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Introduction
Definisi
Etiologi dan Faktor Resiko
Tipe hipertensi
Patofisiologi
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Penanganan
Introduction
BP is an important characteristic of our
body.
Without BP, nutrients, oxygen, and
proteins couldnot travel from the arterial
side of the body to the venous side.
Hypertension is a serious national public
health problem, but its causes are largely
unknown
Numerous potential complications of
hypertension
mortality rate
Complications of hypertension include:
Stroke
MI
Heart Failure
Renal Failure
treated
Consequences of Hypertension
CNS - Stroke, retina
damage
Kidneys - renal
failure, proteinuria
Peripheral Vascular
disease
Hypertension is defined as a
- venous
return
- extracellular fluid volume
- myocardial contractility
- vasoactive
substances
- thickening of arteriolar
wall
<120/<80
121-139/80-89
140-159/90-99
>160/>100
>180/>110)
Hypertensive Emergency
Acute, rapidly evolving end-organ damage
Hypertensive Urgency
DBP > 120 that requires control in BP over 24
to 48 hours
No end organ damage
90mmHG
60% of hypertensives > 80 years old
From age 35/40 many people have
elevated systolic or diastolic pressure
and this elevation leads to the
widening and stiffening of the aorta
elasticity and compliance of the
large blood vessels SBP and
DBP
Medical History
Duration and classification of
hypertension.
Patient history of cardiovascular disease.
Family history.
Symptoms suggesting causes of
hypertension.
Lifestyle factors - Ethanol intake.
Current and previous medications.
minutes of rest.
should be used.
Advantages of Self-Measurement
Identifies white-coat hypertension.
Assesses response to medication.
Improves adherence to treatment.
Potentially reduces costs.
Usually provides lower readings than
Fig. 1 : Some of the factors involved in the control of blood pressure that
affect the basic equation : blood pressure cardiac output x peripheral
resistance.
ANGIOTENSINOGENE
J-G
RENIN
ANGIOTENSIN I
ACE
VASOCONSTRICTION
ANGIOTENSIN II
ALDOSTERON
Na+ RETENTION
BLOOD PRESSURE
Risk Factors
1- Age and Sex
2- Race
3- Family History
Level of BP is strongly familial
4- Smoking
Nicotine constricts blood vessels
Aetiology cont.
Primary hypertension
6- Alcohol
Alcohol increases plasma catecholamine.
(epinephrine and no epinephrine)
7- Sedentary life styles
Regular physical activity can help control
weight and reduce cardiovascular risk.
Aetiology cont.
Primary hypertension
8- Socioeconomic status
It is more prevalent in low socioeconomic
groups and among the less educated.
9- Emotional stress
Stress stimulate sympathetic
nervous systems.
Secondary Hypertension
It develops as a consequence of a
hyperaldosteronism
head injury
Obesity
Obesity= excessive glucose concentration in
Stress
Stress causes temporarily increase in
Salt
Increased salt intake renal sodium
Pathogenesis
Blood pressure is controlled by a
Pathogenesis
Rarely is a single factor in the
Pathogenesis
90-95% of hypertension is primary or
essential hypertension.
Hypertension requires the
participation of the kidney, the heart
and blood vessels
Pathophysiology Cont.
Inability of the kidneys to excrete sodium,
Pathophysiology Cont.
An overactive rennin / Angiotensin leads
Clinical Manifestations
It include
Fatigue, reduced activity tolerance, dizziness,
palpitation, angina, and dyspnoea, early
morning headache, blurred vision,
spontaneous nose- bleed ,and depression.
Diagnostic Studies
The initial diagnosis of hypertension is
Management
P
RSM
With Compelling
Indications
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension
specialist.
Management
Lifestyle modification.
Weight reduction and regular mild exercise
reduce resting heart rate and blood pressure.
Reducing sodium (salt) diet is proven very
Management
Lifestyle modification cont.
consumption.
Treatment : Antihypertensives
ACE Inhibitors, ARBs
Beta blockers
Calcium cannel blockers
Centrally acting alpha-agonist
Diuretics
Direct Vasodilators
DRUG THERAPY
Younger patients :
Older patients :
ACEI / ATII
B blocker
Ca channel blocker
Diuretic (thiazide)
ACE Inhibitors
2nd line to diuretics for most patients
Block angiotensin I to angiotensin II conversion
ACE (Angiotensin Converting Enzyme)
49 49
ACE Inhibitors
Monitor serum K+ & SCr within 4 weeks of
angioedema
hyperkalemia: particularly in patients with CKD
or DM
neutropenia, agranulocytosis, proteinuria,
glomerulonephritis, acute renal failure
50
ACE Inhibitor
Captopril: 12,5 mg, 25 mg, 50 mg
Enalapril : 5 mg
Fosinopril
Lisinopril
Perindopril
Quinapril
Ramipril
Trandolapril
ARBs
Angiotensin II Receptor Blockers
Angiotensin II generation
renin-angiotensin-aldosterone pathway
alternative pathway using other enzymes
such as chymases
receptor
ACE inhibitors partially block effects of
angiotensin II
52
ARBs
Do not block bradykinin breakdown
less cough than ACE Inhibitors
Adverse effects:
orthostatic hypotension
renal insufficiency
hyperkalemia
53
ANGIOTENSIN II RECEPTOR
ANTAGONISTS
Hypertension
Renin
Angiotensinogen
Angiotensin I
ACE
X
X
Aldosterone
secretion
Renal tubular
reabsorption of
sodium and water
Angiotensin II
Non-ACE alternate
pathways (eg, chymase)
ARB
Vasoconstriction
AT1 receptors
Catecholamine
secretion
Antidiuretic hormone
(vasoprressin)
secretion
X
X
BP
56 56
aldosterone antagonists
57
certain patients
trimester
58
Renin Inhibitor
1st agent FDA approved in 2007: aliskiren
Inhibits angiotensinogen to angiotensin I conversion
FDA approved as monotherapy & combination
therapy
Efficacy demonstrated with other antihypertensives
including amlodipine, HCTZ, ACEIs/ARBs
Does not block bradykinin breakdown
less cough than ACE Inhibitors
Adverse effects: orthostatic hypotension,
hyperkalemia
59
60 60
-Blockers
Inhibit renin release
weak association with antihypertensive effect
effects reduce CO
activity (ISA)
do not reduce CO
lower BP
decrease peripheral resistance
Membrane-stabilizing action on cardiac cells at
61
-Blockers
Adverse effects:
bradycardia
atrioventricular conduction abnormalities
acute heart failure
abrupt discontinuation may cause rebound
-Receptors
Distributed throughout the body
concentrate differently in certain organs & tissues
1 receptors:
heart, kidney
stimulation increases HR, contractility, renin
release
2 receptors:
lungs, liver, pancreas, arteriolar smooth muscle
stimulation causes bronchodilation & vasodilation
mediate insulin secretion & glycogenolysis
63
Cardioselective -Blockers
Greater affinity for 1 than 2 receptors
inhibit 1 receptors at low to moderate dose
higher doses block 2 receptors
64
-Blockers
Cardioselective
atenolol, betaxolol, bisoprolol, metoprolol,
nebivolol
Nonselective
nadolol, propranolol, timolol
Nonselective -Blockers
Inhibit 1 & 2 receptors at all doses
Can exacerbate bronchospastic
disease
Additional benefits in:
essential tremor
migraine headache
thyrotoxicosis
66
blood flow
No clear advantage except patients with
bradycardia who must receive a -blocker
Contraindicated post-myocardial infarction &
for patients at high risk for coronary disease
May not be as cardioprotective as other blockers
Rarely used
67
orthostatic hypotension
68
CCBs
Calcium Channel Blockers
Inhibit influx of Ca2+ across cardiac &
dihydropyridines vs non-dihydropyridines
different pharmacologically
similar antihypertensive efficacy
69
CCBs
Dihydropyridines:
amlodipine, felodipine, isradipine,
Non-dihydropyridines:
diltiazem, verapamil
CCBs
Dihydropyridines:
baroreceptor-mediated reflex tachycardia due
Non-dihydropyridines:
decrease HR, slow atrioventricular nodal
conduction
may treat supraventricular tachyarrhythmias
71
Non-dihydropyridine CCBs
ER products preferred for HTN
Block cardiac SA & AV nodes: reduce HR
May produce heart block
Not AB rated as
interchangeable/equipotent due to
different release mechanisms &
bioavailability
Additional benefits in patients with atrial
tachyarrhythmia
72
Dihydropyridine CCBs
Avoid short-acting dihydropyridines
particularly IR nifedipine, nicardipine
syndrome
Effective in older patients with isolated
systolic HTN
73
1-Blockers
Not appropriate monotherapy for HTN
Inhibit smooth muscle catecholamine
orthostatic hypotension
1st dose phenomenon: transient dizziness,
1-Blockers
1st dose at bedtime
Used with diuretics to minimize edema
Caution in elderly patients
Reduce benign prostatic hypertrophy
symptoms
on the prostate
relaxation
decreased urinary outflow resistance
75
Central 2-Agonists
Stimulate 2-adrenergic receptors in
the brain
Central 2-Agonists
Adverse effects:
sodium/water retention
abrupt discontinuation may cause rebound
HTN
depression
orthostatic hypotension
dizziness
77
Central 2-Agonists
Most effective if used with a diuretic
minimizes fluid retention
initiation/discontinuation
78
syndrome
Minoxidil can cause hypertrichosis
80
Reserpine
Peripheral adrenergic antagonist
depletes norephinephrine from sympathetic nerve
Reserpine
Adverse effects:
sedation
depression
decreased CO
sodium/water retention
increased gastric acid secretion
diarrhea
bradycardia
82
83
Diuretics
Exact hypotensive mechanism unknown
Initial BP drop caused by diuresis
reduced plasma & stroke volume decreases
CO and BP
causes compensatory increase in peripheral
vascular resistance
Extracellular & plasma volume return to near
pretreatment levels with chronic use
peripheral vascular resistance becomes lower
than pretreatment values
results in chronic antihypertensive effects
84
Diuretics
Thiazide
chlorthalidone, hydrochlorothiazide (HCTZ),
indapamide, metolazone
Loop
bumetanide, furosemide, torsemide
Potassium-sparing
amiloride, triamterene
Aldosterone antagonists
eplerenone, spironolactone
85
Thiazide Diuretics
Dose in morning to avoid nocturnal diuresis
Adverse effects:
hypokalemia, hypomagnesemia, hypercalcemia,
8686
Loop Diuretics
Dose in AM or afternoon to avoid
nocturnal diuresis
Higher doses may be needed for patients
with severely decreased glomerular
filtration rate or heart failure
Adverse effects:
hypokalemia, hypomagnesemia,
hypocalcemia, hyperuricemia,
hyperuricemia
87
Potassium-sparing Diuretics
Dose in AM or afternoon to avoid nocturnal
diuresis
Generally reserved for diuretic-induced
hypokalemia patients
Weak diuretics, generally used in
combination with thiazide diuretics to
minimize hypokalemia
Adverse effects:
88
Aldosterone antagonists
Dose in AM or afternoon to avoid nocturnal diuresis
Due to increased risk of hyperkalemia, eplerenone
89
Orthostatic Hypotension
Decrease in SBP > 20 mmHg or DBP > 10
Monitoring Antihypertensives
Class
Parameters
Diuretics
blood pressure
BUN/serum creatinine
serum electrolytes (K+, Mg2+, Na+)
uric acid (for thiazides)
-Blockers
blood pressure
heart rate
Aldosterone antagonists
ACE inhibitors
Angiotensin II receptor
blockers Direct Renin
inhibitors
blood pressure
BUN/serum creatinine
serum potassium
blood pressure
heart rate
DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:A Pathophysiologic Approach, 7th
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Edition: http://www.accesspharmacy.com/