HIPERTENSI

Dr. Ismir Fahri, SpJP (K), FIHA, FAsCC, FSCAI

Departemen Kardiologi dan Kedokteran Vaskular
FKIK- UNIB
 Hypertension is the number one risk factor
for global attributable mortality

World Health Organisation. Global atlas on cardiovascular disease prevention and control. 2011.
CVD = Cardiovascular Disease Available at: http://www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/index.html
 HYPERTENSION SYNDROME IS MORE
THAN JUST BLOOD PRESSURE
Decrease
Arterial
compliance Endothelial
Obesity Dysfunction
Abnormal
Abnormal lipid Glucose
Metabolism Metabolism
Accelerated Neurohormonal
Atherogenesis Dysfunction

LV Hypertrophy Renal-function
And Dysfunction Changes
Abnormal Blood-clotting
Insulin Mechanism
Metabolism Change

Kannel WB. JAMA 1996, 275: 1571-1576; Weber MA et al. J Hum Hypertens 1991,
5: 417-423; Dzau VJ et al. J Cardiovasc Pharmacol 1993, 21 (Suppl 1): S1-S5
 Consequences of Hypertension:
Organ Damage

Hypertension

Transient ischemic
attack, stroke LVH, CHD, CHF

Peripheral
Retinopathy arterial Chronic kidney disease
disease

CHF=congestive heart failure; CHD=coronary heart disease; LVH=left ventricular hypertrophy.

Chobanian AV et al. JAMA. 2003;289:2560-2572.
Progression of HT to LVH to HF

5
 HIPERTENSI
•  HIPERTENSI PRIMER
–  90-95%
–  Genetik
•  HIPERTENSI SEKUNDER
–  2-10%
–  Penyakit Ginjal
–  Penyakit pembuluh darah
–  Penyakit Endokrin
•  HIPERTENSI EMERGENSI
 Penyebab Hipertensi Sekunder
§ Obstructive Sleep apnea
§ Berhubungan dengan dengan konsumsi obat
§ Penyakit ginjal kronik
§ Aldosteronisme primer
§ Penyakit pembuluh darah ginjal
§ Terapi steroid jangka panjang
§ Pheochromocytoma
§ Koartasio aorta
§ Penyakit tiroid dan paratiroid
§ Hipertensi karena kehamilan
 Growing Up

ALTITUDE
ACCOMPLISH ACCF/AHA
ONTARGET
CAMELOT ESH/ESC ACCORD-BP ESH/ESC AHA
HYVET ESH/ESC
REIN-2 AHA NICE ASH/ISH

2003 2005 2007 2009 2011 2014 2017 2018

JNC-7 JNC-8
New Guideline
 KLASIFIKASI HIPERTENSI
Klasifikasi Hipertensi pada orang dewasa :
•  JNC 7 (The 7th Report of The Joint National Committee on Prevention
Detection, Evaluation, and Treatment of High Blood Pressure)
•  ESC/ESH (European Society of Hypertension)
•  WHO (World Health Organization)/ISH (International Society of
Hypertension)
•  BHS (British Hypertension Society)/NICE
•  CHEP (Canadian Hypertension Education Program)
•  JNC 8 (The 8th Report of The Joint National Committee on Prevention
Detection, Evaluation, and Treatment of High Blood Pressure)
•  InaSH Konsensus Penatalaksanaan Hipertensi 2019
 KLASIFIKASI HIPERTENSI JNC 7 – 2003
Dewasa usia > 18 tahun

Tekanan darah (mm Hg) kategori

Sistolik Diastolik

<120 dan <80 Normal

120-139 atau 80-89 Prehipertensi

140-159 atau 90-99 Hipertensi stage 1

≥160 atau ≥100 Hipertensi stage 2

Hipertensi sistolik terisolasi : usia >55 tahun à TDS ≥ 140 dan TDD < 90 mmHg

Chobanian AV, et al. Hypertension 2003;42:1206-52

 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hipertensi
SBP >140 mmHg ± DBP >90 mmHg

Category Systolic Diastolic

Optimal <120 dan <80
Normal 120–129 dan/atau 80–84
Normal tinggi 130–139 dan/atau 85–89
Hipertensi ringan 140–159 dan/atau 90–99
Hipertensi sedang 160–179 dan/atau 100–109
Hipertensi berat ≥180 dan/atau ≥110
Hipertensi sistolik terisolasi ≥140 dan <90

* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic hypertension should be
graded 1, 2, or 3 according to systolic BP values in the ranges indicated.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
Powered by
 Categories of BP in Adults*
BP Category SBP DBP

Normal <120 mm Hg and <80 mm Hg

Elevated 120–129 mm and <80 mm Hg

Hg
Hypertension
Stage 1 130–139 mm or 80–89 mm Hg
Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg

*Individuals with SBP and DBP in 2 categories should be

designated to the higher BP category.
BP indicates blood pressure (based on an average of ≥2
careful readings obtained on ≥2 occasions, as detailed in DBP,
diastolic blood pressure; and SBP systolic blood pressure.

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
 BP Patterns Based on Office and Out-of-Office Measurements

Office/Clinic/Healthcare Home/Nonhealthcare/

Setting ABPM Setting
Normotensive No hypertension No hypertension
Sustained
Hypertension Hypertension
hypertension
Masked
No hypertension Hypertension
hypertension
White coat
Hypertension No hypertension
hypertension
ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.

 Berbagai Metoda
Pengukuran Tekanan Darah

Sistolik Diastolik
(mmHg) (mmHg)

TD Klinik 140 90
TD Rumah 135 85
TD Ambulatori
24 jam 130 80
Siang 135 85
Malam 120 70

Japan Society of Hypertension 2009

 Home BP vs Ambulatory BP
Home BP Ambulatory BP
•  Multiple measurements over •  BP data during routine, day-to-
several days, or even longer day activities and
periods •  during sleep
•  in the individual’s usual •  Waking surge
environment •  quantifies short-term BP
•  notes day-to-day BP variability variability
•  cheaper •  Correlation with symptoms
•  more widely available and •  Most accurate
•  more easily repeatable.
 Diagnosis Hypertension
•  If BP is only slightly elevated, repeated measurements should
be obtained over a period of several months to define the
patients ‘usual’ BP as accurately as possible

•  if BP is more marked elevation, evidence of hypertension

related organ damage or a high or very high cardiovascular
risk profile, repeated measurements should be obtained over
shorter periods of time (weeks or days)

•  In general, the diagnosis of hypertension should be based on

at least 2 BP measurements per visit and at least 2 to 3 visits,
although in particularly severe cases the diagnosis can be
based on measurements taken at a single visit.
PATHOPHYSIOLOGY
 Primary Hypertension
Pathophysiology
Ø Heredity – interaction of genetic,
environmental, and demographic factors
Ø Water & Sodium Retention – 20% of pts with
high Na+ diet develop HTN
Ø Altered Renin-Angiotensin Mechanism –
found in 20% of patients
Ø  Stress & Increased SNS Activity
Ø Insulin Resistance & Hyperinsulinemia
Ø Endothelial Cell Dysfunction
 Secondary Hypertension
Pathophysiology
•  Specific cause of hypertension can be identified
•  5+% of adult hypertension
Causes of Secondary Hypertension With Clinical Indications

Common causes
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Uncommon causes
Pheochromocytoma/paraganglioma
Cushing’s syndrome
Hypothyroidism
Hyperthyroidism
Aortic coarctation (undiagnosed or repaired)
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary aldosteronism
Acromegaly
Patofisiologi Hipertensi

MULTIFAKTORIAL
Renin Angiotensin Aldoterone System
(RAAS)
 Hypertension:
The Disease Continuum
Early Paradigm

Natural History of CVD Progression

Elevated BP Target Organ Damage

More Recent Paradigm

Vascular Dysfunction Elevated BP Target Organ Damage

A Proposed Future Paradigm

Endothelial Vascular Elevated BP Target Organ

Dysfunction Dysfunction Damage Angina
? LVH Pectoris
Renal MI Stroke
Damage
PENGUKURAN TD
 Scipione Riva rocci, 1896
menemukan sfignomanometer air raksa
 Measurement device

Aneroid Simple mercury

sphygmomanometer sphygmomanometer

Automated bp device
 Pentingnya akurasi pengukuran
tekanan darah

•  Ketidakakuratan pengukuran TD dapat menimbulkan

masalah à perbedaan 5 mmHg membawa akibat yang
besar
•  Overestimasi orang dengan prehipertensi à
hipertensi
•  Underestimasi orang dengan hipertensi à
normotensi/ klasifikasi HTN yang berbeda

Perlu diketahui faktor-faktor yang mempengaruhi

akurasi pengukuran TD
 GOAL :
CARDIOVASCULAR RISK STRATIFICATION
•  (1) blood pressure level,
•  (2) comorbidity, or Associated
Condition
•  (3) target organ damage
 Cardiovascular Risk Stratification

Blood pressure (mm Hg)

Other risk factor,

High Grade 1 Grade 2
organ damage, or Normal Grade 3 HT
normal HT HT
disease

Average Average Low added Moderate High added

No other risk factors
risk risk risk added risk risk

Low added Low added Moderate Moderate Very high

1-2 risk factors
risk risk added risk added risk added risk

≥ 3 risk factors,
Moderate High High High Very high
mets, organ
added risk added risk added risk added risk added risk
damage, or diabetes

Established CV or Very high Very high Very high Very high Very high
renal disease added risk added risk added risk added risk added risk

HT: hypertension; mets: metabolic syndrome; CV: cardiovascular

Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
TATALAKSANA
 Steps in Managing Hypertension
•  Determine Hypertension,
by measuring BP according to standard
•  (Immediate treatment for hypertensive
Urgency & Emergency)
•  Determine Risk/Global Risk and TOD
•  Plan Treatment
•  Educate Patient ( and Family)
•  Implement Treatment
•  Monitor and evaluate
•  Re-Educate
•  Further treatment
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Lifestyle changes for hypertensive patients

Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day

Moderate alcohol intake Limit to 20-30 g/day men,

10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal 25 kg/m2

Waist circumference goal Men: <102 cm (40 in.)*

Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7 days/week

(moderate, dynamic exercise)

Quit smoking

* Unless contraindicated. BMI, body mass index.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
Powered by
 JNC VII: Management of Hypertension by Blood
Pressure Classification
Initial Drug Therapy
Lifestyle Without Compelling With Compelling
BP Classification Modification Indication Indication

Normal Encourage
<120/80 mm Hg

Prehypertension Yes No drug indicated Drug(s) for the compelling

120-139/80-89 mm Hg indications

Stage 1 hypertension Yes Thiazide-type diuretics Drug(s) for the compelling
140-159/90-99 mm Hg for most; may consider indications; other
ACE-I, ARB, BB, CCB, or antihypertensive drugs
combination (diuretics, ACE-I, ARB, BB,
CCB) as needed
Stage 2 hypertension Yes 2-drug combination for most Drug(s) for the compelling
≥160/100 mm Hg (usually thiazide-type diuretic indications; other
and ACE-I, ARB, BB, or antihypertensive drugs
CCB) (diuretics, ACE-I, ARB,
BB, CCB) as needed
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker; CCB =
calcium channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.
 Adults 18 years or older with HTN

JNC 7 Implement lifestyle modifications

Not at goal BP (<140/90 or < 130/90 for

Summary patients with diabetes or CKD)

Algorithm Initial Drug Choices

No compelling Indications
(Target: <140/90)

Stage 1 HTN: Stage 2 HTN: 2-

Thiazide #1, drug combo for Compelling Indications
(Target:<140/90 or <130/80 if DM or CKD)
may consider most, thiazide +
ACEI/ARB/BB/ ACEI/ARB/BB/
CCB or combo CCB

DM: HF:
ACEI/ MI: BB, CAD: BB,
Diuretic +
ARB #1 CKD: then add then add Stroke:
ACEI, then
ACEI/ ACEI/
(may add ACEI/ ARB (may
add BB
ARB (may diuretic +
diuretic, ARB (may add ACEI
add Aldo add CCB
BB, Aldo ANT
ANT) or diuretic)
or ARB)
CCB)
 The Seventh Report of
the Joint National Committee
Compelling Diuretic ßB ACEI ARB CCB AA
Indications

Heart failure ü ü ü ü ü
Post-MI ü ü ü
High CAD risk ü ü ü ü
Diabetes ü ü ü ü ü
Chronic kidney ü ü
disease
Recurrent stroke ü ü
prevention

AA, aldosterone antagonist; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II-receptor blocker; βB, ß-blocker; CCB, calcium chann
blocker; MI, myocardial infarction;
CAD, coronary artery disease.
Chobanian AV, et al. JAMA. 2003;289(19):2560-2572.
Summary: Treatment of Systolic-Diastolic Hypertension without Other
Compelling Indications
TARGET <140/90 mmHg
Lifestyle modification
A combination of 2 first line drugs may
be considered as initial therapy if the
Initial therapy blood pressure is >20 mmHg systolic
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

2009 Canadian Hypertension Education Program Recommendations

Ps-DZ, 2009
 Algorithm for Treatment of
Hypertension
Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually thiazide-
indications
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
type diuretic and Other antihypertensive drugs (diuretics,
ACEI, or ARB, or BB, or CCB) ACEI, ARB, BB, CCB)
or combination.
as needed.

Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
 Possible Combination between some
Classes of Antihypertensive Drugs
Thiazide diuretic

BB ARB

∝-blocker CCB

Eur Heart J 2007;28:1462-1536

ACE-I
JNC 8
 JNC 8 Algorithm for the Treatment
of Hypertension
Lifestyle modifications

Set BP goal and initiate BP lowering medicationbased on age, DM and CKD

NO DM and CKD With DM or CKD

All age, DM All age, CKD

Age ≥ 60 y.o. Age < 60 y.o. with no CKD w/ or w/o DM

BP goal: BP goal: BP goal: BP goal:

SBP<150 mmHg SBP<140 mmHg SBP<140 mmHg SBP<140 mmHg
DBP <90 mmHg DBP <90 mmHg DBP <90 mmHg DBP <90 mmHg

Initiate ACEI or ARB

Nonblack Black alone or in
Initiate Diuretik,
ACEI, ARB or CCB Initiate Diuretik, or combination w/
alone or in CCB alone or in other drug class (a)
combination (a) combination

James PA, et al. JAMA. December 18, 2013

 Select a drug treatment titration strategy
a.  Maximize 1st med before adding 2nd
b.  Add 2nd med before reaching max dose of 1st med
c.  Start w/ 2 med classes separately or as fixed-dose combination
At goal BP? Yes
No
Reinforce med and lifestyle adherence.
A & B: add and titrate diuretics or ACEI or ARB or CCB (use med class not
previously selected & avoid combined use of ACEI & ARB).
C: titrate dose of initial med to max

At goal BP?
Yes
No
Reinforce med and lifestyle adherence.
Add & titrate diuretic or ARB or ACEI or CCB (use med class not
previously selected & avoid combined use of ACEI & ARB)

At goal BP?
Yes
No
Reinforce med and lifestyle adherence.
Add additional med class (eg BB, AA or others) & or refer to MD w/
expertise in HT management

No At goal BP?
Yes Continue
current
treatment &
a: ACEI & ARB should not be used in combination monitoring (b)
b: If BP fails to be maintained at goal, reenter the algorithm where appropriate based on the
current individual therapeutic plan James PA, et al. JAMA. December 18, 2013
 2014 JAMA Hypertension Guideline
Recommendations
Recommendation Level of Evidence
1. General population > 60 y/o, initiate medications and treat to BP A
goal of 150/90 mmHg.
2. General population < 60 y/o, initiate medications and treat to A/E
DBP goal of 90 mmHg.
3. General population < 60 y/o, initiate medications and treat to E
SBP goal of 140 mmHg.
4. In population > 18 y/o with CKD, initiate medications and treat to E
BP goal of 140/90 mmHg.
5. In population > 18 y/o with DM, initiate medication and treat to E
BP goal of 140/90 mmHg.
 2014 JAMA Hypertension Guideline
Recommendations
Recommendation Level of Evidence
6. In nonblack population (including DM), initial anti-hypertensive B
therapy should consist of thiazide diuretic, CCB, ACE-I or ARB.
7. In general black population (including DM), initial anti-hypertensive C
therapy should include thiazide diuretic or CCB.
8. In population with CKD, initial (or add-on) anti-hypertensive B
therapy should include ACE-I or ARB.
9. Main objective of therapy is to attain and maintain a BP goal and E
can be accomplished in one of two ways if not accomplished with
initial therapy:
1. Increase dose of initial agent.
2. Add a second or, eventually, third agent from above list.
ACE-I and ARB should not be used in combination. Other agents may
be necessary if goal BP cannot be attained or maintained from above
list.
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Blood pressure goals in hypertensive patients

Recommendations
SBP goal for “most” <140 mmHg
• Patients at low–moderate CV risk
• Patients with diabetes
• Consider with previous stroke or TIA
• Consider with CHD
• Consider with diabetic or non-diabetic CKD

SBP goal for elderly 140-150 mmHg

• Ages <80 years
• Initial SBP ≥160 mmHg

SBP goal for fit elderly <140 mmHg

Aged <80 years

SBP goal for elderly >80 years with SBP 140-150 mmHg
• ≥160 mmHg

DBP goal for “most” <90 mmHg

DB goal for patients with diabetes <85 mmHg

SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.

The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information – for all Media, all Disciplines, from all over the World
Powered by
BP goal in the elderly
 HTN in the Elderly
•  Comparison:
–  2014 JAMA: > 60 y/o = < 150/90

–  ESH/ESC: >80 y/o or elderly < 80 y/o = < 150/90

–  CHEP: >80 y/o = < 150/90

–  NICE: > 80 y/o = < 150/90

–  ASH/ISH: > 80 y/o = < 150/90
Panduan Tatalaksana Hipertensi
Ina-SH
 Krisis Hipertensi
•  Hypertensive emergencies are acute, severe
elevations in blood pressure ( HT grdae III) that
are accompanied by progressive target organ
dysfunction such as myocardial or cerebral
ischemia/infarction, pulmonary edema, or renal
failure.
•  Hypertensive urgencies are acute (HT grade III),
severe elevations in blood pressure without
evidence of progressive target organ
dysfunction
PROGNOSIS
TERIMA KASIH