BIODATA

• Nama : Sumarni
• TTL : Makassar, 05 Nopember 1979
• Pendidikan : S1 UNHAS
Sp1 UNAIR
• Pekerjaan : Dosen FK-UNISMUH, FK-UMI
Kardiologis RS Pelamonia,
Bhayangkara, Siloam
• Alamat : Komp. Graha Modern Jaya C32
sumayudi@gmail.com
0811-444-9134
Lecture

HYPERTENSION
Sumarni
 INTRODUCTION

Konsil Kedokteran Indonesia, 2012

OBJECTIVES

• Review the prevalence of hypertension

• Describe criteria for hypertension
• Review the patofisiology of hypertension
• Review the management of hypertension
 PREVALENCE
Hypertension is health problem worldwide
60 % increase
1,15B
1,15B 2000
2025 (projected)

700 639

600 24% increase

Millions

500
413
400 333

300
Developed Countries Developing Countries

Kearney PM et al. Lancet. 2005.

 PREVALENCE
Hypertension in the Asian Region
Patients Prevalence Awareness Treated Controlled
(n) (%) (%) (%) (%)

China 16,364 43,8 26,2 22,2 3,9

India 4711 36 22,1 36,7 27,2

Korea, > 40 years, 6388 43,8 60,1 91,7 38

rural areas
Korea, ≥ 30 years 8485 24,9 63,5 54,8 26,3

Malaysia, >18 years 33,976 32,2 35,8 31,4 31,4

Philippines 3415 21 16 65 20

Singapore 5022 41,5 51,8 84,4 27,1

Tomlinson, et al. Current Medical Research & Opinion. 2011

 PREVALENCE
The death rates due to hypertension in 2002
60 Men
49,6
50 Women
100,000 population

40,5
40
Death Rate/

30

20
14,4 13,7
10

0
Black White

Rosamond, et al. Circulation-AHA. 2008

 CRITERIA
Classification of Blood Pressure in Adults

Systolic Diastolic
Normal <120 And <80
Prehypertension 120 – 139 Or 80 – 89
Stage 1 140 - 159 Or 90 – 99
Stage 2 > 160 Or > 100

(Modified from The seventh report of JNC on Prevention, Detection,

Evaluation, and Treatment of high BP, 2003)
 PATHOPHYSIOLOGY

(Pathophysiology of Heart Disease, 2011)

MECHANISM OF HYPERTENSION

Oparil, et al. Ann Intern Med. 2003.

 PATHOPHYSIOLOGY

Drugs for the Heart, 2013 .

MANAGEMENT
JNC 7 Guidelines Life Style Modification

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with
diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling Indications With Compelling Indications

Stage 1 Hypertension Stage 2 Hypertension

(SBP 140 – 159 or DBP 90 – 99
mmHg). Thiazide-type
diuretics for most. May
considerACEI, ARB, BB, CCB,
or combination
Drugs for the compelling
(SBP > 160 or DBP > 100
indications)
mmHg)2-drug combination
Other antihypertensive
for most (usually thiazide-
drugs diuretics, ACEI, ARB,
type diuretic and ACEI, or
B, CCB) as needed
ARB, or B, or CCB).

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist
JNC report. JAMA. 2003 .
MANAGEMENT
Lifestyle Modification

Weight Ingestion of
loss high fiber
low fat
diet

Increased Moderation
physical of alcohol
activity intake
MANAGEMENT
JNC 7 Guidelines Life Style Modification

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with
diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling Indications With Compelling Indications

Stage 1 Hypertension Stage 2 Hypertension

(SBP 140 – 159 or DBP 90 – 99
mmHg). Thiazide-type
diuretics for most. May
considerACEI, ARB, BB, CCB,
or combination
Drugs for the compelling
(SBP > 160 or DBP > 100
indications)
mmHg)2-drug combination
Other antihypertensive
for most (usually thiazide-
drugs diuretics, ACEI, ARB,
type diuretic and ACEI, or
B, CCB) as needed
ARB, or B, or CCB).

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist
JNC report. JAMA. 2003 .
MANAGEMENT

(Pathophysiology of Heart Disease, 2011)

MANAGEMENT
Diuretics

Drugs for the Heart, 2013 .

MANAGEMENT

Angiotensin-Converting Enzyme Inhibitor (ACE-I)

Drugs for the Heart, 2013 .

MANAGEMENT

Angiotensin-II Receptor Blocker (ARB)

Drugs for the Heart, 2013 .

MANAGEMENT

Calcium Channel Blocker (CCB)

Drugs for the Heart, 2013 .

MANAGEMENT

Drugs for the Heart, 2013 .

MANAGEMENT
β- Blocker (BB)

Drugs for the Heart, 2013 .

 -BLOCKERS DRUGS

Selective With alpha-blocking

Non-selective
activity
- + - +
ISA ISA ISA ISA

Nadolol Pindolol Atenolol Acebutolol Labetalol

Propranolol Carteolol Esmolol (Practolol) Bucindolol
Timolol Penbutolol Metoprolol Celiporlol Carvedilol
Sotalol Alprenolol Bisoprolol
Tertalolol Oxprenolol Betaxolol
Bevantolol
MANAGEMENT

Drugs for the Heart, 2013 .

MANAGEMENT
JNC 7 Guidelines Life Style Modification

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with
diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling Indications With Compelling Indications

Stage 1 Hypertension Stage 2 Hypertension

(SBP 140 – 159 or DBP 90 – 99
mmHg). Thiazide-type
diuretics for most. May
considerACEI, ARB, BB, CCB,
or combination
Drugs for the compelling
(SBP > 160 or DBP > 100
indications)
mmHg)2-drug combination
Other antihypertensive
for most (usually thiazide-
drugs diuretics, ACEI, ARB,
type diuretic and ACEI, or
B, CCB) as needed
ARB, or B, or CCB).

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist
JNC report. JAMA. 2003 .
RECOMMENDATION FOR HYPERTENSION TREATMENT

Diuretics
ESH/ESC Guidelines

AT1-receptor
ß-blockers blockers

Calcium
1-blockers antagonists

ACE inhibitors

Mancia, G. et al. Eur Heart Journal . 2007.

RECOMMENDATION FOR HYPERTENSION TREATMENT

Younger than Older than than 55 year or

55 year black patients
NICE Guidelines

ACEI CCB or Thiazides

Step 1

ACEI + CCB or ACEI + Thiazides

Step 2

ACEI + CCB + Thiazides Step 3

Add:
• Other diuretic or Step 4
•Alfablocker
•Betablocker
Consider consult a specialist
NICE Clinical Guidelines. Hypertension. 2004 .
REGIONAL RECOMMENDATION FOR ANTIHYPERTENSIVE
GUIDELINES RECOMMENDATIONS

Tomlinson, et al. Current Medical Research & Opinion. 2011C

 THERAPY GOAL
Effect of Antihypertensive on Cardiovascular Events
Combined results from HTN treatment trials
Decrease in events (treated compared with controls)
00 Fatal/
Fatal/
CVD Nonfatal
Nonfatal
-10
-10 Fatal/ deaths CHD
CHDevents
events
Nonfatal
-20
-20 CHF strokes -16%
-21%
%

-30
-30
-40
-40
-38%
-50
-50
-52%
-60
-60

Hebert P et ,all. Arch Intern Med. 1993 .

Hebert P et ,all. Arch Intern Med. 1993 . 153; 578-581
Moser M, et al. J Am Coll Cardiol. 1996.
Moser M, et al. J Am Coll Cardiol. 1996. 27; 1210- 121
 INTRODUCTION
Screening of Secondary Hypertension

• Severe blood pressure elevation

• Sudden onset or worsening of hypertension
• Blood pressure responding poorly to drug therapy

ESC and ESG Guidelines of Hypertension

 Renal Parenchymal Disease

• Renal parenchymal disease is the most common cause of

secondary hypertension
• The finding of bilateral upper abdominal masses polycystic
kidney disease
• Renal ultrasoundanatomic data about kidney size and shape,
cortical thickness, urinary tract obstruction and renal masses
• Assessing renal functionthe presence of protein, erythrocytes
and leucocytes in the urine, serum creatinine concentration

ESC and ESG Guidelines of Hypertension

 Renovascular Hypertension

• The second most common cause of secondary hypertension

• Caused by one or more stenoses of the extra-renal arteries
• Abdominal bruit with lateralization, hypokalaemia and
progressive decline in renal function
• The gold standard for the detection of renal artery stenosis
renal angiography
• Angioplasty alone  fibromuscular dysplasia
Stenting  atherosclerotic

ESC and ESG Guidelines of Hypertension

 Phaechromocytoma

• Very rare secondary hypertensive state (0.2–0.4% of all cases of

elevated blood pressure)
• Hypertension occurs in about 70% of all cases of
phaeochromocytoma, being stable or paroxysmal (presenting
with symptoms such as headache, sweating, palpitations and
pallor)
• The diagnosis is based on establishing an increase in plasma or
urinary catecholamines or their metabolites. It can be supported
by pharmacological tests which should precede the carrying out
of functional imaging procedures designed to localize the tumour
• Definite treatment requires excision of the tumour

ESC and ESG Guidelines of Hypertension

 Primary Aldosteronism

• Caused by adrenal adenomas , adrenal hyperplasia, adrenal

carcinoma and the autosomal dominant condition of
glucocorticoid remediable aldosteronism
• Suspected in resistant hypertension and in unprovoked
hypokalaemia
• The surgical technique for removal of a suspected adenoma is
laparoscopic adrenalectomy

ESC and ESG Guidelines of Hypertension

 Cushing’s Syndrome

• Suggested by the typical body habitus of the patient

• The determination of 24-hour urinary cortisol excretion is the
most practical and reliable diagnostic test and a value exceeding
110 mmol (40 mg) is highly suggestive of Cushing’s syndrome
• The diagnosis is confirmed by the 2-day, low-dose
dexamethasone suppression test (0.5 mg every 6 h for eight
doses) or the overnight dexamethasone suppression test (1 mg at
23.00 h)
• In the 2-day test, a urinary cortisol excretion higher than 27
mmol (10 mg) per day on day 2 indicates Cushing’s syndrome.

ESC and ESG Guidelines of Hypertension

 Obstructive Sleep Apnea

• Characterized by recurrent episodes of cessation of respiratory

airflow caused by upper airway inspiratory collapse during sleep,
with a consequent decrease in oxygen saturation
• Signs and symptoms include daytime somnolence, impaired
concentration, unrefreshing and restless sleep, choking episodes
during sleep, witnessed apnoeas, nocturia, irritability and
personality changes, decreased libido and increased motor
vehicle accidents
• Polysomnography remains the ‘gold standard’ diagnostic tool for
assessing sleep-disordered breathing
• Weight loss in obese subjects ameliorates the syndrome, which
is also improved by using positive pressure breathing equipment.

ESC and ESG Guidelines of Hypertension

 Coarctation of aorta

• Coarctation of the aorta is a rare form of hypertension in

children and young adults
• A midsystolic murmur, which may become continuous with time,
is heard over the anterior part of the chest and also over the
back. The femoral pulse is absent or delayed relative to the radial
pulse. Hypertension is found in the upper extremities
concomitantly with low or unmeasurable blood pressure in the
legs
• After repair or stenting, especially in adults, hypertension may
persist due to haemodynamic and vascular effects, and many
patients need to continue antihypertensive therapy.

ESC and ESG Guidelines of Hypertension

 Drug Induced Hypertension

• Substances or drugs that can raise blood pressure include:

liquorice, oral contraceptives, steroids, non steroidal
antiinflammatory drugs, cocaine and amphetamines,
erythropoietin, cyclosporins, tacrolimus
• The patient should be asked about their medication at the time
their clinical history is taken, and the use of drugs that can raise
blood pressure should be monitored carefull

ESC and ESG Guidelines of Hypertension

 INTRODUCTION
Definition of pulmonary Hypertension

Increase in mean pulmonary arterial pressure (PAPm)

≥ 25 mmHg at rest as assesed by right heart
catheterization (RHC)

ESC and ESG Guidelines of Pulmonary Hypertension

Haemodynamic Definition

ESC and ESG Guidelines of Pulmonary Hypertension 42

Classification

Pulmonary Arterial Hypertension

Primary/ idiopathic (IPAH) Associated (APAH)

43
Pathogenesis

The precise mechanism of Vasoactive mediators

PAH development in is not
thoroughly understood
• Endothelial cell dysfunction
thought to play a key
role
• Smooth muscle cell
migration and
dysfunction de-
differentiate more
synthetic phenotype
grow into subendothelial
space produce the fibrous
material
• Abnormal apoptosis

Barst, 2011 44
Symptoms and Signs

• Symptoms : not specified

 Early : breathlessness, fatigue, and poor exercise
tolerance.
 Late : chest pain, syncope, cyanosis, oedema

• Signs : Raised JVP, left parasternal lift, a loud P2,

a pansystolic murmur of TR and a diastolic PR
murmur, ascites, hepatomegaly and peripheral
leg edema

45
ECG and CXR

ECG:

• RV hypertrophy and strain, and RA dilatation.

• RVH present in 87% and RAD in 79% of pts with IPAH.

• Sensitivity 55% & specificity 70%

CXR:

• Central pulmonary arterial dilatation

• ‘Pruning’ (loss) of the peripheral blood vessels

• RA and RV enlargement
46
Echocardiography

• The estimation of PAP = TR maxPG + estimated RAP

• Increased dimensions of right heart chambers
• Abnormal shape and function of the IVS
• Increased RV wall thickness and dilated main PA
• Sensitivity of 90 % and a specificity of 75 % compared with
right heart catheterization (RHC)
• TR>3.4 m/s, PA syst pressure >50 mmHg, with/without
additional echocardiographic variables suggestive of PH
(Class I; LOE B)

Galie, 2009 47
Right Heart Catheterization

RHC is the gold standard test in the

diagnosis and classification of PH
 Determining the PAP accurately
 The only reliable means determining
PVR
 Vasoreactivity test
• The risk of RHC and general
anaesthesia ↑ in the presence of PH
• acute responders only < 10% of adult
pts with IPAH

RHC is indicated in all patients with PAH to confirm the diagnosis,

evaluate the severity and therapy (Class I, LOE C)
Haworth, 2008; Galie, 2009 48
Treatment

49
Galie, 2009
Anticoagulation
Endothelial dysfunction
Long-term hypoxia
Hypercapnia
Secondary polycythemia
Hypercoagulability
Stasis of the microcirculation

Risk of thrombosis and embolism ↑

Anticoagulant therapy has been recommended to be used. However, there

is no evidence to support that anticoagulant therapy provides benefit for
IPAH patients.

50
Diuretic

Decompensated Fluid retention,

RV failure ↑ JVP, hepatic
congestion, ascites,
peripheral oedema

Clinical experience shows clear symptomatic benefit in fluid-

overloaded pts, although there are no RCTs of diuretics in PAH

51
Ballon Atrial Septostomy

Recommended for severe PAH and intractable right heart

failure despite maximal medical therapy

BAS creates a right to left inter-atrial shunt

decreasing right heart filling pressures
improving right heart function & left heart filling.
Improvements in NYHA functional class and 6MW test

Goals : palliation, restoration and maintenance of clinical

stability until a transplant can be performed.

52
Lung Transplantation

• Offered as a last resort to patients with PAH who fail medical

therapy.
• 1-year survival rate after transplantation is 65–70 %
• heart-double lung and double lung

53
THANK YOU