HIPERTENSI ESENSIAL
FAKULTAS KEDOKTERAN UNIVERSITAS MALAHAYATI 2011
DEFENISI
Hipertensi esensial adalah hipertensi yang tidak diketahui penyebabnya. Klasifikasi tekanan darah menurut JNC 7 :
Klasifikasi tekanan darah Normal Prahipertensi Hipertensi derajat 1 Hipertensi derajat 2 TDS (mmHg) < 120 120 139 140 159 160 TDD (mmHg) < 80 80 89 90 99 100
Classification of Blood Pressure
ESC-ESH 2007
Optimal : <120 and < 80 Normal : 120-129 and/or 80 - 84 High Normal : 130-139 and/or 85-89 Grade 1 : 140-159 and/or 90-99 Grade 2 : 160-179 and/or 100-109 Grade 3 : > 180 and/or > 110
JNC-VII
Normal Pre-hypertension Stage 1
H Y P E R T E N S I O N
Stage 2
JNC VII committee, JAMA 2003: 289;2560-2572
Epidemiology of Hypertension
90% lifetime risk of developing hypertension in people normotensive at age 55 People with lower educational and income levels tend to higher levels of blood pressure
American Heart Association Heart Disease and Stroke statistic 2006 Update, Texas, AHA2006
Hypertension in Asia Pacific
Alexandra L.C. Martiniuk et.al J. Hypertension 2007 ; 25 : 88-92
Hypertension is Not Adequately Treated
Off all the USA people with high blood pressure:
11% are not on treatment regimen 25% are not on adequate treatment 34% are on adequate treatment
American Heart Association Heart Disease and Stroke statistic 2006 Update, Texas, AHA2006
The Cardiovascular Continuum
Coronary thrombosis Myocardial ischaemia CAD Atherosclerosis LVH Myocardial infarction Sudden Death Arrhythmia & loss of muscle Remodelling
Ventricular dilatation
Congestive heart failure
Risk factors
Hypertension, smoking, cholesterol, diabetes
Death
Dzau V. Braunwald E, Am Heart J. 1991
PATOGENESIS
Faktor yang mendorong terjadinya hipertensi : 1. Diet & asupan garam, stress, ras, obesitas, merokok, genetis 2. Sistem saraf simpatis : - Tonus simpatis - Variasi diurnal 3. Keseimbangan antara modulator vasodilatasi & vasokonstriksi 4. Pengaruh sistem endokrin setempat yang berperan pada sistem renin, angiotensin & aldosteron
Consequences Structural Changes in Hypertension
Loss of buffering Function Increased blood pressure Structural changes in compliance arteries Transmits Systolic pressure Wave to small arteries Compliance Load on heart
Perpetuation of Hypertension Left Ventricular Hypertrophy Predisposes of Atherosclerosis
Shear stress on Artery wall
Endothelial dysfunction
Dzau VJ. Hypertension. 2001;37:1047-1052
The Progression from Hypertension to Heart Failure
LVH Diastolic dysfunction CHF Systolic dysfunction Death
Hypertension
MI
Normal LV Structure & Function Time (decades)
LV remodeling
Subclinical LV dysfunction
Overt Heart Failure
Time (months)
Vasan RS, Levy D. 1996. Arch Intern Med 156 : 1759-1796
Cumulative Incidence of Heart failure in Normotensive and Hypertensive Patients
20 15
CHF Cumulative Incidence 10 (%)
Stage 1 hypertension Stage 2 hypertension
5
Normal BP
0
5 10 Years From Baseline Exam 15
Lenfant C, Roccella EJ. J Hypertens Suppl. 1999;17:S3-S7. Data from Levy D et al. JAMA. 1996;275:1557-1562.
KERUSAKAN ORGAN TARGET
1. Jantung : - Hipertrofi ventrikel kiri - Angina atau infark miokardium - Gagal jantung Otak : - Stroke atau Transient ischemic attack Penyakit ginjal kronis Penyakit arteri perifer Retinopati
2.
3. 4. 5.
Faktor resiko penyakit kardiovaskuler pada hipertensi : Merokok Obesitas Kurangnya aktivitas fisik Dislipidemia DM Mikroalbuminuria Umur ( laki-laki > 55 thn, perempuan 65 thn) Riwayat keluarga dengan penyakit jantung kardiovaskuler prematur (lakilaki < 55 thn, perempuan < 65 thn)
EVALUASI HIPERTENSI
Tujuan : 1.Menilai pola hidup & identifikasi faktor-faktor resiko kardiovaskular lainnya 2.Mencari penyebab kenaikan tekanan darah 3.Menentukan ada atau tidaknya kerusakan target organ & penyakit kardiovaskular
Menentukan adanya penyakit penyerta sistemik, yaitu :
Aterosklerosis
Diabetes
Penyakit ginjal
PENGOBATAN
Tujuan pengobatan :
Target tekanan darah < 140/90 mmHg Penurunan morbiditas & mortalitas kardiovaskular
Menghambat laju penyakit ginjal proteinuria
Pengobatan hipertensi terdiri dari : 1. Terapi nonfarmakologis Berhenti merokok menurunkan berat badan mengurangi konsumsi alkohol berlebih latihan fisik menurunkan asupan garam meningkatkan konsumsi buah & sayur menurunkan asupan lemak
2. Terapi farmakologis Jenis-jenis obat yang dianjurkan :
Diuretika Beta blocker Calsium Channel Blocker atau Calcium antagonist Angiotensin Converting Enzyme Inhibitor Angiotensin II Receptor AT1 receptor antagonist/blocker (ARB) * Tunggal atau kombinasi
Possible Combinations of Antihypertensive Agents
Diuretics
Beta-blockers
Angiotensinreceptor blockers
Diltiiazem
Alpha-blockers Calcium channel blockers
ACE inhibitors
Guidelines Committee. J Hypertens 2003; 21: 1011-53.
LIFESTYLE MODIFICATIONS
Not Goal BP
INITIAL DRUG CHOICES
Without Compelling Indications
With Compelling Indications
Drug(s) for the compelling indications. Other antiHT Drugs (Diuretics, ACEI, ARB,
Stage 1 Thiazide-Type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination
Stage 2 Two Drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB
BB, CCB) as needed
US-JNC VII Report
Renal Protection
Strict BP Control Target BP: <130/85 mm Hg 130/80 (ADA guidelines)
<125/75 mm Hg (if proteinuria > 1g/24h)
Control of Proteinuria Ideally = 0 mg/24h Mikroalbumiuri (0-300mg/24h)
American Diabetes Association. Diabetes Care. 2002;25 (Suppl.1):S85-S89.
Pemilihan obat antihipertensi dipengaruhi oleh beberapa faktor, yaitu : Faktor sosio ekonomi Profil faktor resiko kardiovaskular Ada tidaknya penyakit penyerta Variasi individu thd obat antihipertensi Kemungkinan adanya interaksi obat yg digunakan pasien utk penyakit lain
