Tata

Laksana Praktis
Hipertensi Kronik

Dr Renan Sukmawan ST SpJP(K) PhD MARS

Departemen Kardiologi dan Kedokteran Vaskular
Fakultas Kedokteran Universitas Indonesia
Pusat Jantung Nasional Harapan Kita

Perhimpunan Dokter Spesialis Kardiovaskular (PERKI)

• NICE Guidelines 2019
• ESC/ESH Guidelines 2018
• ACC Guidelines 2019
 The guidelines: ESC SCORE Chart

4 Fifth Joint Task Force on Cardiovascular Disease Prevention in Clinical Practice Eur Heart J 2012;33:1635–1701
Target Tekanan Darah
Modifikasi Gaya Hidup
 Table 7. Best Proven Nonpharmacological Interventions For the
Prevention and Treatment of Hypertension

Nonpharmacological Goal Approximate Impact on SBP

Intervention Hypertension Normotension Reference
Weight loss Weight/body fat Best goal is ideal body -5 mm Hg -2/3 mm Hg (S4.4-2)
weight, but aim for at least
a 1-kg reduction in body
weight for most adults who
are overweight. Expect
about 1 mm Hg for every 1-
kg reduction in body
weight.
Healthy diet DASH dietary pattern‡ Consume a diet rich in -11 mm Hg -3 mm Hg (S4.4-7, S4.4-8)
fruits, vegetables, whole
grains, and low-fat dairy
products, with reduced
content of saturated and
total fat.
Reduced intake Dietary sodium Optimal goal is <1500 -5/6 mm Hg -2/3 mm Hg (S4.4-12, S4.4-10)
of dietary sodium mg/d, but aim for at least a
1000-mg/d reduction in
most adults.
Enhanced intake Dietary potassium Aim for 3500–5000 mg/d, -4/5 mm Hg -2 mm Hg (S4.4-14)
of dietary preferably by consumption
potassium of a diet rich in potassium.
 Table 7. Best Proven Nonpharmacological Interventions For the
Prevention and Treatment of Hypertension (cont’d)

Nonpharmacological Goal Approximate Impact on SBP

Intervention Hypertension Normotension Reference
Physical activity Aerobic • 90–150 min/wk -5/8 mm Hg -2/4 mm Hg (S4.4-19, S4.4-20)
• 65%–75% heart rate
reserve
Dynamic resistance • 90–150 min/wk -4 mm Hg -2 mm Hg (S4.4-19)
• 50%–80% 1 rep
maximum
• 6 exercises, 3
sets/exercise, 10
repetitions/set
Isometric resistance • 4 × 2 min (hand grip), -5 mm Hg -4 mm Hg (S4.4-21, S4.4-63)
1 min rest between
exercises, 30%–40%
maximum voluntary
contraction, 3
sessions/wk
• 8–10 wk
Moderation in Alcohol consumption In individuals who drink -4 mm Hg -3 mm Hg (S4.4-20, S4.4-24,
alcohol intake alcohol, reduce alcohol† to: S4.4-25)
•Men: ≤2 drinks daily
•Women: ≤1 drink daily
 Monotherapy Vs Combination therapy
Therapeutic strategies of hypertension (ESH-ESC guidelines 2007)
Eur Heart J 2007;28:1462-1536
Mild BP Marked BP elevation
Low-mod CV risk Choose between High / very high CV risk
Conventional BP target Lower BP target

Single agent 2 drug combination

at low dose at low dose

If goal BP not achieved

Previous agent Switch to different Previous Add a

at full dose Agent at low dose combination third drug
at full dose at low dose

If goal BP not achieved

2-3 drug combination 3 drug combination

Full dose monotherapy at full dose
At full dose
Clinical Trial and Guideline Basis for Compelling
Indications for Individual Drug Classes
(JNC VII)
Recommended
Drugs
Compelling

Aldo Ant
Clinical trial basis

Diuretic
Indication*

ACEI
ARB
CCB
BB
Heart Failure ACC/AHA Heart Failure Guideline, MERITHF,
COPERNICUS, CIBIS, SOLVD, AIRE, TRACE,
ValHEFT, RALES, CHARM

Postmyocardial ACC/AHA Post-MI Guideline, BHAT, SAVE,

Infarction Capricorn, EPHESUS

High Coronary Disease ALLHAT, HOPE, ANBP2, LIFE, CONVINCE,

Risk EUROPA, INVEST

Diabetes NKF-ADA Guideline, UKPDS, ALLHAT

Chronic Kidney Disease NKF Guideline, Captopril Trial, RENAAL, IDNT,

REIN, AASK

Recurrent Stroke PROGRESS

Prevention
 Recommended Drugs
Condition
Diuretik BB ACE-I ARB CCB ALD-antag
Subclinical organ damaged
LVH
Atherosclerosis
Renal Dysfunction
Clinical event
Previous stroke
Previous MI
Angina pectoris
Heart Failure
Atrial fibrillation
Recurrent
Permanent
ESRD/proteinuria
Peripheral artery dis.
Condition
ISH (elderly)
Metabolic Syndrome
Diabetes Melitus
Pregnancy
Blacks

ESC-ESH. 2007 Guidelines for the management of hypertension

 Treatment of Hypertension

“ More intensive therapy

was associated with
better results”
 Case Study
Laki-laki usia, 62 tahun, datang ke ruang praktek anda
dengan keluhan angina. FR: smoker dan diabetes.
Pada PF TD 190/120, N 102x/menit. Pada auskultasi
tidak terdengar murmur atau gallop, pada paru tak
terdengar ronkhi atau wheezing.
-Bagaimana pada tahapan tata laksana pasien ini
-Apakah kemungkinan Dd/ pada pasien ini
-Pemeriksaan lanjutan yang disarankan
-Terapi yang dapat diberikan segera
Factors involved in the control
of blood pressure
Enjoy Indonesia