Hipovolemic ShockEssential Hipertensi&

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36Prevalensi Hipertensi

Prevalensi :Berdasar kriteria Hipertensi WHO 1968 (tekanan darah > 160/95 mmHg), prevalensi hipertensi di dunia sekitar 5-18 %. Prevalensi hipertensi di Indonesia tidak jauh berbeda yaitu sekitar 6-15 %, walaupun dilaporkan adanya prevalensi yang rendah yaitu :- Ungaran1,8 %- Lembah Balim0,6 %serta adanya prevalensi yang tinggi :- Silungkang19,4 %- Talang17,8 %Prevalensi Hipertensi di Jawa Timur hampir sama yaitu :- Sumberpucung(1976)10 %- Lawang(1987)11 %- Kampak(1987)17 %

23%16%42%19%Hypertensive patients who are treated but uncontrolledHypertensive patientswho are treated and controlledHypertensive patients who are unawarePatients who are awarebut remain untreatedand uncontrolled22 % of American adults 18 to 70 years of age have hypertension20 % of Indonesian adults have hypertensionNew Criteria (WHO-ISH 1999) 140 / 90 mmHgSource : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102

Klasifikasi Hipertensi (JNC 7 - 2003)

HipertensiBerdasarkan penyebabnya dapat dibedakan :Primer (essential)tidak ada penyebab yang spesifik yang dapat diidentifikasi90-95% dari kasus hipertensiSekunderdiketahui penyebabnya5-10% dari kasus hipertensipenyakit ginjal merupakan penyebab tersering kasus hipertensi sekunder

Etiology HypertensionSecondary Hypertension :Renal disease :Renal arterial diseaseRenal parenchymal diseaseRenal tumorsArteritis (polyarteritis nodosa, neurofibromatosis)Endocrine DisordersCushings syndromeAcromegalyPrimary aldosteronismPheochromocytomaCoarctation of the aortaNeurologic disordersIncreased intra cranial pressure (tumor)Drug-induced hypertensionCorticosteroidsAmphetaminesOral contraceptivesPsychogenic disorders

Fisiologi

SV=EDV-ESVCO=SV x HRBP=CO x PR

PATOPHYSIOLOGYThe factors affecting cardiac output: - sodium intake, renal function, & mineralocorticoids - the inotropic effects occur via extracellular fluid volume augmentation - an increase in heart rate and contractility

Peripheral vascular resistance is dependent upon the sympathetic nervous system, humoral factors, and local autoregulation

(Sharma, 2003)

Neurohormonal control of blood pressureBlood pressure=Cardiac output (CO) x Peripheral resistance (PR) Hypertension= Increased COand/or Increased PR Preload

Fluid volumeRenal sodiumretention Contractility Fluid volumeVasoconstrictionSympatheticnervoussystemRenin-angiotensin-aldosteronesystemGeneticfactorsExcesssodiumintake(Adapted from Kaplan, 1994)

Hypertension :The Disease Continuum

Komplikasi Hipertensi

Effects of blood pressure on the risk of cardiovascular diseaseAverage annual incidence rate per 10.000Source : Framingham study (after Gorlin)1009080706050403020100

180Systolic blood pressure (mmHg)CHD

StrokeCHF

SymptomsHeadacheDizzinessFatiguePounding of the heartSymptoms are not specific and no more frequent than in patients with normotension.Symptoms of complications : heart failure, chest pain, claudication, vision

Evaluasi Klinis Hipertensi : Tujuan :1. Konfirmasi hipertensi dan tingkatnya2. Menyingkirkan & menemukan hipertensi sekunder3. Menentukan kerusakan organ target4. Mencari faktor risiko kardiovaskuler dan kondisi klinik lain

Riwayat Klinis :Riwayat keluarga HT, DM, dislipidemia, PJK, stroke atau sakit ginjalLama & tingkat TD sebelumnya & hasil Tx. serta efek Adanya PJK, gagal jantung, penyakit serebrovaskuler, ginjal, perifer, DM, pirai, dislipidemia, asma bronkhiale, & informasi obatFaktor risiko (diet lemak, Na & alkohol, rokok, aktifitas fisik, & BB)Riwayat obat-obatan (kontrasepsi, NSAID, kokain & amfetamin) dapat TD.Faktor pribadi, psikososial dan lingkungan.

Pemeriksaan Fisik :Pemeriksaan fisik & TD yang telitiTinggi, berat, & BMI (Body mass Index) Sistem kardiovaskuler : ukuran jantung, gagal jantung, arteri perifer (carotis, aorta, renal) Paru (ronkhi & bronkhospasme), bising abdomen. Fundus optikus & sistim syaraf (mengetahui kerusakan serebro-vaskuler).

Technique of blood pressure measurement recommended by the British Hypertension Society2.The patient should be relaxed and the arm must be supported. Ensure no tight clothing constricts the arm3.The cuff must be level with the heart. If the circumference exceeds 33cm, a large cuff must be used (2/3 of arm). Place stethoscope diaphram over brachial artery4.The column of mercury must be vertical. Inflate to occlude the pulse (>30 mmHg). Deflate at 2-3 mm/s. measure systolic ( first sound / Korotkoff I ) & diastolic (disappearence / Korotkoff IV or V ) to nearest 2 mmHg(From British Hypertension Society 1985)1.Several time, rest 5 minutes before

Recommended Technique for Measuring Blood Pressure Standardized technique:

Have the patient rest for 5 minutes Use an appropriate cuff size Use a mercury manometer or a recently calibrated electronic device

Position cuff appropriately Increase pressure rapidly Support arm with antecubital fossa or heart level To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 30 mmHg above level of diseappearance of radial pulse Place stethoscope over the brachial arteryRecommended Technique for Measuring Blood Pressure (cont.)

Recommended Technique for Measuring Blood Pressure (cont.) Drop pressure by 2 mmHg / beat:- appearance of sound (phase I Korotkoff) = systolic pressure- disappearance of sound (phase V Korotkoff) = diastolic pressure Take 2 blood pressure measurements, 1 minute apart

Diagnosis of HypertensionHypertension is defined as:- BP 140/90 mm Hg- during 1-5 visits- with an average of 2 readings per visit

Pengukuran tekanan darah ambulatorySekarang terdapat alat otomatis untuk mengukur tekanan darah selama 24 jam atau lebih.Indikasi pemeriksaan tersebut (ABPM = Ambulatory Blood Pressure Monitoring) ialah sebagai berikut :1. Adanya variasi tekanan darah yang besar 2.Office hypertension 3. Dicurigai adanya episode hipotensi4.Hipertensi yang resisten terhadap pengobatan

Pemeriksaan lain-lainLaboratorium :Urinalisis & mikroskopik urinSerum kalium, kreatinin, gula darah puasa & 2 jam dan profil lemak, asam uratPemeriksaan tambahan :Pemeriksaan hormonal seperti pengukuran aktifitas renin plasma, aldosteron plasma dan katekolamin urine atas indikasi khusus (hipertensi sekunder)EKG & Foto polos dadaEkhokardiografi (curiga kerusakan organ target /LVH / lainnya)Ultrasonografi vaskuler (curiga penyakit arteri karotis, aorta atau perifer lain)Ultrasonografi renal (curiga penyakit ginjal)Angiografi

Minimal BP Goal of TherapyRecommendations (SBP/DBP mmHg)(Bakris GL, et al for the National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis. 2000) (JNC VI. Arch Intern Med. 1997)*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.Proteinuria > 1 g/24h.

Terapi HipertensiTerapi Non-farmakologisMenurunkan berat badan (5-20 mmHg/10 kg)Latihan dan olah raga (4-9 mmHg)Menghindari alkohol yang berlebihanMengurangi asupan garam (2-8 mmHg)Stop merokokMenurunkan asupan lemak jenuh

Lifestyle Modification

ModificationApproximate SBP reduction (range)

Weight reduction 520mmHg/10 kg loss

Adopt DASH eating plan 814 mmHg

Dietary sodium reduction 28 mmHg

Physical activity 49 mmHg

Moderation of alcohol consumption 24 mmHg

Terapi HipertensiTerapi Farmakologistujuan terapi antihipertensiMemperbaiki fungsi endotheluntuk menurunkan resistensi vaskular sistemikmempertahankan curah jantungmempertahankan suplai darah ke organ dan jaringanPengobatan diberikan seumur hidupKepatuhan yang buruk merupakan penyebab kegagalan terapi antihipertensi yang paling besar

Pilihan terapi antihipertensiDiuretikBeta-blockerAntagonis kalsiumACE-inhibitorAngiotensin II receptor antagonis (AIIRA / ARB)Alpha1-blocker (sentral & perifer)

Possible combinations of different classes of antihypertensive agents. The most rational combinations are represented as thick lines.ACE, angiotensin-converting enzyme; AT1, angiotensin II type 1.ACE inhibitorsDiuretics1-blockers-blockersAT1 receptorblockersCalciumantagonists

Algorithm for Treatment of Hypertension

Reasons of inadequate BP ControlAcceptance of inadequate control by physicianDifficulty achieving BP control with one agent/suboptimal regimensBP goals are more aggressive than in previous yearsLack of compliance due to :perceived side effects of antihypertensive medication(s)frequency of dosing/multiple agents to attain control(Adapted from JNC VI. Arch Intern Med. 1997)

Presentasi pasien hipertensi yang terkontrolAdapted from G. Mancia / L. Ruilope

WHO-ISH (1999) Klasifikasi Derajat Tekanan Darah menurut WHO-ISH 1999 yang diadaptasi dari JNC VI 1997

HipertensiSecondary Hypertension :

Renin inhibitorsAII receptor blockersAngiotensin IIReninConverting enzymeAngiotensinreceptorsAngiotensinogenACE inhibitorAngiotensin ILiverTissueCirculatingLocalNon Renin pathways - t-PA - Cathepsin G - ToninNon-ACE pathways - Chymase - CAGE - Cathepsin GThe Renin-Angiotensin SystemAlternate Pathway

Brown, M.J., Lancet 2000;355:653-4Risiko Infark Miokard dan Stroke

Lenfant C, Roccella EJ. J Hypertens Suppl. 1999;17:S3-S7.Data from Levy D et al. JAMA. 1996;275:1557-1562.Cumulative Incidence of CHF : Normotensives and Stage 1 and 2 Hypertensives

Effects of Angiotensin II at AT1 and AT2 ReceptorsBlocked by ARB sAT2AT1VasoconstrictionAldosterone releaseOxidative stressVasopressin releaseSNS activationInhibits renin release Renal Na+ and H2O reabsorptionCell growth and proliferationVasodilationAntiproliferationApoptosisAntidiuresis/antinatriuresisBradykinin productionNO releaseSiragy H. Am J Cardiol. 1999;84:3S8S.

Role of A II in Vascular DiseaseReprinted with permission from Dzau VJ. Hypertension. 2001;37:1047-1052.

Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failureBrain Stroke or transient ischemic attackChronic kidney diseasePeripheral arterial diseaseRetinopathy

Khattar, R.S. et al. Circulation 1999; 100:1071-4Assessment of the 24-hour blood pressure load isa good clinical method to identify high-risk patientsTotal Mortality and Continuous Ambulatory Blood Pressure

Benefits of Lowering BP

Goals of Therapy(JNC-VII)Reduce CVD and renal morbidity and mortality. Treat to BP

Hypertension Prevalence and Treatment : North America and EuropePrevalence of Hypertension 0510152025303540455055Country %USCanadaGermanyItalySwedenEnglandSpainFinlandWolf-Maier K et al. JAMA. 2003;289:2363-2369.Patients on Therapy

25%12.5%12.5%50%Hypertensive patients who are treated but uncontrolledHypertensive patientswho are treated and controlledHypertensive patients who are unawarePatients who are awarebut remain untreatedand uncontrolledSource : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102RULE OF HALF

BP Control RatesTrends in awareness, treatment, and control of high blood pressure in adults ages 1874

Sources: Unpublished data for 19992000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.

National Health and Nutrition Examination Survey PercentII

197680III(Phase 1)198891III(Phase 2)199194

19992000Awareness51736870Treatment31555459Control10292734

Antihypertensive Agents CombinationACE INHIBITORDIURETICAT-2 RBCa-ANTAGONIST-BLOCKER -BLOCKERESC-ESH 2003

CVD Risk FactorsHypertension*Cigarette smokingObesity* (BMI >30 kg/m2)Physical inactivityDyslipidemia*Diabetes mellitus*Microalbuminuria or estimated GFR

Classification and Management of BP for adults* Treatment determined by highest BP category. 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

Compelling Indications for Individual Drug Classes

Compelling Indications for Individual Drug Classes

Hipovolemic Shock

*******Maintenance of BP below 140/90 mmHg coupled with lifestyle modifications may prevent stroke, preserve renal function, and prevent or slow the progression of HF.2 In addition, specific recommendations for special populations with hypertension have been made. The optimal BP goal in patients with concurrent DM, and for patients with HF is