hipertensi coass ipd

8/10/2019 HIPERTENSI COASS IPD

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Haerani Rasyid,Syakib Bakri

Sub Bagian Ginjal & HipertensiBagian / SMF Ilmu Penyakit DalamRS UNIVERSITAS HASANUDDIN


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Continuing MedicalImplementation
http://www.vsmmedtech.com/http://www.vsmmedtech.com/


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Blood Pressure Measurement (1)

Office Blood PressureAllow the patient to sit quietly for several minutes

Patients should be seated with back supported and arm bared and

supported.

Patients should refrain from smoking or ingesting caffeine for 30minutes prior to measurement.

Use a validated device

Take at least two measurements spaced by 1-2 min

Use a standard bladder (12-13 x 35 cm), but a larger one for

bigarmsHave the cuff at the heart level

Deflate the cuff slowly (2 mmHg/s)

Measure BP also in standing position in elderly and diabetic patients

Measure BP in the both arms


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Blood Pressure Measurement (2)

Home Blood Pressure

Pro :

More information for the doctors decisionImproved patients adherence to treatment

Con :

May cause anxietyMay induce self-modification of treatment


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Continuing MedicalImplementation

3

RECOMMENDED BLOOD PRESSURERECOMMENDED BLOOD PRESSURE

MEASUREMENT TECHNIQUEMEASUREMENT TECHNIQUE

2.

The cuff must be level with heart.

If arm circumference exceeds 33 cm,a large cuff must be used.

Place stethoscope diaphragm over

brachial artery.

2.2.

The cuff must be level with heart.The cuff must be level with heart.

If arm circumference exceeds 33 cm,If arm circumference exceeds 33 cm,a large cuff must be used.a large cuff must be used.

Place stethoscope diaphragm overPlace stethoscope diaphragm over

brachial artery.brachial artery.

1.

The patient shouldbe relaxed and the

arm must besupported.

Ensure no tight

clothing constricts

the arm.

1.1. The patient shouldThe patient should

be relaxed and thebe relaxed and the

arm must bearm must besupported.supported.

Ensure no tightEnsure no tight

clothing constrictsclothing constricts

the arm.the arm.

3.

The column ofmercury must be

vertical.

Inflate to occlude thepulse. Deflate at 2 to

3 mm/s. Measure

systolic (first sound)and diastolic

(disappearance) tonearest 2 mm Hg.

3.3.

The column ofThe column ofmercury must bemercury must be

vertical.vertical.

Inflate to occlude theInflate to occlude thepulse. Deflate at 2 topulse. Deflate at 2 to

3 mm/s. Measure3 mm/s. Measure

systolic (first sound)systolic (first sound)and diastolicand diastolic

(disappearance) to(disappearance) tonearest 2 mm Hg.nearest 2 mm Hg.

StethoscopeStethoscope

MercuryMercury

machinemachine


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Classification of Blood Pressure for Adults(JNC 7, May 2003)

Systolic Diastolic

Normal 100


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Definitions and Classificationof BP Levels (mmHg)

Category Systolic Diastolic

Optimal


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Consequences of Uncontrolled

Blood Pressure

Stroke, hemorrhage

LVH, CHD, CHF

Renal failure

Peripheral vascular disease

Retinopathy

Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatmentof High Blood Pressure (JNC VI).Arch Intern Med. 1997;157:2413-2446.


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Hypertension

Oxidative &

mechanical stress

Inflammation

Early tissue

dysfunction

Atherothrombosis and

progressive CV

disease

Tissue injury (MI, Stroke, Renal

insufficiency, peripheral arterial

insufficiency)

Pathologic remodeling

Target organ

damage

End-organ failure(CHF, ESRD)

DeathSmooking,

Dyslipidemia,Diabetes


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HypertensionIt

s More Than Just Blood Pressure

Hypertension perceived as simply adisease of numbers

Hypertension Syndrome

A Complex inherited syndrome of cardiovascular risk factors


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Characteristics of theHypertension Syndrome

Increased blood pressureDyslipidemiaInsulin resistance, tendency to glucose

intoleranceTruncal ObesityMicroalbuminuria, early changes in renal

functional reserve

Increase activity of vascular coagulation factorsReduced arterial complianceHypertrophy and altered diastolic function of

left ventricle


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Change in the management of cardiovascular diseases

from the traditional approach of managing multiple

independent risk factors(silos approach) to a new

paradigm of integrated identification and management ofall risk factors contributing to the risk of cardiovascular

disease (global approach).


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ExcessSodiumintake

FewerNephrons

Stress GeneticAlteration

Obesity Endothelialfactors

RenalSodiumretention

DecreasedFiltrationsurface

SympatheticNervoussystem

overactivity

Renin-Angiotensin

Excess

CellMembraneAlteration

Hyperinsulinemia

Structural

hypertroph

Functional

Constriction

Contractility

Venousconstriction

FluidVolume

Preload

CARDIAC OUTPUT PERIPHERAL RESISTANCEXBLOOD PRESSURE =

Autoregulation

Increased CO Increased PRand/orHypertension =


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Diagnostic Evaluation

Aims

Establishing BP values

Identifying secondary causes of hypertension

Searching for:

a) other risk factors;b) subclinical organ damage;

c) concomitant diseases;

d) accompanying CV and renal complications.


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Particular conditions

Isolated office hypertension (White coat hypertension)

Office BP persistently 140/90 mmHg Normal daytime ambulatory or home BP < 130-135/85

Due to stress and SNS stimulation. CV risk is less than by raised office and ambulatory or home BPbut may be slightly greater than by normotension

Isolated ambulatory hypertension (Masked hypertension)

Office BP persistently normal (< 140/90 mmHg) Elevated ambulatory ( 125-130/80 mmHg) or home BP ( 130-135/85 mmHg)

CV risk is close to that of hypertension. Due to normal variation of circadian rhythm, autonomicnervous system dysfunction, physical or psychological stress, night consumption of alcohol, smokingand sleep apnea.


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Guidelines for family and clinical history

1. Duration and previous level of high BP

2. Indications of secondary hypertension:

family history of renal disease (polycystic kidneys)

renal disease, urinary tract infection, haematuria, analgesic abuse(parenchymal renal disease)

drug/substance intake, such as: oral contraceptives, liquorice,

carbenoxolone, nasal drops, amphetamines, steroids, non-steroidal anti-

inflammatory drugs, erythropoietin, cyclosporine, cocaine (drug induced

hypertension) episodes of sweating, headache, anxiety, palpitation (phaeochromocytoma)

episodes of muscle weakness and tetany (aldosteronism)


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3. Risk factors:

family and personal history of hypertension and CV disease

family and personal history of dyslipidaemia

family and personal history of diabetes mellitus

smoking habits

dietary habits ; lack of physical exercise

obesity

snoring; sleep apnea (information also from partner)

Personality type; stress due to personal, family and

environmental factors


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4. Symptoms of organ damage:

brain and eyes: headache, vertigo, transient ischemic attacks,sensory or motor deficit , impaired vision

heart: palpitation, chest pain, shortness of breath, swollenankles

kidneys: thirst, polyuria, nocturia, haematuria

peripheral arteries: cold extremities, intermittent claudication

5. Previous antihypertensive therapy:

Drug(s) used, efficacy and adverse effects


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Physical examinations

1. Signs suggesting secondary hypertension

2. Signs of organ damage

3. Evidence of visceral obesity.


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Physical examination forsecondary hypertension, organ damage and visceral obesity

Signs suggesting secondary hypertension

Features of Cushing syndrome

Skin stigmata of neurofibromatosis (phaeochromocytoma) Palpation of enlarged kidneys (polycystic kidneys)

Auscultation of abdominal murmurs

(renovascular hypertension)

Auscultation of precordial or chest murmurs; Diminished and delayedfemoral pulses femoral BP

(aortic coarctation or aortic disease)


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Physical examination forsecondary hypertension, organ damage and visceral obesity

Signs of organ damage

Brain: murmurs over neck arteries, motor or sensory defects

Retina: fundoscopic adnormalities

Heart: location and characteristics of apical impulse, abnormal

cardiac rhythms, ventricular gallop, pulmonary rates, peripheral

oedema

Peripheral arteries: absence, reduction or asymmetry of pulses, cold

extremities, ischemic skin lesions

Carotid arteries: systolic murmurs


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Physical examination for secondary hypertensionorgan damage and visceral obesity

Evidence of visceral obesity

Body weight

Increased body mass index

[body weight (Kg)/height (m2)]

overweight 25 Kg/m2; obesity 30 Kg/m2

Increased waist circumference

(standing position) > 90 cm; > 80 cm


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Laboratory investigations

Routine tests:

Hemoglobin and hematocrit Fasting plasma glucose

Fasting serum triglycerides Serum total cholesterol, LDL-cholesterol, HDL-cholesterol Serum creatinine, potassium, uric acid

Urinalysis (complemented by microalbuminuria dipstick test and

microscopic examination) Estimated creatinine clearance (Cockroft-Gault formula) or glomerularfiltration rate (MDRD formula)

Electrocardiogram (ECG) Thorax X-ray


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Recommended tests

Echocardiogram

Carotid ultrasound Quantitative proteinuria (if dipstick test positive)

Ankle-brachial BP index

Fundoscopy

Glucose tolerance test (if fasting plasma glucose > 5,6 mmol/l(102 mg/dL)

Home and 24h ambulatory BP monitoring

Pulse wave velocity measurement (where available)


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Extended evaluation (domain of the specialist)

Further search for cerebral, cardiac, renal and vascular disease,

mandatory in complicated hypertension

Search for suspected secondary hypertension suggested by history,

physical examination or routine tests:

measurement of renin, aldosterone,

corticosteroids,

catecholamines in plasma and/or urine;

renal and adrenal ultrasound;

computer-assisted tomography (CT);

magnetic resonance imaging (MRI);

arteriographies


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Searching for subclinical organ damage

Importance of subclinical organ damage as an intermediate stage in thecontinuum of vascular disease and as a determinant of total CV risk.

Heart

Electrocardiography should be part of all routine assessment ofhypertensives in order to detect LVH, LV strain, ischemic conditionand arrhythmias

Echocardiography is recommended whenever a more sensitive

detection of LVH is considered useful. Concentric remodeling andhypertrophy carries the worst prognosis, while LV diastolicdysfunction, consists an early ECHO sign, which can be evaluated byDoppler measurement of transmittal velocities.


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Blood vessels

Ultrasound scanning of extracranial carotid arteries is recommended insymptomatic carotid stenosis (previous TIA), but also in asymptomaticatherosclerosis suspected by carotid murmurs and reveals vascularhypertrophy, increased IMT, thickening of carotid bifurcation andpresence of plaques.

Peripheral large artery stiffening (an important vascular alterationleading to isolated systolic hypertension in the elderly), can bemeasured by pulse wave velocity. This method might be more widelyrecommended if its availability were greater.

A low ankle-brachial BP index (


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Kidney

Diagnosis of hypertension-related renal damage is based on a reduced renalfunction or detection of hyperalbuminuria

Measurement of serum creatinine as well as estimation of glomerularfiltration rate by specific formulas, should be part of routine procedures,allowing classification of renal dysfunction and respective stratification of CVrisk

Presence of urinary protein should be sought in all hypertensives by dipstick.In dipstick negative patients, low grade albuminuria, namely microalbuminuria,should also be determined in spot urine and as ratio to creatinine excretion


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Fundoscopy

Examination of eye grounds is recommended only in hypertensive with

severe hypertension, since mild retinal changes (grade 1: arteriolarnarrowing; grade 2: arteriovenous nipping) appear to be largely non-

specific alterations except in young patients

In contrast, grade 3 (hemorrhages and exudates) and 4 (papilloedema)

retinal changes, present only in severe hypertension and are associatedwith an increased CV risk


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Brain Silent brain infarcts, lacunar infarction (small / deep vessel disease),

microbleeds and white matter lesions are not infrequent among

hypertensives, especially elderly and can be detected by MRI or CT (MRI

being generally superior to CT)

Availability and costs do not allow use of these techniques in asymptomatic

patients

In elderly hypertensives, cognitive tests (e.g. Mini-mental scale) may also

help to detect initial brain deterioration

f h


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Initiation of antihypertensive treatmentOther riskfactors, TargetOrgan Damage ordisease

NormalSBP 120-129 orDBP 80-84

HighnormalSBP 130-139 orDBP 85-89

Grade 1 HTSBP 140-159 orDBP 90-99

Grade 2 HTSBP 160-179 orDBP 100-109

Grade 3 HTSBP 180 orDBP 110

No other riskfactors

No BP intervention No BP intervention

Lifestyle changesfor several monthsthen drug treatmentif BP uncontrolled

Lifestyle changesfor several weeksthen drug treatmentif BP uncontrolled

Lifestylechanges +immediate drugtreatment

1-2 riskfactors

Lifestyle changes Lifestyle changes

Lifestyle changes

for several weeksthen drug treatmentif BP uncontrolled

Lifestyle changes

for several weeksthen drug treatmentif BP uncontrolled

Lifestyle

changes +immediate drugtreatment

>3 riskfactors, MSor TOD

Lifestyle changesLifestyle changesand consider drugtreatment Lifestyle changes +

drug treatment

Lifestyle changes +

drug treatment

Lifestylechanges +

immediate drugtreatment

Diabetes Lifestyle changesLifestyle changes +drug treatment

EstablishedCV orrenaldisease

Lifestyle changes +immediate drugtreatment




Lifestylechanges +immediate drugtreatment


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II. Criteria for the diagnosis of hypertension and recommendations for follow-up

BP: 140-179 / 90-109

ABPM (If available)Clinic BPM Home BPM (If available)

Yes

Hypertension Visit 2Target Organ Damage

or Diabetesor Chronic Kidney Disease

or BP >180/110?

Hypertension Visit 1BP Measurement,

History and Physicalexamination

HypertensiveUrgency /Emergency

Diagnosisof HTN

No

Elevated Out ofthe Office BPmeasurement

Elevated RandomOffice BP

Measurement


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Hypertension Visit 1BP Measurement,

History and Physicalexamination

Hypertension Visit 2within 1 month

Yes

BP >140/90 mmHg andTarget organ damage or

Diabetes or Chronic KidneyDisease or BP >180/110?

Diagnostic tests orderingat visit 1 or 2

HypertensiveUrgency /Emergency

Diagnosisof HTN

BP: 140-179 / 90-109mmHg

No

Elevated Out ofthe Office BPmeasurement

Elevated RandomOffice BPMeasurement


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BP: 140-179 / 90-109

ABPM (If available)

Diagnosisof HTN

Awake BP>135 SBP or

>85 DBP or24-hour

>130 SBP or>80 DBP

Awake BP100DBP

>140 SBP

or>90 DBP

< 140 /90

Diagnosis

of HTN

Continue tofollow-up

135/85< 135/85

Diagnosisof HTN

Continueto follow-

up

or

Patients with high normal blood pressure (clinic SBP 130-139 and/or DBP 85-89) should befollowed annually.


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* Consider Home blood pressuremeasurement in hypertensionmanagement, to assess for thepresence of masked hypertension orwhite coat effect and to enhanceadherence.

Symptoms, Severehypertension, Intolerance

to anti-hypertensivetreatment or Target Organ

Damage

Are BP readings below target during 2 consecutive visits?

Non Pharmacological treatment

With or without Pharmacological treatment

Diagnosis of hypertension

Follow-up at 3-6month intervals *

NoYes

Yes

More frequentvisits *

Visits every 1to 2 months*

No


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Treatment of Hypertension????

Non-farmakologik

Farmakologik

JNC VII 2004: berjenjang dancompelling indications

BHS-NICE 2006 : terapi sekuensial

Pengobatan awal dan kombinasi :

ESH-ESC 2009, CHEP 2009, JHS 2009

Modifikasi gaya hidup untuk pengendalian


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Modifikasi gaya hidup untuk pengendalian

Hipertensi

Modifikasi Rekomendasi Penurunan Tekanan DarahSistolik kurang lebih

Menurunkan berat

badan

Pelihara berat badan normal

(BMI 18.5-24.9)5-20 mm Hg utk setiappenurunan 10 kg BB

Menjalankan menuDASH

Konsumsi makanan kaya buah,sayur, susu rendah lemak dan

rendah lemak jenuh

8-14 mm Hg

Mengurangi asupan

garam/sodium

Kurangi natrium sampai tidaklebih dari 2.4 g/hari atau NaCl 6

g/hari

2-8 mm Hg

Meningkatkan aktifitasfisik

Berolahraga erobik teraturseperti misalnya berjalan kaki

(30 men/hari 4-5 hari

seminggu)

4-9 mm Hg

Kurangi konsumsi

alkohol

Batasi konsumsi alkohol,jangan

lebih dari 2 /hari utk pria dan 1

/hari utk perempuan.

2-4 mm Hg

Source: The Seventh Report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.
http://c/Documents%20and%20Settings/Administrator/Local%20Settings/Temp/DASH.txthttp://c/Documents%20and%20Settings/Administrator/Local%20Settings/Temp/DASH.txt


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DASH diet

Dietary Approaches to StopHypertension.

Was an 11 week trial.Differences from the food pyramid:

An increase of 1 daily serving of

veggies and increase of 1-2 servings offruit inclusion of 4-5 servings ofnuts,seeds, and beans.


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Tips for Reducing Sodium

Buy fresh, plain frozen or canned noadded saltveggies.

Use fresh poultry, lean meat, and fish.Use herbs, spices, and salt-free

seasonings at the table and while

cooking.Choose convenience foods low in salt.

Rinse canned foods to reduce sodium.


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Maintain Healthy Weight

Blood pressure rises as weight rises.

Obesity is also a risk factor for heart

disease.Even a 10# weight loss can reduce

blood pressure.


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Be Physically Active

Helps lower blood pressure and lose/maintain weight.

30 minutes of moderate level activity onmost days of week. Can even break itup into 10 minute sessions.

Use stairs instead of elevator, get offbus 2 stops early, Park your car at thefar end of the lot and walk!


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Limit Alcohol Intake

Alcohol raises blood pressure and canharm liver, brain, and heart

What counts as a drink? 12 oz beer

5 oz of wine

1.5 oz of 80 proof whiskey

Quit Smoking


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When to initiate Antihypertensive

Therapy?


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Initiation of antihypertensive treatment

ESH/ESC/ISH, based on

Total level of cardiovascular risk and level of systolic and

diastolic Blood Pressure

Level of systolic and diastolic BP

JNC-7, based on

JNC 7 Algorithm for Treatment of Hypertension


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Not at Goal Blood Pressure (


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Compelling indications

Indication Drug choice

ACEi / ARBs esp. type 1 DM

Non-diabetic renal failure

with proteinuria

Congestive heart failure

Isolated systolic

hypertension

ACEi / ARBs

ACEi, diuretic

Diuretic (preferred),

Long-action CCB

Myocardial infarction Beta-blocker (no ISA),

ACEi if systolic dysfunction

Diabetes with proteinuria



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May have favourable effect on co-morbid conditions

Angina pectoris

Atrial fibrillation, tachycardia

Diabetes with proteinuria

Dyslipidemia

Congestive heart failure

Osteoporosis

Beta-blocker, calcium blocker

Beta-blocker, calcium blocker

Calcium blocer (non-DHP)

Alpha blocker

Carvedilol, losartan

Thiazide diuretic

Adapted from the Sixth Report of the Joint National Committee on detection, Evaluation and DiagnosHigh Blood Pressure (JNC VI). ArchIntern Med 1997; 157:2413.


Contraindications Dr g


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Contraindications Drug

Depression

Liver disease

Pregnancy

Reserpine

Methyldopa

ACEi, ARBs

Second or third degree

heart block

Beta-blocker, CCB (non-

DHP)

Bcronchospastic disease Beta Blocker



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May have adverse effect on comorbid condition

Depression

Diabetes Mellitus

Gout

Liver disease

Renovascular disease

Beta-blocker, central alpha

agonist

Beta-blocker, high dose diuretic

Diuretic

Labetalol

ACEi, ARBs

Adapted from the Sixth Report of the Joint National Committee on detection, Evaluation and Diagnosis of High Blood

Pressure (JNC VI). ArchIntern Med 1997; 157:2413.


The BHS Recommendations for a Simplified Approach to Blood


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Pressure Lowering Therapy

Older (e.g. 60 yr)Younger (e.g.


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1-blockers

2007 ESH/ESC Guidelines

CCBs

Diuretics

ACE inhibitors

AT1-receptor

blockers-blockers

NICE CLINICAL GUIDELINE 2011


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NICE CLINICAL GUIDELINE

2011

NICE CLINICAL GUIDELINE 2011

200

Recommendations for Follow up


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Continuing Medical

Implementation

20

Canadian Hypertension Education Program Recommendations 52

Recommendations for Follow-up

Are BP readings below target during 2 consecutive visits?

Non Pharmacological treatment

With or without Pharmacological treatment

Diagnosis of hypertension

Follow-up at 3-6

month intervalsSymptoms, Severe

hypertension, Intolerance toanti-hypertensive treatmentor Target Organ Damage

NoYes

NoYes

More frequentvisits

Monthly visits


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PLAN OF ACTION

CONFIRM

DIAGNOSIS

CONFIRM OF

TARGET ORGAN

INVL- KIDNEY

- DM

- HEART

PLAN OF TREATMENT

- CHOICE OF DRUG

- CHOICE OF COMBINATION

TARGET BP

WHICH DRUG

SHOULD BE USE

- Diuretic

- BBlocker

- ACE-I

- ARB

- CCB

-

M

O

N

I

T

O

R

IN

G

Lifestyle modification


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Not a Goal BP

160 mmHg

DBP > 100 mmHg

2 Drug Combination foir Most

Usualy Thiazide Type diuretic

And ACEI or ARB or

BB or CCB

Drug For the Compeling

indication

Other anti Hypertensive drugs

DiureticsAnd ACEI or ARB or

BB or CCB as needed

Not a Goal BP

Optimize dosages or Add Additional drugs until Goal BP is achived

Consider Consultation With Hypertension SDpecialistl

Algoritthm for Treatment of Hypertension JNC VII,2003


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Is to achieve the maximum reduction in the totalIs to achieve the maximum reduction in the totalrisk of Cardiovascular morbidity andrisk of Cardiovascular morbidity and

mortalitymortality

GO ALS OF TREATMENTGO ALS OF TREATMENT


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ain classes of

antihypertensive drugs

Diuretics

Inhibit the reabsorption of salts and water from kidneytubules into the bloodstream

Calcium-channel antagonists

Inhibit influx of calcium into cardiac and smoothmuscle

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

Vasodilators

Direct renin inhibitors

Control of Blood Pressure and


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Control of Blood Pressure and

Antihypertensive Sites of Action

BP is controlledvia changes in

Cardiacoutput

VasomotortonePlasmavolume

Sympathetic

Stimulation

1

2

3

4

b-Blockersa1-Blockers

Vasodilators

ACE InhibitorsAT1-RA

Diuretics

1

1

2

2

1

14

Sympathetic

Stimulation

Sympathetic

Stimulation

Sympathetic

Stimulation

Heart

Kidney

Postcapillary Venules

(Capacitance Vessels)

Precapillary Arteriole

(Resistance Vessels)

Renin

Aldosterone

Angiotensin

3

Activates

Activates3

3


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