EDDY WIRAWAN,SpJP.

FIHA

SMF.Penyakit Jantung
RSUD. ULIN BANJARMASIN
Hypertension: definition
Hypertension is the presence of abnormally raised blood
pressure in an individual
It is a progressive cardiovascular syndrome associated with
target organ damage, often present before high BP values are
observed
hypertension cannot be classified solely by discrete blood
pressure thresholds
Historically, diastolic blood pressure (DBP) has been
considered the most important marker for hypertension
However, raised systolic blood pressure (SBP) represents a
greater risk than raised DBP
Raised SBP without significantly raised DBP is termed isolated
systolic hypertension (ISH)

Giles et al. J Clin Hypertens (Greenwich) 2005;7:505512

ESH Guidelines. J Hypertens 2003;21:10111053
JNC 7. JAMA 2003;289:25602572
Hypertension: causes
More than 95% of cases have no primary identified cause and
are referred to as "essential hypertension
Some (<5%) of patients have hypertension resulting from
underlying renal or adrenal disease
blood pressure across populations Essential hypertension
results from the interaction of environmental factors
diet
physical inactivity
stress
alcohol
with genetic factors
account for approximately 30% of the variation in

Beevers et al. BMJ 2001;322:912916

Hypertension: pathophysiology
Numerous factors contribute to the
pathophysiology of hypertension
Systemic and local renin-angiotensin system
Sympathetic nervous system
Insulin resistance
Obesity
Arterial stiffness
Vasoactive substances, such as nitric oxide and
endothelin
Endothelial function
Kallikrein-kinin system
Natriuretic peptides

Beevers et al. BMJ 2001;322:912916

Prevalence of hypertension*
Prevalence increases with age

88 Men
Women
70

53

Prevalence of hypertension (%)

35

18

0
20-29 30-39 40-49 50-59 60-69 70+
Age range

* SBP >140 mmHg, DBP >90 mmHg, or on

antihypertensive treatment Kearney et al. Lancet 2005;365:217223
 Prevalences of HTN in Indonesia
(Basic Health Research - 2007)
Recruited 19.114 person-across 438 districts
(percentage)

(Indonesia Ministry of Health Affair

 Trends in the Awareness, Treatment,
and Control of Hypertension in the
U.S. 80
73
70 68

60 55 53
51
50 Awareness
Treated
(%)
40 Controlled
31 29
30 27

20
10
10

0
NHANES II NHANES III NHANES III
(1976-1980) (Phase I) (Phase II)
(1988-1991) (1991-1994)
Controlled BP = SBP <140 mm Hg and DBP <90 mm Hg.
The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatmen
of High Blood Pressure. Arch Intern Med. 1997;157:24132446.
CARDIOVASCULAR MORTALITY RISK DOUBLES
WITH EACH 20/10 MMHG INCREMENT*

CV mortality risk
8
8x
6

4
4x
2
2x
1x
0
115/75 135/85 155/95 175/105
SBP/DBP (mmHg)

*Individuals aged 4069 years 8

Lewington et al. Lancet 2002;360:190313
 Cardiovascular Risk Factors
Probability (per 1000)
800
Diastolic blood pressure (105 mmHg)
Systolic blood pressure (195 mmHg)
600

400

200

0
No risk +High +Glucose +Smoking +LVH
factors cholesterol intolerance

Castelli (1984)
Benefit of Lowering BP

Average percent reduction

Stroke incidence 35 40 %

Myocardial
20 25 %
infarction

Heart failure 50 %
CLASSIFICATION OF BLOOD PRESSURE IN US ADULTS:
JNC VII GUIDELINES

BP category Systolic Diastolic

(mmHg) (mmHg)
Normal <120 and <80
Pre-hypertension 120139 or 8089
Hypertension, 140159 or 9099
stage 1
Hypertension, 160 or 100
stage 2
Chobanian et al.12
JAMA 2003;289:256072
Hypertension: classification
JNC 7 ESH
Normal SBP <120 and Normal SBP 120129 or
DBP <80 DBP 8084
Pre-hypertension SBP 120139 or High normal SBP 130139 or
DBP 8089 DBP 8589
Stage 1 SBP 140159 or Grade 1 SBP 140159 or
DBP 9099 DBP 9099
Stage 2 SBP 160 or Grade 2 SBP 160179 or
DBP 100 DBP 100109
Grade 3 SBP 180 or
DBP 110

ESH Guidelines. J Hypertens 2003;21:10111053

JNC 7. JAMA 2003;289:25602572
 RAA-System- Intervension of ACE-I

BRADYKININ SYSTEM ANGIOTENSIN SYSTEM

Kininogen Angiotensinogen
Kallikrein ACE-I Renin

Bradykinin Ang I
Endothelium
+ + _ ACE _
(enzyme)

Prostaglandin Inactive Ang II

NO
peptide

Potentiation of
sympathetic activity
SMC Vasodilation Vaso
mitogenesis constriction
platelet FGF Aldosterone
aggregation PDGF release
JNC VII AND ESHESC SUMMARY :
Target Blood Pressure Goals

Type of hypertension BP goal (mmHg)

Uncomplicated <140/90
Complicated
Diabetes mellitus <130/80
Kidney disease <130/80

Chobanian et al. JAMA 2003;289:256072

Guidelines Committee. J Hypertens 2003;21:101153
Hypertension: assessment
For office measurements, the auscultatory technique with a
mercury sphygmomanometer is the method of choice
Home blood pressure monitoring (HBPM) avoids white-coat
hypertension and allows blood pressure to be assessed at
different times
24-hour ambulatory blood pressure monitoring (ABPM) gives
a better prediction of risk
ABPM is a non-invasive, automated procedure, often
using an oscillometric technique
24-h mean blood pressure is typically lower than office
blood pressure
Optimal 24-h mean SBP/DBP is <125/75 mmHg

Pickering et al. Circulation 2005;111:697716

 DETERMINANTS OF
VENTRICULAR FUNCTION
CONTRACTILITY
CONTRACTILITY

PRELOAD
PRELOAD AFTERLOAD
AFTERLOAD

STROKE
STROKE
VOLUME
VOLUME

-- Synergistic
Synergistic LV
LV contraction
contraction
HEART
HEART
-- LV
LV wall
wall integrity
integrity
-- Valvular
Valvular competence
competence RATE
RATE

CARDIAC
CARDIAC OUTPUT
OUTPUT
Target-organ damage increases cardiovascular risk

Endothelial dysfunction

The endothelium plays a key role in controlling peripheral

arteriolar resistance
Endothelial dysfunction can be observed as an inappropriate
response to vasodilators/vasoconstrictors
Nitric oxide is a key endogenous vasodilator
It is one of the earliest markers for target-organ damage
It is associated with cardiovascular disorders such as
atherosclerosis, hypertension and heart failure
In the kidney, it is associated with fibrosis, vascular smooth
muscle proliferation and, eventually, renal dysfunction

Klahr, Morrissey. Kidney Int Suppl 2000;75:S7S14

 The
The Progression
Progression from
from
hypertension
hypertension
to
to congestive
congestive heart
heart failure
failure
Diastolic
LVH dysfunction

Hypertension CHF Death

MI Systolic
dysfunction

Normal LV LV Subclinical Overt

Structure & Functionremodeling LV dysfunction Heart Failure

Time Time
(decades) (months)

Vasan RS, Levy D. 1996. Arch Intern Med 156 : 1759-

JNC VII: ALGORITHM FOR TREATMENT
OF HYPERTENSION
Lifestyle modifications

Not at goal BP*

HTN without HTN with compelling

compelling indications indications

Drug(s) for the

Stage 1 Stage 2
compelling indications
Thiazide-type diuretics Two-drug combination
Other antihypertensive
for most. May consider for most (usually
drugs (diuretics, ACE
ACE inhibitor, ARB, - including thiazide-type
inhibitor, ARB, -
blocker, CCB, or diuretic)
blocker, CCB) as
combination
needed

If not at goal, optimise dosages or add additional drugs until goal BP is achieved.
Consider consultation with hypertension specialist

goal <140/90 mmHg or <130/80 mmHg for those 24

h diabetes or chronic kidney disease Chobanian et al. JAMA 2003;289:256072
UPDATED UK NICE GUIDELINES FOR THE
TREATMENT OF NEWLY DIAGNOSED HYPERTENSION
55 years or black
<55 years
at any age

CCB or thiazide-
Step 1 ACEI (or ARB*)
type diuretic

ACEI (or ARB*) + CCB or

Step 2
ACEI (or ARB*) + thiazide diuretic

Step 3 ACEI (or ARB*) + CCB + diuretic

Add further diuretic therapy, -blocker, or -blocker.

Step 4
Consider seeking specialist advice

*If ACE inhibitor (ACEI) not tolerated http://www.nice.org.uk/download.aspx?o=CG034fullguideline.

 ESH-ESC Guidelines 2007
Treatment algorithms

Mild BP elevation Choose between Marked BP elevation

Low/moderate CV risk High/very high CV risk
Conventional BP Lower BP target
target

Single agent Two-drug combination

at low dose at low dose
If goal BP not
achieved
Previous agent Switch to different Previous combinaton Add a third dose
at full dose agent at full dose at low dose
at low dose
If goal BP not
achieved

Two-to three-drug Full dose Two-to three-drug

combination at full monotherapy combination at full
dose dose
Monotherapy versus combination therapy
strategies

J Hypertens. 2007;25:11051187.
Faktor Tekanan darah (mmHg)
risiko Normal Hipertensi Hipertensi Hipertensi
kerusakan tinggi derajat I derajat II derajat III
target oran (TDS 130 (TDS 130 (TDS 130 (TDS 130
yang 139 atau 139 139 139
asimomati TDD 85 atau TDD Atau TDD Atau TDD
k atau 89) 85 89) 85 89) 85 89)
penyakit

Tanpa FR Risiko Risiko Risiko

lain rendah sedang tinggi
1 2 FR Risiko Risiko Risiko Risiko
rendah sedang sedang tinggi
tinggi
3 FR Risiko Risiko Risiko Risiko
Rendah Sedang tinggi tinggi
sedang tinggi
OD, CKD Risiko Risiko Risiko Risiko
std 3 atau Sedang tinggi tinggi tinggi
DM -tinggi sangat
tinggi
CVD Risiko Risiko Risiko Risiko
simtomatik sangat sangat sangat sangat
, CKD std tinggi tinggi tinggi tinggi
4 atau DM
 Kenaikan TD pada pengukuran di luar klinik Kenaikan TD pada pengukuran acak di klinik

Kunjungan Hipertensi 1 Pengukuran TD, Anamnesis, dan

Pemeriksaan fisik
Hipertensi urgensi / emergensi
Permintaan uji diagnostik pada kunjungan 1

Kunjungan Hipertensi 2 dalam 1 bulan YA

TD 180/110 mmHg ATAU Diagnosisi Hipertensi

TD 140-179/90-109 mmHg dengan kerusakan target organ
TIDAK
Td 140-179 / 90-109 mmHg

Pengukuran TD Klinik ABPM (jika tersedia) HBPM (jika tersedia)

Kunjungan hipertensi 3
< 135/85
TD bangun < TD bangun < ATAU 135 SBP atau
160 SBP atau Diagnosis
135/85 135/85 85 DBP
100 DBP hipertensi Ulang HBPM
atau 85 DBP
< 160 / 100 ABPM atau HBPM 24 jam 24 jam
Atau jika tersedia < 130/80 < 130 SBP Bila< 135/85
Kunjungan hipertensi 4 -5 80 DBP
140 SBP atau Diagnosis
90 DBP hipertensi
Diagnosis Diagnosis
Lanjutkan kontrol Lanjutkan kontrol
<140 / 90 Lanjutkan kontrol Hipertensi Hipertensi
Bila TD selalu normal tinggi (130-139/85-89), pasien harus dimonitor rutin
setiap tahun
Diagnostic evaluation
Family and clinical history
Duration and previous level of high BP
Indications of secondary hypertension
Risk factors
Symptoms of organ damage
Previous antihypertensive
therapy(efficacy,adverse event)
Personal,family,environmental factors
Diagnostic evaluation
Physical examinations
Signs suggesting secondary
hypertension
Signs of organ damage
Evidance of visceral obesity
Laboratory investigation
ROUTINE TESTS
Fasting plasma glucose
Serum total cholesterol
Serum LDL-cholesterol
Serum HDL-cholesterol
Fasting serum triglycerides
Serum potassium
Serum uric acid
Serum creatinine
Hemoglobin and hematocrit
Urinalysis ( complemented by microalbuminuria
dipstick test and microscopic examination )
ECG
Estimated creatinine clearance (Cockroft-Gault
formula)
Laboratory tests
Routine Tests
Electrocardiogram
Urinalysis
Blood glucose and hematocrit
Serum potasium , creatinine,or the corresponding
estimate GFR
Lipid profile after 9-12 hour fast that includes HDL,LDL
and TG

Optional test
Measurement of urinary albumin excretion

More extensive testing for identifiable causes is not

generaly indicated unless BP control is not achived
Laboratory investigation
RECOMMENDED TESTS
Echocardiogram
Carotid ultrasound
Quantitative proteinuria ( if dipstick
positive)
ABI Blood pressure
Funduscopy
Glucose tolerance test
Home and 24 h BP monitoring
Pulse wave velocity measurement
Extended evaluation( domain of the
specialist )

Further search for cerebral ,

cardiac,renal and vascular damage.
Mandatory in complicated hypertension.
Search for secondary hypertension
when suggested by history,physical
examination or routine
test;measurement of
renin,aldosterone,corticosteroids,catech
olamines in plasma and/or urine ,
arteriografi ,renal and adrenal
ultrasound , CT
 Thiazede diiuretic

Angiotensin
Beta-blockers receptor
blockers

Alpha-blockers Calcium
antagonist

ACE-inhibitors
Classification and Management of BP for Adult
Aged 18 Years or Older ( JNC-VII )

Management

Initial Drug Therapy

BP Systolic Diastolic Lifestyle

Classification mmHg mmHg Modification Without Compelling Indication With
Compelling Indication

Normal < 120 and < 80 Encourage

Prehypertension 120-139 or 80-89 Yes No antihypertesive drug Drug(s)for
compelling
Stage 1 140-159 or 90-99 Yes Thiazide for most Drug(s)for
compelling
Hypertension may consider ACE inh indications
ARB, blocker,CCB,or Other
antihypertensive drugs
combination
(diuretics,ACE inhib,ARB,

blocker,CCB as need

Stage 2 160 or 100 Yes 2-Drug combination for most Drug(s)for the
compelling
Hypertension (usually thiazide and ACE inhib indications
or ARB or blocker or CCB) Other antihypertensive
Cardiovascular Risk Factors

Major Risk Factors

Hypertension
Cigarette smoking
Obesity ( BMI 30 )
Physical Inactifity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR < 60 mL/min
Age ( > 55 years for men,> 65 years for
women )
Family history of premature cardiovascular
disease
Target Organ Damage
Heart
Left ventricular hypertrophy
Angina or myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or TIA
Chronic kidney disease
Peripheral arterial disease
Retinopathy
Treatment Overview
Goal of therapy
Lifestyle modification
Pharmacologic treatment
Algorithm for treatment of
hypertension
Classification and management
of BP for adults
Follow up and monitoring
Lifestyle Modifications to Manage
Hypertension
Approximate Systolic BP
Modification Recommendation Reduction,Range

Maintain normal body weight

Weight reduction ( BMI, 18.5-24.9 )
5-20 mmHg/10-kg weight loss

Consume a diet rich in

Adopt DASH fruits,vegetables,and low fat
dairy products with reduced 8 14 mmHg
eating plan content of saturated and total
fat
Reduce dietary sodium intake
Dietary sodium to no more than 100 mEq/L
2 8 mmHg
reduction (2.4 g sodium or 6 g sodium
chloride)
Engage in regular aerobic
physical activity such brisk
Physical activity walking (at least 30 minutes 4 9 mmHg
per day, most days of the
week)
Limit consumption to no more than 2
drinks per day (1 oz or 30 ml ethanol
Moderation of eg. 24 oz beer,10 oz wine) in most
2 4 mmHg
alcohol consumption men and no more than 1 drink per
day in women and lighter-weight
persons
Special Considerations
Compeling Indications
Other special situations
Minority populations
Obesity and the metabolic syndrome
LVH
PVD
Hypertension in older persons
Dimentia
Hypertension in women
Hypertension urgencies and emergencies
Identifiable Causes of Hypertension
Sleep apnea
Drug-induced or drug-related
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and cushing
syndrome
Pheochromocytoma
Coarctation of aorta
Thyroid or parathyroid disease
Goals of Therapy

Reduce CVD and renal morbidity and

mortality

Treat to BP < 140/90 mmHg or

BP < 130/80 mmHg in patients with
diabetes or chronic kidney disease

Achieve SBP goal especially in persons 50

years of age
New Features and Key
Messages
For persons over age 50, SBP is a more important
than DBP as CVD risk factor

Starting at 115/75 mmHg CVD risk doubles with

increment of 20/10 mmHg throughout the BP range

Persons who are normotensive at age 55 have a 90%

lifetime risk for developing HTN

Those with SBP 120 139 mmHg or 80 89 mmHg

should be considered prehypertensive who require
health promoting lifestyle modifications to prevent
CVD