HIPERTENSI

Divisi Kardiologi
Bagian Ilmu Penyakit Dalam
FK Universitas Islam Sultan Agung Semarang
2017
 The ‘rule of halves’ – the need for effective
diagnosis and treatment of hypertension

Proportions of the general population who have undiagnosed

hypertension (160/95 mmHg) or who are untreated or
inadequately treated (Scotland, 1984-1986)
◼ Undiagnosed hypertension
◼ Diagnosed but untreated
◼ Treated but uncontrolled
Men (n=1262) ◼ Treated and controlled Women (n=1061)

Smith et al (1990)
 Blood Pressure Classification
JNC-VII 2003

BP Classification SBP mmHg DBP mmHg

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 140–159 or 90–99

Hypertension
Stage 2 >160 or >100
Hypertension
Diagnostic evaluation
 Types of hypertension
◼ Essential Hypertension
hypertension with no apparent cause 90-95%

◼ Secondary Hypertension
hypertension of known cause
◼ chronic renal diseases 2.5-5%
◼ Renovascular diseases 0.5-4%
◼ Oral contraceptive pills 0.2-1%
◼ Coarctation of the Aorta 0.1-1%
◼ Primary aldosteronism 0.1-0.5%
◼ Pheochromocytoma 0.1-0.2%
Garry P. Reams & John H. Bauer
 Risk Factors

◼ Age
◼ Gender
◼ Race
◼ Genetic factors
◼ other:
• obesity
• high alcohol intake
• high Na intake
• abnormal renin values
• high stress level
• low birth weight
• drugs
 Complications of HTN
1 Vascular
2 Retinal

3 Cardiac

4 CNS

5 Renal
 Vascular Complications
Komplikasi pada pembuluh darah
◼ Arterioscelorosis
•  wall:lumen ratio
• remodeling
◼ Atherosclerosis
• Plaque
◼ Fibrous cap
◼ necrotic center
◼ Fibrinoid necrosis.
◼ Aortic dissection.
 Retinal complications
◼ Hypertensive
retinopathy Venous
tapering
Increased light
reflexes from
Blurred optic
arterioles
disc

Punctate
hard
exudate

Normal hemorrhage

KW : I - IV
 Cardiac complications
Left ventricular myocardium Coronary vascular bed
(myocardial factor) (coronary factor)

Hypertrophy Dilatation CAD Coronary

Microangiopathy

Decrease in contractility
Abnormal increase in c. resistance

Impairement in LV fuction Impairment of O2 availability

Coronary insufficiency, MI
Heart failure Heart failure
This left ventricle is very thickened (slightly over 2 cm in
thickness), but the rest of the heart is not greatly enlarged. This is
typical for hypertensive heart disease. The hypertension creates a
greater pressure load on the heart to induce the hypertrophy.
 CNS Complications
◼ Hypertensive
encephalopathy
◼ Cerebral
hemorrhage
◼ Ischemic stroke
◼ TIAs
 Renal Complications
◼ Benign arteriolar Nephrosclerosis
◼ Malignant arteriolar

Nephrosclerosis
◼ Chronic Renal Failure
lanjutan
 Goal of Hypertension
Prevention and Management
◼ To reduce morbidity and mortality by the
least intrusive means possible. This may
be accomplished by achieving and
maintaining:

• SBP < 140 mm Hg

• DBP < 90 mm Hg

• controlling other cardiovascular risk

factors
 Anti-Hypertensive Drugs:
Sites of Action
Blood Cardiac Total
Pressure = Output X Peripheral
Resistance
-Blockers ACE Inhibitors
AT1 Blockers
a-Blockers
a2-Agonists
CCBs* CCBs
DA1 Agonists
Diuretics Diuretics
Sympatholytics
Vasodilators

* = non-dihydropyridine CCBs
 Classification and Management
of BP for adults (JNC-VII 2003)
Initial drug therapy
BP SBP* DBP* Lifestyle
classificati mmH mmH modificat Without compelling With
on g g ion indication compelling
indications
Normal <120 and Encourag
<80 e
Prehyperte 120– or 80– Yes No Drug(s) for
nsion 139 89 antihypertensive compelling
drug indicated. indications. ‡

Stage 1 140– or 90– Yes Thiazide-type Drug(s) for the

Hypertensi 159 99 diuretics for most. compelling
on May consider ACEI, indications.‡
ARB, BB, CCB, or Other
combination. antihypertensiv
Stage 2 >160 or Yes Two-drug combination e drugs
Hypertensio >100 for most† (usually (diuretics,
n thiazide-type diuretic ACEI, ARB, BB,
*Treatment determined by highest BP category. and ACEI or ARB or BB CCB) as
or CCB).
†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. needed.
 Treatment of Hypertension
Background

• Hypertension is the major risk factor for coronary

heart disease and congestive heart failure
• Hypertension is second only to diabetes as the cause
of renal failure
• In a recent meta analysis, treating hypertension
reduced the incidence of stroke by 38% and
coronary heart disease by 16%
• In a US survey, only 21% of hypertensive patients
had their blood pressure controlled at <140/90
mmHg
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Initiation of lifestyle changes and antihypertensive drug treatment

Blood pressure (mmHg)
Other risk factors,
asymptomatic organ damage or High normal SBP Grade 1 HT SBP Grade 2 HT Grade 3 HT
disease 130−139 140−159 or DBP SBP 160−179 SBP ≥180
or DBP 85−89 90−99 or DBP 100−109 or DBP ≥110
• Lifestyle changes for • Lifestyle changes for
• Lifestyle changes
several months several weeks
No other RF • No BP intervention • Immediate BP drugs
• Then add BP drugs • Then add BP drugs
targeting <140/90
targeting <140/90 targeting <140/90
• Lifestyle changes for • Lifestyle changes for
• Lifestyle changes
• Lifestyle changes several weeks several weeks
1−2 RF • No BP intervention • Then add BP drugs • Then add BP drugs
• Immediate BP drugs
targeting <140/90
targeting <140/90 targeting <140/90
• Lifestyle changes for
• Lifestyle changes • Lifestyle changes
• Lifestyle changes several weeks
≥3 RF • No BP intervention • Then add BP drugs
• BP drugs targeting • Immediate BP drugs
<140/90 targeting <140/90
targeting <140/90

• Lifestyle changes • Lifestyle changes • Lifestyle changes

• Lifestyle changes
OD, CKD stage 3 or diabetes • BP drugs targeting • BP drugs targeting • Immediate BP drugs
• No BP intervention
<140/90 <140/90 targeting <140/90

• Lifestyle changes • Lifestyle changes • Lifestyle changes

Symptomatic CVD, CKD stage ≥4 • Lifestyle changes
• BP drugs targeting • BP drugs targeting • Immediate BP drugs
or diabetes with OD/RFs • No BP intervention
<140/90 <140/90 targeting <140/90

BP, blood pressure; CKD, chronic kidney disease; CV, cardiovascular; CVD, cardiovascular disease; DBP, diastolic blood pressure; HT, hypertension; OD,
organ damage; RF, risk factor; SBP, systolic 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
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 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
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 Algorithm for Treatment of
Hypertension

Begin or Continue Lifestyle Modifications

• Lose weight • Maintain potassium
• Limit alcohol • Maintain calcium and
• Increase physical activity magnesium
• Reduce Sodium • Stop smoking
• Reduce saturated fat,
cholesterol

Not at Goal Blood Pressure

 Algorithm for Treatment of
hypertension
Lifestyle Modifications

Not at Goal BP ( <140/ 90 mmHg or <130/80 mmHg

for those with diabetes or chronic kidney disease )

Initial Drug Choices

Hypertension without Hypertension with

Compelling Indication Compelling Indication

Stage 1 Hypertension Stage 2 Hypertension Drug for the compelling

(Systolic BP 140-159 mmHg or (Systolic BP > 160 mmHg or diastolic indication
diastolic BP 90-99 mmHg) BP > 100 mmHg) Other AH drug ( Diuretic
Thiazide , ACE-I, ARB, B-Blocker, CCB, 2 drug combination ( Thiazide and ACE-I , ARB, B-Blocker,
or combination ACE-I or ARB or B-Blocker or CCB ) CCB) as needed

Not at Goal BP

Optimize dosages or Add Drugs Until Goal BP is Achieved

Consider Consultation With hypertension Specialist
JNC. VII, 2003
 Algorithm for Treatment of
Hypertension (continued)

Initial Drug Choices*

Uncomplicated
• Diuretics
• -blockers

*Based on randomized controlled trials.

 Algorithm for Treatment of
Hypertension (continued)

Initial Drug Choices*

Compelling Indications
• Heart failure
– ACE inhibitors
– Diuretics
• Myocardial infarction
− -blockers (non-ISA)
– ACE inhibitors (with systolic dysfunction)
• Diabetes mellitus (type 2) with proteinuria
– ACE inhibitors
• Isolated systolic hypertension (older persons)
– Diuretics preferred
– Long-acting dihydropyridine calcium antagonists

*Based on randomized controlled trials.

 2013 ESH/ESC Guidelines for the management of arterial hypertension

Compelling indications for hypertension treatment

Class Contraindications
Compelling Possible
Diuretics Gout Metabolic syndrome
(thiazides) Glucose intolerance
Pregnancy
Hypercalcemia
Hypokalaemia

Beta-blockers Asthma Metabolic syndrome

A–V block (grade 2 or 3) Glucose intolerance
Athletes and physically active patients
COPD (except for vasodilator beta-blockers)

Calcium antagonists Tachyarrhythmia

(dihydropyridines) Heart failure

Calcium antagonists A–V block (grade 2 or 3, trifascicular block)

(verapamil, diltiazem) Severe LV dysfunction
Heart failure

ACE inhibitors Pregnancy Women with child bearing potential

Angioneurotic oedema
Hyperkalaemia
Bilateral renal artery stenosis

Angiotensin receptor blockers Pregnancy Women with child bearing potential

Hyperkalaemia
Bilateral renal artery stenosis
Mineralocorticoid Acute or severe renal failure (eGFR <30 mL/min)
receptor antagonists Hyperkalaemia

A-V, atrio-ventricular; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerular filtration rate; LV, left ventricular.

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
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 Individualized approach to treating
hypertension

Satisfactory

 Dose
Respnse
Monotherapy Partial
(after 4 to 6 weeks)
Add 2nd drug

Minimal Substitute drug

Menard (1992); Materson (1995)

 2013 ESH/ESC Guidelines for the management of arterial hypertension

Monotherapy vs. drug combination strategies to achieve target BP

Mild BP elevation Choose between Marked BP elevation

Low/moderate CV risk High/very high CV risk

Single agent Two–drug combination

Switch Previous agent Previous combination Add a third drug

to different agent at full dose at full dose

Full dose Two drug Switch Three drug

monotherapy combination to different two–drug combination
at full doses combination at full doses

Moving from a less intensive to a more intensive therapeutic strategy

should be done whenever BP target is not achieved.
BP, blood pressure; CV, cardiovascular.

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
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Combination Therapy
ARB/ACE-I and CCB
Concept of Counteregulation

Calcium Chanel
Blockers

RAS Activation
Arteriole Dilatation SNS Activation
-Vasoconstriction

RAS = renin-angiotensin system

SNS = sympathetic nervous system
Combination Therapy for
Hypertension

Concept of Counteregulation

ACE-I or ARB
CCB

RAS IN-Activation
SNS IN-Activation
-Veno- artery dilatation
 Obesity Weight reduction
Weight reduction will lead to
a fall in BP of a rate of 2-3
mmHg/Kg for SBP and 2
mmHg/Kg for DBP.
◼ Reduces the risk of CAD,
cerebrovascular and
peripheral vascular
disorders.
◼ Weight reduction →
decreased insulin and
adrenaline levels →
decreased sympathetic
activity → reduction in BP.
 Pregnant Women
◼ Chronic hypertension is high blood
pressure present before pregnancy or
diagnosed before 20 week of gestation.
◼ Preeclampsia is increased blood pressure
that occurs
in pregnancy (generally after the 20th
week) and is accompanied by edema,
proteinuria, or both.
◼ ACE inhibitors and angiotensin II receptor
blockers
are contraindicated for pregnant women.
◼ Methyldopa,  bolckers and Ca Antagonis
recommended for women diagnosed
during pregnancy.
 Renal Disease
◼ Hypertension may result from renal
disease that reduces functioning
nephrons.
◼ Evidence shows a clear relationship
between high blood pressure and end-
stage renal disease.
◼ Blood pressure should be controlled to
< 130/85 mm Hg or lower (< 125/75
mm Hg) in patients with proteinuria in
excess of 1 gram per 24 hours.
◼ ACE inhibitors work well to control
blood pressure and slow progression
of renal failure.
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment in the elderly

Clinical scenario Recommendations

Elderly patients with SBP ≥160 mmHg • Reduce SBP to 140-150 mmHg

Fit elderly patients aged <80 years with initial SBP • Consider antihypertensive treatment
≥140 mmHg • Target SBP: <140 mmHg

Elderly >80 years with initial SBP ≥160 mmHg • Reduce SBP to 140-150 mmHg
providing in good physical and mental condition

Frail elderly • Hypertension treatment decision at discretion of treating

clinician, based on monitoring of treatment clinical
effects

Continuation of well- tolerated hypertension • Consider when patients become octogenarians

treatment

All hypertension treatment agents are recommended • Diuretics, CCBs, preferred for isolated systolic
and may be used in elderly hypertension

SBP, systolic blood pressure; CCB, calcium channel blockers.

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
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 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with diabetes

Recommendations Additonal considerations
Mandatory: initiate drug treatment in patients with SBP • Strongly recommended: start drug treatment when
≥160 mmHg SBP ≥140 mmHg

SBP goals for patients with diabetes: <140 mmHg

DBP goals for patients with diabetes: <85 mmHg

All hypertension treatment agents are recommended • RAS blockers may be preferred
and may be used in patients with diabetes • Especially in presence of preoteinuria or
microalbuminuria

Choice of hypertension treatment must take comorbidities into account

Coadministration of RAS blockers not recommended • Avoid in patients with diabetes

SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.

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
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 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with metabolic syndrome

Recommendations Additonal considerations
Lifestyle changes for all • Especially weight loss and physical activity
• Improve BP and components of metabolic syndrome,
delay diabetes onset

Antihypertensive agents that potentially improve – or not • RAS blockers

worsen – insulin sensitivity are recommended • CCBs

BBs and diuretics only as additional drugs • Preferably in combination with a potassium-sparing
agent

Prescribe antihypertensive drugs with particular care in • BP ≥140/90 mmHg after lifestyle changes to mantain
patients with metabolic disturbances when… BP <140/90 mmHg

No drug treatment in patients with metabolic syndrome and high normal BP

BP, blood pressure; BB, beta blockers; CCB, calcium channel blockers; RAS, renin–angiotensin system.

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
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 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with nephropathy

Recommendations Additonal considerations

Consider lowering SBP to <140 mmHg

Consider SBP <130 mmHg with overt proteinuria • Monitor changes in eGFR

RAS blockers more effective to reduce albuminuria than • Indicated in presence of microalbuminuria or overt
other agents proteinuria

Combination therapy usually required to reach BP goals • Combine RAS blockers with other agents

Combination of two RAS blockers • Not recommended

Aldosterone antagonist not recommended in CKD • Especially in combination with a RAS blocker
• Risk of excessive reduction in renal function,
hyperkalemia

SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.

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
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 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with cerebrovascular disease

Recommendations Additonal considerations

Do not introduce antihypertensive treatment during first • Irrispective of BP level

week after acute stroke • Use clinical judgment with very high SBP

Introduce antihypertensive treatment in patients with • Even when initial SBP is 140-159 mmHg
history of stroke or TIA

SBP goals for hypertensive patients with history of stroke or TIA: <140 mmHg

Consider higher SBP goal in elderly with previous stroke or TIA

All drug regimens recommended for stroke prevention • Provided BP is effectively reduced

TIA, transient ischaemic attack; SBP, systolic blood pressure; BP, 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
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 2013 ESH/ESC Guidelines for the management of arterial hypertension

Hypertension treatment for people with heart disease

Recommendations Additonal considerations

SBP goals for hypertensive patients with CHD: <140 mmHg

BBs for hypertensive patients with recent MI • Other CHD: other antihypertensive agents can be
used; BBs, CCBs preferred

Diuretics, BBs, ACE-I, ARBs, and/or mineralcorticoid • Reduce mortality and hospitalization
receptor antagonist for patients with heart failure or
severe LV dysfunction

No evidence that any hypertension drug beneficial for • However, in these patients and patients with
patients with heart failure and preserved EF hypertension and systolic dysfunction: consider
lowering SBP to ∼ 140 mmHg
• Guide treatment by symptom relief

Consider ACE-I and ARBs (and BBs and mineralcorticoid receptor antagonist in coexisting heart failure) in
patients at risk of new or recurrent AF

Antihypertensive therapy in all patients with LVH • Initiate treatment with an agent with greater ability to
regress LVH (ACE-I, ARBs, CCBs)

SBP, systolic blood pressure; BB, beta-blocker; MI, myocardial infarction; ACE-I, angiotensin-converting-enzyme inhibitor; ARB, angiotensin receptor blocker; LV, left ventricular;
EF, ejection fraction; CHD, coronary heart disease; CCB, calcium channel blockers; AF, atrial fibrillation; LVH, left ventricular hypertrophy.

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
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Much Thanks~~
今 後 也 請 大 家 多 多 指 教 ! ! c