Hipertensi Pit 2014

Treatment of Hypertension

Nur Samsu Division of Nephrology and Hypertension 2014

Initial Evaluation 1.

2.

3. 4. 5.

Confirm diagnosis (Repeat readings, home BP, ABP) Screen for secondary causes Estimate CV risk status Assess Target Organ Damage Co-morbid conditions

Common problems in BP measurement Wrong cuff size  Excess pressure of stethoscope  Patient arm at the wrong level  White coat effect  Auscultatory Gap (silent gap) 

Risk Factors of Clinical Events 

BP level



Calculated CV risk (estimated from factors such as age, gender, smoking history etc.)



Presence of target organ damage



Presence of established CV disease



Concomitant disease associated with CV risk (e.g. diabetes or CKD)

FRAMINGHAM RISK CALCULATOR

Blood Pressure and Cardiovascular Risk: ESHESC Guidelines BP (mmHg) Other RF, OD or disease

Normal

High normal

Grade 1

Grade 2

SBP 120–129 or DBP 80–84

SBP 130–139 or DBP 85–89

SBP 140–159 or DBP 90–99

SBP 160–179 or DBP 100–109

SBP 180 or DBP 110

No other RF

Average risk

Average risk

Low added risk

Moderate added risk

High added risk

1–2 RF

Low added risk

Low added risk

Moderate added risk

Moderate added risk

Very high added risk

3 RF, MS, OD or diabetes

Moderate added risk

High added risk

High added risk

High added risk

Very high added risk

Established CV or renal disease

Very high added risk

Very high added risk

Very high added risk

Very high added risk

Very high added risk

MS = metabolic syndrome OD = subclinical organ damage RF = risk factors

Grade 3

Reproduced from the Task Force of ESH–ESC. J Hypertens 2007;25:1105–87 Copyright © 2007, with permission from Lippincott Williams and Wilkins

Co-morbid conditions Hypertension Syndrome!! It’s More Than Just Blood Pressure Obesity

Decreased Arterial Compliance

Endothelial Dysfunction Abnormal Glucose Metabolism

Abnormal Lipid Metabolism

Hypertension

Accelerated Atherogenesis LV Hypertrophy and Dysfunction

Abnormal Insulin Metabolism

Neurohormonal Dysfunction

Renal-Function Changes Blood-Clotting Mechanism Changes

Kannel WB. JAMA. 1996;275:1571-1576. Weber MA et al. J Hum Hypertens. 1991;5:417-423. Dzau VJ et al. J Cardiovasc Pharmacol. 1993;21(suppl 1):S1-S5.

More Than 80% of Hypertensive Patients Have Additional Comorbidities Men

None 19%

Women

≥ Four 8% Three 22%

One 26%

Two 25%

Comorbidities: • Obesity • Glucose intolerance • Hyperinsulinemia • Reduced HDL-C • Elevated LDL-C • Elevated TG • LVH

None 17%

≥ Four 12% Three 20%

One 27% Two 24%

>50% have 2 or more comorbidities Kannel WB. Am J Hypertens. 2000:13:3S-10S.

Hypertension Management Algorithm

ESH-ESC 2013

Mancia et al. Eur Heart J 2013;34(28):2159-219

Management Algorithm of Hypertension Adult aged ≥18 years with hypertension

Implement lifestyle interventions (continue throughout management)

Set BP goal and initiate BP lowering-medication based on age, diabetes, and CKD General population Diabetes or CKD (no diabetes or CKD) present

Age ≥60 years

Age < 60 years

All ages Diabetes present , No CKD

SBP