 160-179 / 100-109
3,88 95% CI (2,82- 5,34) 180-209 / 110-119
4,25 95% CI (2,63-6,86) ≥ 210 / 120
Hsu, et al. Arch Intern Med. 2005
Diabetes: The Most Common Cause of ESRD
Primary Diagnosis for Patients Who Start Dialysis

Other Glomerulonephritis
10% 13% No. of patients
700
No. of dialysis patients
Projection
Diabetes Hypertension
95% CI
600 50.1% 27%
(thousands)
500
400
300 520,240
281,355
200
243,524
100 r2=99.8%
0 1984 1988 1992 1996 2000 2004 2008
United States Renal Data System. Annual data report. 2000.
©2005. American College of Physicians. All Rights Reserved.

www.pernefri.org/renal
VA Cooperative Study : Mortality and Morbidity
In Patients with Diastolic Blood Pressure Between
115 and 129 mmHg
Placebo Anti
Hypertensive
Drugs
No. in study 70 73
Deaths 4 0
Complications 23 2
Accelerated hypertension 12 0
Cerebrovascular accidents
4 1
Coronary artery disease
Congestive heart failure 2 0
Renal damage 2 0
Treatment failure 2 0
1 1
From Veterans administration Cooperative Study Group on
Antihypertensive agents: JAMA 1967;202:116
Nasib penderita Hipertensi tanpa pengobatan
(TDD 95-114 mmHG)
VA Study AS 1970
Kelainan/Diagnosa Placebo Terapi aktif
CVA 20 5
PJK 15 11
Payah Jantung 11 0
Krisis hipertensi 4 0
Gagal ginjal 5 0
Lain-lain 6 0
N = 380 Lama studi 5 tahun

Blood Pressure Reduction of 2 mmHg Decreases the
Risk of Cardiovascular Events by 7–10%
• Meta-analysis of 61 prospective,
observational studies
• 1 million adults
• 12.7 million person-years
7% reduction in
risk of ischaemic
heart disease
2 mmHg mortality
decrease in
mean SBP 10% reduction in
risk of stroke
mortality
Lewington et al. Lancet 2002;360:1903–13

BP Differences of 10 mmHg Are Associated
With Up to a 40% Effect on
CV Risk
• Meta-analysis of 61 prospective, observational studies
• 1 million adults
• 12.7 million person-years
30% reduction in
risk of IHD
mortality
10 mmHg decrease
in mean SBP
40% reduction in risk

of stroke mortality
Lewington S et al. Lancet. 2002;360:1903–1913.

Hypertension merupakan beban
kesehatan yang besar
• Diseluruh dunia, hipertensi merupakan awal dari:
– 62% dari strokes1
– 49% dari serangan jantung (heart attacks)1
• Hypertension is the third leading risk factor for disease
– Causes 7.1 million premature deaths each year1
– 4.5% of global burden of disease1
• Hypertension represents a high burden on healthcare
expenditure
– In 2004, the direct and indirect cost of high blood
pressure
in the US was $55.5 billion; drug costs accounted for
$21 billion2
Karenanya, pengelolaan hipertensi adalah “priority”

Kes Mas
1. WHO, 2002; 2. AHA, 2004
Sejarah munculnya obat
Anti-hipertensi.
Effectiveness and general tolerability
1940’s 1950 1957 1960’s 1970’s 1980’s 1990’s 2000
Direct Alpha- ACE ARBs DRI

vasodilators blockers inhibitors
Peripheral Thiazide
sympatholytics diuretics
Central 2
Ganglion agonists Calcium
blockers antagonists-
Calcium
Veratrum antagonists- DHPs
alkaloids non-DHPs
Beta-
blockers
DHP, dihydropyridine;
ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker
Part 2: Recommendations for
Hypertension Treatment
Education Program
Recommendations
III. Treatment of Adults with Systolic/Diastolic
Hypertension without Other Compelling Indications
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Long-
Thiazide Beta-
ACEI ARB acting
blocker*
CCB
A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20
mmHg systolic or >10 mmHg diastolic above target
• BBs are not indicated as first line therapy for age 60 and above
ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in
prescribing to women of child bearing potential
Lifestyle Recommendations for Hypertension:
Dietary
Dietary Sodium
High in: Less than 2300mg / day
(Most of the salt in food is ‘hidden’ and comes
• Fresh fruits from processed food)
• Fresh vegetables
• Low fat dairy products
• Dietary and soluble fibre Dietary Potassium
• Plant protein Daily dietary intake >80 mmol
Low in: Calcium supplementation

• Saturated fat and cholesterol No conclusive studies for hypertension
• Sodium
Magnesium supplementation
No conclusive studies for hypertension
www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.
Physical Activity
Should be prescribed to reduce blood pressure
F Frequency - Four to seven days per week
I Intensity - Moderate
T Time - 30-60 minutes
Type Cardiorespiratory Activity

T - Walking, jogging
- Cycling
- Non-competitive swimming
Exercise should be prescribed as an adjunctive to pharmacological therapy

Weight Loss
Height, weight, and waist circumference (WC) should be measured
and body mass index (BMI) calculated for all adults.
Hypertensive and all patients

BMI over 25
- Encourage weight reduction
- Healthy BMI: 18.5-24.9 kg/m2
Waist Circumference
Men <102 cm Women <88 cm
For patients prescribed pharmacological therapy: weight loss has

additional antihypertensive effects. Weight loss strategies should employ a
multidisciplinary approach and include dietary education, increased physical
activity and behaviour modification
CMAJ 2007;176:1103-6
Waist Circumference Measurement
Measure here
Iliac crest
Courtesy J.P. Després 2006

Alcohol
Low risk alcohol consumption

• 0-2 standard drinks/day
• Men: maximum of 14 standard drinks/week
• Women: maximum of 9 standard drinks/week
A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or

12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).
Stress Management
Stress management
Hypertensive patients
in whom stress appears to be an important issue
Behaviour Modification
Individualized cognitive behavioural interventions are

more likely to be effective when relaxation techniques
are employed.
Lifestyle Therapies in Adults with Hypertension:
Summary
Intervention Target
Reduce foods with
< 2300 mg /day
added sodium
Weight loss BMI <25 kg/m2
Alcohol restriction < 2 drinks/day
Physical activity 30-60 minutes 4-7 days/week
Dietary patterns DASH diet
Smoking cessation Smoke free environment
Waist circumference Men <102 cm Women <88 cm
III. Treatment of Adults with Systolic/Diastolic
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
therapy
Long-
Thiazide Beta-
ACEI ARB acting
blocker*
CCB
A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20
mmHg systolic or >10 mmHg diastolic above target
• BBs are not indicated as first line therapy for age 60 and above
ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in
prescribing to women of child bearing potential
III. Add-on Therapy for Systolic/Diastolic
If partial response to monotherapy
1. Add-on Therapy IF BLOOD PRESSURE IS NOT

CONTROLLED CONSIDER
• Nonadherence
• Secondary HTN
2. Triple or Quadruple Therapy • Interfering drugs or lifestyle
• White coat effect
If blood pressure is still not controlled, or there are adverse effects,

other classes of antihypertensive drugs may be combined (such as
alpha blockers or centrally acting agents).
How to Escalate Antihypertensive Therapy:
General Recommendations
therapy
Thiazide ACE-I Long-acting Beta-

diuretic ARB
CCB blocker*
Dual Combination
(any 2 except ACE/ARB/Beta blocker combos )
Triple or Quadruple therapy

V. Summary: Treatment of Systolic-Diastolic
TARGET <140/90 mmHg
A combination of 2 first line drugs may
be considered as initial therapy if the
blood pressure is >20 mmHg systolic
Initial therapy
or >10 mmHg diastolic above target
Thiazide Long-acting Beta-

ACEI ARB
diuretic CCB blocker*
CONSIDER
Dual Combination
• Nonadherence
• Secondary HTN
• Interfering drugs or
lifestyle *Not indicated as first
Triple or Quadruple
line therapy over 60 y
• White coat effect Therapy
BP Reduction / Adverse Effect
by Increasing the Dose of the Initial Drug
Half standard Standard Twice standard

0 20
15
Adverse effects (%)

-3
 DBP (mmHg)
10
5
-6
-9 -5
Half standard Standard Twice standard
Thiazides Beta-blockers ACEI ARB CA
Law et al., BMJ 2003; 326:1427

Model 1.
Pilihan O.A.H.
Faktor Risiko/Penyulit Pilihan Obat Keterangan
Obat Lini Pertama (OLP) BB bukan indikasi sbg

OLP untuk usia >60 th
Kombinasi 2 OLP bila

TD >20/10 mmHg
Th , ACEI, ARB, CCB diatas target
HIPERTENSI Kombinasi boleh triple,
TANPA INDIKASI KHAS. Quadruple.
BB
ACEI, ARB dan DRI
Kontra indikasi untuk
(Target <140/90 mmHg) Kehamilan. Hati hati
meresepkan pada
wanita usia subur.
Th = thiazide, ACEI=angiotensin converting enzyme inhibitor, ARB=angiotensin receptor blocker,

CCB=calcium channel blocker DRI=direct renin inhibitor. LA=long acting, DHP=dihydropyridine
Model 2.
Pilihan O.A.H.
Faktor Risiko/Penyulit Sesuaikan gaya hidup Keterangan
Obat Lini Pertama (OLP)

Kombinasi 2 atau 3 obat
bila respons partial.
LANSIA
Th , ARB, Bila belum terkendali,
ISOLATED SYSTOLIC CCB/LA-DHP Kombinasi obat lain
HYPERTENSION (ACEI, Alpha-blockers,
obat kerja sentral, atau
TANPA INDIKASI KHAS non-DHP CCB).
(Target <140 mmHg)

Model 3 a
Pilihan O.A.H.
Faktor Risiko/Penyulit Sesuaikan Gaya Hidup Keterangan
D Indikasi khusus Obat Lini Pertama

e
LEFT VENTRICULAR ACEI, ARB, CCB, Th.

HYPERTROPHY (LVH) BB (bila usia <60 th)
(Target <140/90 mmHg)

Model 3 b
Pilihan O.A.H.
Indikasi khusus Indikasi khusus Indikasi khusus
D Indikasi khusus Obat Lini Pertama

e Hati hati kombinasi CCB
non-DHP dan BB.
BB, LA-CCB.
Hindari CCB non-DHP
Bila fungsi LV buruk.
ACEI tidak dianjurkan
untukkebanyakan pasien
Stable Angina PJK Kombinasi ACEI dan ARB
tak dianjurkan kecuali
ARB tidak inferior gagal jantung refrakter.
Terhadap ACEI.
Lebih disukai kombinasi
ACEI dan CCB.

Model 3 c
Pilihan O.A.H.
Indikasi khusus
D Obat Lini Pertama
e
Infark Miokard Baru BB dan ACEI atau ARB
BB bermasalah ?:
Gagal jantung: Hindari non-DHP CCB
CCB LA-DHP pada Gagal Jantung.
atau LA-CCB.

Model 3 d
Pilihan O.A.H.
Indikasi khusus Obat Lini Pertama

D
e
ACEI dan BB BB yang dipakai pada trials:

bisoprolol, carvedilol, metoprolol
Disfungsi Sistolik Bila intoleran thd ACEI,
ARB
Perlu tambahan: diuretik
(Th untuk Hipertensi, loop Bila ada kontraindikasi thd
untuk volume). ACEI/ARB: hidralazine
kombinasi dengan ISDN.
Masih perlu tambahan:
kombinasi ACEI/ARB,
LA DHP-CCB (amlodipin)

Model 4
Pilihan O.A.H.

D
e Pertimbangkan penurunan
tekanan darah pada fase
akut stroke atau TIA.
Kombinasi
Stroke / TIA ACEI/Diuretik
lebih disukai.
Kombinasi ACEI/ARB tidak
dianjurkan

Model 5a
Pilihan O.A.H.

D Kombinasi ACEI/ARB tak
e dianjurkan bila tanpa
Penyakit Ginjal proteinuria
Kronik
dan Selalu monitor K+ dan
kreatinin pada pasien yang
Proteinuria*
ACEI atau ARB mendapat ACEI/ARB
•Albumin/creatinin ratio >30 (bila tak toleran)
mg/mmol, atau
Tambahan:Th, bila overload:
Proteinuria >500 mg/24 jam
loop-diuretik. Awas bila ada stenosis
arteria renalis bilateral.
(Target <130/80 mmHg) Kombinasi dengan lain.

Model 5b
Pilihan O.A.H.

D
e
Hati hati pemakaian ACEI

Th , ACEI, ARB, CCB atau ARB pada stenosis
bilateral atau pada yang
Stenosis Arteria unilateral dgn satu ginjal
Renalis
BB

Model 6 a
Pilihan O.A.H.

D Selalu monitor K+ dan
kreatinin pada pasien yang
e
mendapat ACEI/ARB
ACEI atau ARB

Diabetes Mellitus Tambahan: Th
dengan Nefropati dan/atau Bila creatinin >1m5 mg/dl atau
LA-CCB CCT < 30 ml/men gantilkan Th
Bila kontra indikasi thd dengan loop intuk pengendalian
Batas: > 130/80 mmHg ACEI/ARB volume.
Target < 130/80 mmHg. atau intoleran ganti dengan
LA-CCB atau Th
Proteinuria>1gr/hr Kombinasi 3-4 obat
125/75 mmHg kemungkinan perlu

Model 6b
Pilihan O.A.H.

D 1. ACEI atau ARB atau Kombinasi ACEI dan ARB
e 2. Th atau DHP-CCB. tak dianjurkan bila tanpa
proteinuria.
Kombinasi OLP
Penambahan satu atau
BB kardioselektif:
Diabetes Mellitus lebih, BB kardioselektif
bisoprolol, carvedilol,
tanpa Nefropati atau LA-CCB
metoprolol
Batas: > 130/80 mmHg Bila ACEI, ARB, DHP-
Sering memerlukan
Target < 130/80 mmHg. CCB, Atau Th kontra-
>3 jenis obat untuk
Proteinuria>1gr/hr indikasi atau intoleran
mencapai target.
125/75 mmHg BB kardioselektif atau
LA non-DHP-CCB.

Model 7
Pilihan O.A.H.

D
e
Th , ACEI, ARB, CCB

MRC trial of treatment
BB diragukan manfaat of mild hypertension
Smoking nya kecuali bila ada 1985.
Indikasi spesifik spt
angina
(Target <140/90 mmHg)

AN Y QUESTION ?

Hipertensi-Konsekwensi Dan Terapi

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Hipertensi-Konsekwensi Dan Terapi

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HYPERTENSION

HIGH BLOOD PRESSURE

ELEVATED BLOOD PRESSURE

RAISED BLOOD PRESSURE

Ensure the cuff size is appropriate

2009 Canadian Hypertension Education Program Recommendations

2012 Canadian Hypertension

Hypertension Visit 1 Hypertensive

Diagnostic tests ordering

BP ≥ 140/90 mmHg and

BP: 140-179 / 90-109

BP: 140-179 / 90-109

Office BPM ABPM (If available) HBPM

HBPM = Home Blood

Office BPM ABPM (If available) Home BPM

© Continuing Medical Implementation …...bridging the care gap

In general a diagnosis of hypertension should be based

J Hypertens 2007 25:1113-4.

Sharma D et al: IHJ Feb 2006, Pakistan Med Research Council

ISPA 25,50% Asma 3,50%

Tifoid 1,60% Psikotik 4,60%

Ascobat Gani/ASKES/Jogya 2 12 2011

35.3 34.8 Women

Hypertension is an important public health challenge worldwide.

Cheung et al. J Clin Hypertens. 2006;8:93–98.

CAD Death Rate per 10,000 Person-years

120 140 160 180 70 80 90 100 110

0 120 140 160 180 0 120 140 160 180

Usual SBP (mmHg) Usual SBP (mmHg)

Primary Diagnosis for Patients Who Start Dialysis

©2005. American College of Physicians. All Rights Reserved.

Kelainan/Diagnosa Placebo Terapi aktif

N = 380 Lama studi 5 tahun

Lewington et al. Lancet 2002;360:1903–13

40% reduction in risk

Lewington S et al. Lancet. 2002;360:1903–1913.

Karenanya, pengelolaan hipertensi adalah “priority”

Effectiveness and general tolerability

1940’s 1950 1957 1960’s 1970’s 1980’s 1990’s 2000

Direct Alpha- ACE ARBs DRI

Low in: Calcium supplementation

F Frequency - Four to seven days per week

T Time - 30-60 minutes

Type Cardiorespiratory Activity

Exercise should be prescribed as an adjunctive to pharmacological therapy

Hypertensive and all patients

For patients prescribed pharmacological therapy: weight loss has

Courtesy J.P. Després 2006

Low risk alcohol consumption

• Men: maximum of 14 standard drinks/week

• Women: maximum of 9 standard drinks/week

A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or

Individualized cognitive behavioural interventions are

If partial response to monotherapy

1. Add-on Therapy IF BLOOD PRESSURE IS NOT

If blood pressure is still not controlled, or there are adverse effects,

Thiazide ACE-I Long-acting Beta-

Triple or Quadruple therapy

Thiazide Long-acting Beta-

Half standard Standard Twice standard

Adverse effects (%)

Thiazides Beta-blockers ACEI ARB CA

Law et al., BMJ 2003; 326:1427