kuliah pakar hipertensi

7/23/2019 Kuliah Pakar Hipertensi

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BAGIANBAGIANILMU PENYAKIT DALAMILMU PENYAKIT DALAM

FK FK UKIUKI

Jakarta,Jakarta, 2222 SeptemberSeptember 20120155

IPE!TENSI

Sa"a#a Pa$%%abea$



PATOFISIOLOGI HIPERTENSI Autoregulation

BLOOD PRESSURE = CARDIAC OUTPUT x PERIPHERAL RESISTANCE

Hypertension = Increase CO an!or Increace PR

Preload Contractility Functional Structural

Constriction hypertrophy

Fluid Volume

Volume Redistribution Sympathetic Renin- Cell Hyper

nervous over- Angiostensin Membran nsulinemia

Renal !ecreased activity "#cess Alteration

Sodium $iltration

Retension sur$ace

Stress %besity

"#cess &enetic &enetic "ndothelium

Sodium Alteration Alteration derived

nta'e $actors



&#a''()(*at(+$ a$ ma$a%eme$ +)&#a''()(*at(+$ a$ ma$a%eme$ +)b#++ pre''-re )+r a-#t' .JN& /IIb#++ pre''-re )+r a-#t' .JN& /II

BPC"assi#ication

SBp$%%H&

DBp$%%H&

Li#esty"e'ODIFICATION

INITIAL GRUG THERAP(

)it*o+t Co%pe""in&Inication

)it* Co%pe""in&inication

Nor%a" ,-./ An ,0/ Enco+ra&eNo Anti*ypertension

Dr+& inicate

Dr+&1s2 #or co%ppe""in&

inicationPre*ypertension -./3-45 Or 0/305 (es

Sta&e -

*ypertension

-6/3-75 Or 5/355 (es T*ia8ie3type i+retics#or %ost9 'ay consierACEI:ARB:BB: CCB orco%;ination

Dr+&1s2 #or t*eco%pe""in& inicationsOt*er anti*ypertensi<er+&s 1i+ratics: ACEI:ARB: BB: CCB2 asneeeSta&e .

*ypertension

,-/ Or ,.-/ (es T>o r+& co%;ination #or%ost 1+s+a""y T*ia8ie3type i+retics an ACEI or

ARB or BB or CCB2

DBP* diagnostic blood pressure, SBP, systotic blood pressureDBP* diagnostic blood pressure, SBP, systotic blood pressureDrug abbreviations :ACEL, angiotension converting enxyme inibitor! A"B#, Angiotension receptor bloc$er! BB beta%bloc$er!Drug abbreviations :ACEL, angiotension converting enxyme inibitor! A"B#, Angiotension receptor bloc$er! BB beta%bloc$er!CCB, calcium canel bloc$er!CCB, calcium canel bloc$er!**&&!!

&&!!



Ea#-at(+$ b3e*t(e'Ea#-at(+$ b3e*t(e'

'o identi(y $no) causes

'o assess presence or absence o( targetorgan damage and cardiovascular disease

'o identi(y oter ris$ (actors or disorders

tat migt guide treatment



Ea#-at(+$ &+mp+$e$t'Ea#-at(+$ &+mp+$e$t'

• edical istory

• Pysical examination• "outine laboratory tests

• +ptional tests



EDCAL -S'+".EDCAL -S'+".

D+ration an c"assi#ication o# *ypertension

Patient *istory o# cario<asc+"ar isease

Fa%i"y *istory Sy%pto%s s+&&estin& ca+ses o#

*ypertension

Li#esty"e #actors

C+rrent an pre<io+s %eications



Pysical ExaminationPysical Examination

B"oo press+re reain&s 1t>o or %ore2

?eri#ication in contra"atera" ar%9

Hei&*t: >ei&*t: an >aist circ+%#erence

F+n+scopic exa%ination

Exa%ination o# t*e nec@: *eart: "+n&s:

a;o%en: an extre%ities

Ne+ro"o&ica" assess%ent



Laboratory 'ests "ecommendedLaboratory 'ests "ecommended

Be(ore nitiating 'erapyBe(ore nitiating 'erapy Urina"ysis

Co%p"ete ;"oo co+nt

B"oo c*e%istry 1potassi+%: soi+%:

creatinine: an #astin& &"+cose2

Lipi pro#i"e 1tota" c*o"estero" an HDL

c*o"estero"2

-.3"ea e"ectrocario&ra%



++ p ptional 'ests and Procedurestional 'ests and Procedures

• Creatinine clearance

• icroalbuminuria

• /0%our urinary protein• Serum calcium

• Serum uric acid

• 1asting triglycerides• LDL colesterol

• 2lycosolated

emoglobin

• 'yroid%Stimulating

ormone

• Plasma renninactivity3urinary sodium

determination

• Limited ecocardiograpy• 4ltrasonograpy

• easurement o( an$le3arm

index



Examples o( denti(iableExamples o( denti(iable

Causes o( -ypertensionCauses o( -ypertension • "enovascular disease

• "enal parencymal disease

• Polycystic $idneys

• Aortic coarction

• Peocromocytoma

• Primary aldosteronism

• Cusing syndrome

• -yperparatyroidism

• Exogenous causes



Components o( Cardiovascular Components o( Cardiovascular

"is$ in Patients 5it -ypertension"is$ in Patients 5it -ypertension

Ma3+r !('k Fa*t+r' 4

Smo$ing Dyslipidemia Diabetes mellitus Age older tan 67 years

Sex 8men or postmenopausal )omen9 1amily istory o( cardiovascular disease



Clinical "is$ 1actors (or Strati(icationClinical "is$ 1actors (or Strati(ication

+( Patients 5it -ypertension+( Patients 5it -ypertension

• -eart diseases

• Stro$e or transient iscemic attac$ • #epropaty

• Periperal arterial disease

• "etinopaty



'ypes o( -ypertension'ypes o( -ypertension

Pri%ary HTN

a"so @no>n as essentia" HTN9

acco+nts #or 57 cases o# HTN9 no +ni<ersa""y esta;"is*e ca+se @no>n9

Seconary HTN

"ess co%%on ca+se o# HTN 1 729

seconary to ot*er potentia""y recti#ia;"e ca+ses



Causes o( Secondary -'#Causes o( Secondary -'#

Co%%onntrinsic renal disease

Renovascular diseaseMineralocorticoid e#cess

Sleep (reathing disorder



!('k Strat()(*at(+$!('k Strat()(*at(+$

"is$ 2roup A #o ris$ (actors

#o target organ disease3clinical cardiovascular disease

"is$ 2roup B At least one ris$ (actor, not including diabetes

#o target organ disease3clinical cardiovascular disease

"is$ 2roup C 'arget organ disease 3clinical cardiovascular disease and3or diabetes!

5it or )itout oter ris$ (actors



'reatment Strategies and'reatment Strategies and"is$ Strati(ication"is$ Strati(ication

-ig%normal

8;7%;<3=>%=<9

Stage

807%><3<7%<<9

Stages / and ;

8?673 ? 779

Li(estyle modi(ication


8up to / monts9

Drug terapy




8up to 6 monts9**

Drug terapy


Drug terapy


Drug terapy


Drug terapy


+r tose )it eart (ailure, renal insu((iciency, or diabetes+r tose )it eart (ailure, renal insu((iciency, or diabetes

1or tose )it multiple ris$ (actors, clinicians sould consider drugs as initial 'erapy plus li(estyle1or tose )it multiple ris$ (actors, clinicians sould consider drugs as initial 'erapy plus li(estyle

modi(icationmodi(ication

Blood PressureBlood PressureStages 8mm-g9Stages 8mm-g9 "is$ 2roup A"is$ 2roup A "is$ 2roup B "is$ 2roup C "is$ 2roup B "is$ 2roup C



G+a# +) perte$'(+$G+a# +) perte$'(+$Pree$t(+$ a$ Ma$a%eme$tPree$t(+$ a$ Ma$a%eme$t

• 'o reduce morbidity and mortality by te least

intrusive means possible! 'is may beaccomplised by

% Acieving and maintaining SBP @ 07 -g

and DBP @ <7 mm -g!

% Controlling oter cardiovascular ris$ (actors!



L()e't#e M+()(*at(+$'L()e't#e M+()(*at(+$'

F+r Pree$t(+$ a$ F+r era## a$Ma$a%eme$t &ar(+a'*-#ar ea#t"• Lose )eigt i( over)eigt

• Limit alcool inta$e

• ncrease aerobic pysical activity

• "educe sodium inta$e

• aintain adeuate inta$e o(

Potassium

• aintain adeuate inta$e o(calcium and magnesium

• Stop Smo$ing

• "educe dietary saturated (at andcolesterol



Parmacologic 'reatmentParmacologic 'reatment

• Decreases cardiovascular morbidity and mortality

based on randomised controlled trials

• Protects against stro$e, coronary events, eart(ailure, progression o( renal disease, progression

to more severe ypertension, and all%cause

mortality



Spe*(a# &+$'(erat(+$'Spe*(a# &+$'(erat(+$'I$ Se#e*t($% Dr-% T"erapI$ Se#e*t($% Dr-% T"erap

• Demograpics

• Coexisting diseases and 'erapies

• uality o( li(e• Pysiological and biocemical measurements

• Drug interactions

• Economic considerations



Dr-% T"erapDr-% T"erap

• A lo) dose o( initial drug sould be used slo)ly

titrating up)ard!

• +ptimal (ormulation sould provide /0%oure((icacy )it once%daily dose )it at least >7 o(

pea$ e((ect remaining at end o( /0 ours

• Combination terapies may provide additionale((icacy )it (e)er adverse e((ects



&#a''e' +) &#a''e' +)

A$t("perte$'(e Dr-%'A$t("perte$'(e Dr-%' • ACE inibitors

• Adrenergic inibitors

• Angiotensin receptor bloc$ers• Calcium antagonists

• Direct vasodilators

• Diuretics



&+mb($at(+$ T"erap(e'&+mb($at(+$ T"erap(e'

• adrenergic bloc$ers and diuretics

• ACE inibitors and diuretics

• Angiotensin receptor antagonists and diuiretics• Calcium antagonists and ACE inibitors

• +ter combinations



F+#F+###+6-p+6-p

• 1ollo) up )itin to / monts a(ter initiating terapy

• "ecogniFe tat ig%ris$ patients o(ten reuire ig

dose or combination terapies and sorter intervals bet)een canges in medications

• Consider reasons (or lac$ o( responsiveness i( blood

pressure is uncontrolled a(ter reacing (ull dose

• Consider reducing dose and number o( agents a(ter year at or belo) goal!



&a-'e' )+r ($ae7-ate&a-'e' )+r ($ae7-ate

!e'p+$'e t+ r-% T"erap!e'p+$'e t+ r-% T"erap

• Pseudo resistance

• #on aderence to terapy

• Golume overload• Drug%related causes

• Associated conditions

• denti(iable cause o( ypertension



perte$'(e Emer%e$*(e'perte$'(e Emer%e$*(e'

A$ Ur%e$*(e'A$ Ur%e$*(e' E%er&encies re+ire i%%eiate ;"oo

press+re re+ction to pre<ent or "i%it

tar&et or&an a%a&e Ur&encies ;ene#it #ro% re+cin& ;"oo

press+re >it*in a #e> *o+rs

E"e<ate ;"oo press+re a"one rare"y

re+ires e%er&ency t*erapy Fast3actin& r+&s are a<ai"a;"e9



Dr-%' Aa(b#ab#e )+rDr-%' Aa(b#ab#e )+r

perte$'(e Emer%e$*(e'perte$'(e Emer%e$*(e' ?asoi"ators Arener&ic In*i;itors )itroprusside • *abetalol )icardipine • "smolol Fenoldopam • Phentolamine )itroglycerin "nalaprilat Hydrala+ine



A#%+r(t"m F+r Treatme$t +)A#%+r(t"m F+r Treatme$t +)

perte$'(+$perte$'(+$. JN& /II. JN& /II



L()e't#e M+()(*at(+$'L()e't#e M+()(*at(+$'.JN& /II.JN& /II

N+t at G+a# B#++ Pre''-re .8190:;0 mm%N+t at G+a# B#++ Pre''-re .8190:;0 mm%

.81<0:=0 mm% )+r pat(e$' 6(t" (abete' +r *"r+$(* k($e ('ea'e.81<0:=0 mm% )+r pat(e$' 6(t" (abete' +r *"r+$(* k($e ('ea'e

I$(t(a# Dr-% &"+(*e'I$(t(a# Dr-% &"+(*e'

>(t"+-t &+mpe##($%>(t"+-t &+mpe##($%I$(*at(+$I$(*at(+$

>(t" &+mpe##($% I$(*at(+$>(t" &+mpe##($% I$(*at(+$

Sta%e 1Sta%e 1

perte$'(+$perte$'(+$

.SBP 190?15; +r DBP.SBP 190?15; +r DBP;0?;; mm%;0?;; mm%

T"(a@(e ?tpe (-ret*T"(a@(e ?tpe (-ret*)+r m+'t Ma *+$'(er)+r m+'t Ma *+$'(erA&EI, A!B, BB, &&B,A&EI, A!B, BB, &&B,+r *+mb($at(+$+r *+mb($at(+$

Sta%e 2Sta%e 2

perte$'(+$perte$'(+$

.SBP C10 +r DBP.SBP C10 +r DBPC100 mm%C100 mm%

T+?r-% *+mb($at(+$ )+rT+?r-% *+mb($at(+$ )+rm+'t .-'-a## t"(a@(e ?m+'t .-'-a## t"(a@(e ?tpe (-ret(* a$ A&EItpe (-ret(* a$ A&EI+r A!B +r BB +r &&B+r A!B +r BB +r &&B

Dr-%.S )+r t"eDr-%.S )+r t"e*+mpe##($% ($(*at(+$'*+mpe##($% ($(*at(+$'.'e tab#e .'e tab#e

t"er a$t("perte$'(et"er a$t("perte$'(er-%' . (-ret(*', A&EI,r-%' . (-ret(*', A&EI,A!B, BB, &&B a'A!B, BB, &&B a'$eee$eee

NT AT GAL BLD P!ESSU!ENT AT GAL BLD P!ESSU!E

pt(m(@e +'a%e' +r a a(t(+$a# r-%' -$t(# %+a# b#++ pre''-re (' a*"(ee &+$'(erpt(m(@e +'a%e' +r a a(t(+$a# r-%' -$t(# %+a# b#++ pre''-re (' a*"(ee &+$'(er*+$'-#tat(+$ 6(t" "perte$'(+$ 'pe*(a#('t*+$'-#tat(+$ 6(t" "perte$'(+$ 'pe*(a#('t

DBP, (a't+#(* b#++ pre''-re, SBP, ''t+#(* b#++ pre''-reDBP, (a't+#(* b#++ pre''-re, SBP, ''t+#(* b#++ pre''-re

Dr-% abbre(at(+$'4 A&EIC a$%(+te$'($ *+$ert($% e$@me ($"(b(t+r A!BC,a$%(+te$'($Dr-% abbre(at(+$'4 A&EIC a$%(+te$'($ *+$ert($% e$@me ($"(b(t+r A!BC,a$%(+te$'($re*ept+r b#+*ker BBC beta?b#+*ker &&BC *a#*(-m *"a$$e# b#+*kerre*ept+r b#+*ker BBC beta?b#+*ker &&BC *a#*(-m *"a$$e# b#+*ker



A#%+r(t"m )+r Treatme$t +)A#%+r(t"m )+r Treatme$t +)perte$'(+$ .*+$t($-e perte$'(+$ .*+$t($-e

Begin or Continue Li(estyle odi(ications

L+'e 6e(%"t Ma($ta($ p+ta''(-m L(m(t a#*+"+# Ma($ta($ *a#'(-m a$ ma%$e'(-m

I$*rea'e p"'(*a# a*t((t St+p Sm+k($%

!e-*e '+(-m !e-*e 'at-rate )at *"+#e'ter+#

N+t at G+a# B#++ Pre''-reN+t at G+a# B#++ Pre''-re



Spe*()(* Dr-% I$(*at(+$'Spe*()(* Dr-% I$(*at(+$'

So%e anti*ypertensi<e r+&s %ay *a<e#a<o+ra;"e a##ects on co3%or;i conitions

Angina- β-bloc'ers- Calcium antagonists

Atrial tachycardia and

$ibrillation- β-bloc'ers- )ondihydropyridine Calcium antagonists

-eart (ailure% Carvedilol

% Losartan

H yocardial in(arction

% DiltiaFem% Gerapamil



Spe*()(* I$(*at(+$' .*+$t($-eSpe*()(* I$(*at(+$' .*+$t($-e

Some antihypertensive drugs may have $avourable a$$ectson co-morbid conditions ,

Cyclorsporine-induced

hypertension 3 Calcium antagonists!iabetes mellitus . and /01ith proteinuria

3 AC" nhibitos pre$erred0

3 Calcium antagonists

!iabetes mellitus type /0- Lo>3ose i+retics

!yslipidemia- 2 -bloc'ers

Pr+'tat('m .be$(%$ pr+'tat(*"perp#a'(a? I %bloc$ers

!e$a# ($'-))(*(e$* .*a-t(+$($ re$+a'*-#ar "perte$'(+a$ *reat($($e < m%:# 25 Hm+#:L

% ACE inibitors



SELAMAT BELAJA! SELAMAT BELAJA!

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