HYPERTENSION
SYAIFUL AZMI
Subdivision of Nephrology, Faculty of Medicine
Andalas University
Padang
Buku pegangan.
• HARRISON
: INTERNAL MEDICINE
• SUPARTONDO : ILMU OENYAKIT DALAM
• NORMAN KAPLAN : CLINICAL
HYPERTENSION
Section 1: Definition and Classification
of Hypertension
Definition and classification of
hypertension: ESH/ESC 2003
Hypertension is defined as blood pressure 140/90 mmHg
Category
Systolic
(mmHg)
Diastolic
(mmHg)
Optimal
<120
<80
Normal
120-129
80-84
High normal
130-139
85-89
Grade 1 hypertension (mild)
140-159
90-99
Grade 2 hypertension (moderate)
160-179
100-109
Grade 3 hypertension (severe)
180
110
Isolated systolic hypertension
140
<90
When a patient’s systolic and diastolic blood pressures fall into different
categories, the higher category should apply
ESH/ESC Guidelines 2003
J Hypertens 2003;21:1011-1053
Definition and classification of
hypertension: JNC VII
Hypertension is defined as blood pressure 140/90 mmHg
Category
Systolic
(mmHg)
Diastolic
(mmHg)
<120
and <80
Pre hypertension
120-139
or 80-89
Stage 1 hypertension
140-159
or 90-99
Stage 2 hypertension
160
or 100
Normal
JNC VII. JAMA 2003;289:2560-2572
Definition and classification of
hypertension: WHO/ISH 1999/2003
Hypertension is defined as blood pressure 140/90 mmHg
Category
Systolic
(mmHg)
Diastolic
(mmHg)
Optimal
<120
<80
Normal
<130
<85
High-normal
130-139
85-89
Grade 1 hypertension (mild)
Subgroup: borderline
140-159
140-149
or 90-99
90-94
Grade 2 hypertension (moderate)
160-179
or 100-109
Grade 3 hypertension (severe)
180
or 110
Isolated systolic hypertension
Subgroup: borderline
140
140-149
<90
<90
When a patient’s systolic and diastolic blood pressures fall
into different categories, the higher category should apply
2003 WHO/ISH Statement on Hypertension.
J Hypertens 2003;21:1983-1992; 1999 WHO/ISH Guidelines for the
Management of Hypertension. J Hypertens 1999;17:151-183
Section 2: Prevalence of Hypertension
Prevalence of hypertension*:
North America and Europe
80
Prevalence (%)
70
60
Men
Women
Total
50
40
30
20
10
0
* BP 140/90 mmHg or treatment with antihypertensive medication
Wolf-Maier K, et al. JAMA 2003;289:2363-2369
Prevalence (%)
Prevalence of hypertension: Asia
80
70
60
50
40
30
20
10
0
Men
Women
Total
Gu DF, et al. Hypertension 2002;40:920-927; Singh RB, et al. J Hum Hypertens 2000;14:749-763; Janus ED. Clin Exp Pharmacol Physiol
1997;24:987-988; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al.
Singapore Med J 2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27:405-409; Muhilal H. Asia Pacific J Clin Nutr 1996;5:132-134;
Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48:827-836 [in Japanese]
Prevalence of hypertension:
Other countries
80
Prevalence (%)
70
60
Men
Women
Total
50
40
30
20
10
0
Ordunez P, et al. Pan Am J Public Health 2001;10:226-231;
Cubillos-Garzon LA, et al. Am Heart J 2004;147:412-417; Amad S, et al. J Hum Hypertens 1996;10:S31-S33
TABEL 4 Prevalensi Hipertensi Pada Populasi,
Obese, TGT dan DM di SumBar 2005
N
O
1
2
3
4
5
6
7
8
KOTA
POPULASI
(%)
OBESE
(%)
TGT
(%)
DM
(%)
P.Panjang
Bt.Sangkar
Solok
Pariaman
Payakumbuh
Painan
Bukittinggi
Padang
22.3
23.4
26.1
22.9
19.1
16.0
26.6
11.8
22.4
23.4
24.6
22.2
17.6
17.7
37.6
12.0
26.3
32.5
33.3
35.6
326.6
36.4
38.2
25.3
33.3
42.2
41.2
40.0
18.4
29.4
28.6
23.1
RERATA
21.1
22.2
30.4
30.0
Section 3 : Classification of
hypertension
CLASSIFICATION
• PRIMARY ( ± 90 % )
• SECUNDARY ( ± 10 % )
renovascular hypertension
renal parenchymal hypertension
hypertension with pregnancy
pheochromocytoma
primary aldosteronemia
drug induced or related causes
JNC 7 2003, Caplan, clinical hypertension 2002
Section 4 : Risk factors of
Hypertension
Table Cardiovaskuler risk factors
Major Risk Factors
Hypertension*
Cigarette* (body mass index  30 kg/m2)
Physical inactivity
Dislipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR < 60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men under age 55 or women under age 65)
Target Organ Damage
Heart
•
Left ventricular hypertrophy
•
Angina or prior myocardial infarction
•
Prior coronary revascularization
•
Heart failure
Brain
•
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy
GFR, glomerular filtration rate
* Components of the metabolic syndrome
JNC VII 2003
Risk factors
•
•
•
•
•
•
•
•
•
•
Gender
Race
Age
Family history
Cigarette smoking
Obesity ( BMI ≥ 30 Kg/m2 )*
Physical activity
Dyslipidemia*
Diabetes Mellitus*
Microalbuminuria
*
componen of metabolic syndrome
JNC 7 2003
Bahaya HIPERTENSI
(bila tdk dikendalikan)
Kerusakan pada Organ Target
• LVH
• Gagal
Jantung
• PJK
Retinopati
(buta)
Stroke
Penyakit Ginjal
khronik
• Gagal Ginjal
Terminal
Section 5 : Pathophysiology and
Pathogenesis of Hypertension
PATHOPHYSIOLOGY OF HYPERTENSION
Several hypothesis exists of the original
pathogenesis of hypertension
- Excess Na intake
- Renal Na retention
- RAS
- Stress & sympathetic activity
- Peripheral resistance
- Endothelial dysfunction
- Obesity
- Insulin resistance
Pathogenesis hipertensi
( Kaplan N, 2002 )
Renin-angiotensin-aldosterone system
Angiotensinogen
(-)
Renin
Bradykinin
Angiotensin I
Angiotensinconverting
enzyme
Angiotensin II
BP
BP, blood pressure
Inactive kinins
AT1
•
•
•
•
•
Vasoconstriction
Aldosterone secretion
Catecholamine release
Proliferation
Hypertrophy
AT2
•
•
•
•
•
Vasodilation
Inhibition of cell growth
Cell differentiation
Injury response
Apoptosis
Ellis ML, et al. Pharmacotherapy 1996;16:849-860;
Carey RM, et al. Hypertension 2000;35:155-163
Section 6 : Diagnosis of Hypertension
SYMPTOMS
Headache
Nocturia
Palpitation
Dizziness
Tinitus
Epistaxis
Kaplan N , 2002
PHYSICAL EXAMINATION
25
TABLE. IMPORTANT ASPECTS OF THE PHYSICAL
EXAMINATION
ACCURATE MEASUREMENT OF BLOOD PRESSURE
GENERAL APPEARANCE : DISTRIBUTION OF BODY FAT,
SKIN LESSION,MUSCLESTRENGTH.
FUNDUSCOPY.
NECK : PALPATION AND AUSCULTATION OF CAROTIDS, THYROID.
HEART : SOUND, RHYTHM, SIZE.
LUNG : RALES.
ABDOMEN : RENAL MASSES, BRUIT OVER AORTA OR RENAL
ARTERIES, FEMORAL PULSES, WAIST CIRCUMFERENCE.
EXTREMITIES : PERIPHERAL PULSES, EDEMA.
NEUROLOGIC ASSESSMENT, INCLUDING COCNITIVE
FUNCTION.
LABORATORY TEST
• ROUTINE LAB WORK UP
• RISK FACTORS : BLOOD SUGAR, LIPID
•
PROFILE, ELECTROLYTES.
• LAB OF TARGET ORGAN DEMAGE
• PLASMA INSULIN, PLASMA RENIN
ACTIVITY
FUNDUSCOPY EXAMINATION :
RETINOPATHY
CARDIAC ASSESSMENT : LVH, ARYTHMIA
CEREBRAL ASSESSMENT :
ENCEPHALOPATHY
RENAL ASSESSMENT
Section 7 : Treatment Guidelines
Table Lifestyle modifications to manage hypertension *†
Modification
Recommendation
Approximate SBP
Reduction (range)
Weight reduction
Maintain normal body weight (body mass
index 18.5-24.9 kg/m2)
5-20 mmHg/10 kg weight
loss23-24
Adopt DASH eating plan
Consume a diet rich in fruits, vegetables,
and lowfat dairy products with a reduced
content of saturated and total fat
8-14 mmHg25-26
Dietary sodium reduction
Reduce dietary sodium intake to no more
than 100 mmol per day (2.4 g sodium or
6 g sodium chloride)
2-8 mmHg25-27
Physical activity
Engage in regular aerobic physical
activity such as brisk walking (at least 30
min per day, most days of the week0
4-9 mmHg26-27
Moderation of alcohol
consumption
Limit consumption to no more than 2
drinks ( 1 oz or 30 mL ethanol; e.g., 24
oz beer, 10 oz wine, or 3 oz 80-proof
whiskey) per day in most men and to no
more than 1 drink per day in women and
lighter weight persons
2-4 mmHg30
DASH, Dietary Approaches to Stop Hypertension.
*
For overall cardiovascular risk reduction, stop smoking.
†
The effects of implementing these modifications are dose and time dependent, and could be greater for some
individuals
JNC VII 2003
THE IDEAL ANTIHYPERTENSIVE AGENT
- Effectively reduces BP
- Maintains BP control over 24 hours with
once-a-day dosing
- Effective in all hypertensive patients
- No adverse effects
- No negative metabolic side effects
History of antihypertensive drugs
Effectiveness and general tolerability
1940’s
1950
1960’s
1957
Alphablockers
Direct
vasodilators
Peripheral
sympatholytics
Ganglion
blockers
Veratrum
alkaloids
1970’s
Thiazide
diuretics
Central 2
agonists
Calcium
antagonistsnon-DHPs
1980’s
ARBs
ACE
inhibitors
Calcium
antagonistsDHPs
Betablockers
DHP, dihydropyridine;
ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker
1990’s
2000
Multiple antihypertensive agents
are needed to achieve target BP
Trial
Number of antihypertensive agents
Target BP (mmHg) 1
2
3
4
UKPDS
DBP <85
ABCD
DBP <75
MDRD
MAP <92
HOT
DBP <80
AASK
MAP <92
IDNT
SBP <135/DBP <85
ALLHAT SBP <140/DBP <90
DBP, diastolic blood pressure; MAP, mean arterial pressure;
SBP, systolic blood pressure
Bakris GL, et al. Am J Kidney Dis 2000;36:646-661;
Lewis EJ, et al. N Engl J Med 2001;345:851-860;
Cushman WC, et al. J Clin Hypertens 2002;4:393-404
Main classes of antihypertensive drugs
• Diuretics
– Inhibit the re absorption of salts and water from kidney
tubules into the bloodstream
• Calcium-channel antagonists
– Inhibit influx of calcium into cardiac and smooth muscle
• Beta-blockers
– Inhibit stimulation of beta-adrenergic receptors
• Angiotensin-converting enzyme (ACE) inhibitors
– Inhibit formation of angiotensin II
• Angiotensin II receptor blockers (ARBs)
– Inhibit binding of angiotensin II to type 1 angiotensin II
receptors
Clinical trial and guideline basis for compelling indications for individual drug
classes
RECOMMENDED DRUGS+
CLINICAL TRIAL BASIS+
COMPELLING INDICATION
DIURETIC
Heart failure

Postmyocardial infarction
BB
ACEI




ARB

High coronary disease risk



Diabetes






Chronic Kidney disease
Recurrent stroke prevention


CCB
ALDO ANT

ACC/AHA Heart Failure Guideline,40 MERIT-HF, 41 COPERNICUS,42 CIBIS,43 SOLVD,44 AIRE,45
TRACE,44 ValHEFT,47 RALES48

ACC/AHA post-MI Guideline,49
BHAT,50 SAVE,51 Capricorn,52
EPHESUS,53

ALLHAT,33 HOPE,34 ANBP2,36
LIFE,32 CONVINCE31

NKF-ADA Guideline,31,32 UKPDS,34
ALLHAT33
NKF Guideline,22 captopril Trial,55
RENALL,56 IDNT,57 REIN,58 AASK59
PROGRESS35
JNC VII , 2003
 Compeling indications for antihypertensive drugs are based on benefits from outcome studies or existing
clinical guidelines; the compelling indications is managed in parallel with the BP
+ Drug abbreviations; ACEI, angiotensin converting enzyme inhibitor; ARB,angiotensin receptor blicker;
Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker
± Conditions for which trials demonstrate benefit of specific classes of antihypertensive drugs.
Treatment strategy: WHO/ISH 2003
Compelling indication
Preferred drug
Elderly with isolated systolic
hypertension
Diuretic, DHPCCB
Renal disease
Diabetic nephropathy type 1
ACE-I
Diabetic nephropathy type 2
ARB
Non-diabetic nephropathy
ACE-I
Cardiac disease
Post-myocardial infarction
ACE-I, beta-blocker
Left ventricular dysfunction
ACE-I
Congestive heart failure (diuretics
almost always included)
Beta-blocker,
spironolactone
Left ventricular hypertrophy
ARB
Cerebrovascular disease
ACE-I + diuretic, diuretic
DHPCCB, dihydropyridine calcium-channel blocker;
ACE-I, angiotensin-converting enzyme inhibitor;
ARB, angiotensin II receptor blocker; CCB, calcium-channel blocker
2003 WHO/ISH Statement on Hypertension.
J Hypertens 2003;21:1983-1992
Treatment initiation: JNC VII
Lifestyle
modification
Normal
Prehypertension
Stage 1
hypertension
Stage 2
hypertension
Encourage
Yes
Yes
Yes
Initial drug therapy
Without
compelling
indication
No antihypertensive drug
indicated
Thiazide-type
Two-drug
diuretics for most; combination for
may consider
most (usually
ACE-I, ARB, BB,
thiazide-type
CCB, or
diuretic and
combination
ACE-I or ARB
or BB or CCB)
With
compelling
indications
Drug(s) for compelling
indications
Drug(s) for compelling indications;
other antihypertensive drugs
(diuretics, ACE-I, ARB, BB, CCB)
as needed
ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II
receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker
JNC VII. JAMA 2003;289:2560-2572
Goals of treatment: JNC VII
• The SBP and DBP targets are
<140/90 mmHg
• The primary focus should be on achieving the
SBP goal
• In patients with hypertension and diabetes or
renal disease, the BP goal is <130/80 mmHg
SBP, systolic blood pressure; DBP, diastolic blood pressure;
BP, blood pressure
JNC VII. JAMA 2003;289:2560-2572
Hypertension treatment strategy: JNC VII
Lifestyle modifications
Not at goal blood pressure (<140/90 mmHg)
(<130/80 mmHg for patients with diabetes or chronic kidney disease)
Initial drug choices
Without compelling
indications
Stage 1 hypertension
(SBP 140-159 or DBP
90-99 mmHg)
Thiazide-type diuretics
for most. May consider
ACE-I, ARB, BB, CCB
or combination
Stage 2 hypertension
(SBP 160 or DBP 100 mmHg)
Two-drug combination for
most (usually thiazide-type
diuretic and ACE-I or
ARB, or BB, or CCB)
With compelling
indications
Drug(s) for the
compelling indications
Other antihypertensive
Drugs (diuretics, ACE-I,
ARB, BB, CCB) as needed
Not at blood pressure goal
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
SBP, systolic blood pressure; DBP, diastolic blood pressure; ACE-I,
angiotensin-converting enzyme inhibitor; ARB, angiotensin II
receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker
JNC VII. JAMA 2003;289:2560-2572
Circumstances in which ACE Inhibitors and ARBs Should Not Be
Used
Do Not Use
ACE Inhibitor
ARB
Pregnancy(A)
History of angioedema (A)
Cough due to ACE inhitors (A)
Allergy to ACE or ARB (A)
Allergy to ACE inhibitor or ARB (A)
Pregnancy (C)
Cough dua to ARB (C)
Use with Caution
Women not practicing contraception (A)
Bilateral renal artery stenosis*
Drugs causing hyperkalemia (A)
Bilateral renal artery stenosis*
Drugs causing hyperkalemia (A)
Women not practicing contraception (C)
Angioedema due to ACE inhibitors (C)
K-DOQI AJKD, 2004
* Including renal artery stenosis in the kidney transplant or in a solitary kidney.
Letters in parentheses denote strength of recommendations.
Diuretik : Hati hati pada :
- gangguan elektrolit
- dislipidemia
Beta bloker hati hati pada :
- Asma bronkhial / spasme bronkhus
- Diabetes melitus