MANAGEMENT OF HYPERTENSION IN PRIMARY CARERia Bandiara

OBJECTIVESTo promote the primary prevention of hypertension through the adoption and maintenance of healthy lifestylesTo promotes early and accurate diagnosis of hypertensionTo improve the quality of care of person with hypertensionTo promotes the referral of person with hypertension

Global Mortality 2000: Impact of HypertensionLower mortality, developing regionAttributable Mortality (in thousands; total 55,861,000)080007000600050004000300020001000High blood pressureTobaccoHigh cholesterolUnsafe sexHigh BMIPhysical inactivityAlcoholUnderweightHigh mortality, developing regionDeveloped regionBMI = body mass index. Adapted with permission from Ezzati M, et al. Lancet. 2002;360:1347-1360.

Klasifikasi tekanan darah menurut ASH/ISH 2013, JNC VII (Chobanian,2003) & 2014 Hypertension Guideline (report JNC 8)

KategoriTekanan Darah SistolikTekanan Darah DiastolikNormal100 mmHg

Same with 2003, 2007HT : BP 140/90ESH/ESC 2013

HYPERTENSIONChronic medical condition in which blood pressure is elevated

Systemic, arterial hypertension

Essential (primary) hypertensionSecondary hypertension

PRIMARY HYPERTENSION

SECONDARY HYPERTENSIONHigh blood pressure is a result of another conditionAdrenal cortical abnormalities :Cushings syndrome ( adrenal glands overproduce the hormone cortisol)More than 85 % of patients with Cushings syndrome have hypertensionPrimary aldosteronism ( overproduction of aldosterone by adrenal glands)Aldosteronism causes sodium and water retention, potassium excretion in the kidneys - arterial hypertension

Diseases of the kidney (polycystic kidney disease genetic disorder of the kidneys)Diseases of the renal arteries supplying the kidney RENOVASCULAR HYPERTENSIONNeuroendocrine tumors (pheochromocytoma)Medication side effects (NSAID)

Risk Factors for HypertensionKnown modifiable risk factors for hypertension are:ObesityExcessive intake of salt and caloriesInadequate physical activityUncontrolled hyperglycemic statesHigh alcohol consumptionTobacco useLow potassium intakeSleep apneaPsychosocial stress is often implicated but difficult to measure

Non-modifiable factors include:AgeRace Family history of hypertension or diabetes

REGULATION OF BLOOD PRESSUREBaroreceptor reflex changes in arterial pressure medulla (brain stem)Location : left and right carotid sinuses, aortic arch

Renin angiotensin system (RAS)Long term adjustment of arterial pressureKidney - compensationEndogenous vasoconstrictor angiotensin I

Aldosterone release (adrenal cortex)Stimulates sodium retention and potassium excretion by the kidneyIncreases fluid retention and indirectly arterial pressure

SPHYGMOMANOMETERUses the height of a column of mercury to reflect the circulating pressure

Blood pressure values millimeters of mercury (mm/Hg)

Aneroid and electronic devices do not use mercury

SIGNS AND SYMPTOMSNo symptoms many people unaware they have hypertension, accidentally found; complications:Nonspecific symptoms mild symptomsHeadache Morning headacheTinnitus ringing in earsDizzinessConfusionFatigueShortness of breathChanges in vision - blindnessNausea AnxietyNose bleedsHeart palpitationsFlushed skinPale skinChest pain

Consequences of Hypertension: Organ DamageCHF=congestive heart failure; CHD=coronary heart disease; LVH=left ventricular hypertrophy.Chobanian AV et al. JAMA. 2003;289:2560-2572.HypertensionLVH, CHD, CHFChronic kidney diseaseRetinopathyTransient ischemic attack, strokePeripheralarterialdisease

Screening for hypertension should be a routine part of every health care encounter for adults.

Blood pressure monitoring should be carried out regularly in those at risk for hypertension.

This includes persons with a family history of hypertension, stroke, heart disease or diabetes.

SCREENING FOR HIGH BLOOD PRESSURE

Patient EvaluationTwo consecutive blood pressure measurements

Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment

Reveal identifiable causes of high BP

Assess the presence or absence of target organ damage and CVD

Risk factors influencing outcome CVD, cardiovascular disease; DBP, diastolic blood pressure; MI, myocardial infarction; SBP, systolic blood pressure; TIA, transient ischaemic attack.

CVD risk factorsIncreased SBP and DBPAdvanced age (>55 years for men, >65 years for women)SmokingDyslipidaemiaFamily history of premature CVDAbdominal obesityIncreased C-reactive protein level

Target organ damageLeft ventricular hypertrophyUltrasound evidence of arterial wall thickening or a plaqueSlight increase in serum creatinineMicroalbuminuria

Clinical diseaseCerebrovascular disease: ischaemic stroke, cerebral haemorrhage, TIAHeart disease: MI, angina, coronary revascularisation, CHFRenal disease: diabetic nephropathy, renal impairmentPeripheral vascular diseaseAdvanced retinopathy: haemorrhages or exudates, papilloedema

Stratification of Total CV Risk *European Heart Journal doi:10.1093/eurheartj/eht151

Laboratory Investigations*

ESTABLISHING THE DIAGNOSIS AND RECOMMENDATIONS FOR FOLLOW-UPPatients with pre-hypertension but without diabetes, chronic renal failure or cardiovascular disease are treated with non-pharmacologic therapies such as weight reduction, sodium restriction and avoidance of excess alcohol. They should also have their blood pressure measured every six months since they are of significant risk of developing hypertension overtime.

If persons with Stage 1 levels have no evidence of end organ damage, repeated BP measurements over three months are necessary.

If persons with Stage 2 levels have no evidence of end-organ damage, BP measurements should be repeated on at least one other occasion within one month.

Persons with Stage 3 levels with no evidence of end-organ damage should have their blood pressure measured within one week. In some cases therapy should be started, if the risk level assessment so warrants. Higher levels e.g. >210/120, if associated with complications may constitute a Hypertensive Emergency

Labile hypertensives will show fluctuation of BP from normal to Stage or higher hypertensive ranges and such patients should be monitored regularly. Persistence of diastolic readings above 90 mm Hg will usually indicate established hypertension.The diagnosis of hypertension can be established on the basis of a single diastolic pressure > 100 mm Hg, if there is evidence of target organ damage. The patient should be classified as hypertensive with specific target organ disease, risk level assessed and treatment begun.Isolated systolic hypertension is diagnosed when there is an average of four readings 140 mm Hg on two occasions with a diastolic BP < 90mm Hg (JNC 7 criteria). Isolated systolic hypertension should be carefully re-evaluated at intervals.White-coat hypertension may occur in patients whose BP is raised only in the clinic but not at other times. A white-coat effect may further raise BP in a patient with hypertension.ESTABLISHING THE DIAGNOSIS AND RECOMMENDATIONS FOR FOLLOW-UP

Managing Hypertension

Dietary factors Dietary modifications are mainstay for prevention and initial treatment of hypertension. In hypertensive patients, in addition to a well-balanced diet, the dietary sodium intake

Reduced salt intake BP reduction was the highest in the group with the lowest sodium levels.Reduce the intake of salt and sodium in the diet to approximately 2400 mg/day

Maintain a healthy weight, lose weight if overweight.

Be more physically activeManaging Hypertension

When to start Anti-HT RxBP 140/90 after lifestyle change BP 160/100: start drug promptly Elderly: SPB 160 mmHg Not recommend anti-HT drug for High normal BP (130-139 / 85-89 mmHg) ISH in young patient, but should close F/U with lifestyle change

2007Elderly: start drug if BP 140/90DM, CKD, CVD: start drug if BP > 130 / 85

BP targetSBP < 140 mmHgDM (I,B) Low-moderate CV risk (I,A) Previous stroke/TIA, CHD, CKD (II A)Elderly < 80 yr: SPB keep 140-150 mmHg (I, A)Elderly > 80 yr: 140-150 mmHg if good physical and mental condition (I, B)DBP < 90 mmHg for allExcept DM: DBP < 85 mmHg

Initiation of lifestyle changes and antihypertensive drug treatment. Risk Fx: male, age 55 (M) 65 (F), smoking, dyslipidemia, IFG, abnormal OGTT, obesity, abdominal obesity, FHx premature CVD < 55 yr (M), < 65 yr (F)DM: high to very high riskESH/ESC 2013

CHOICE OF ANTIHYPERTENSIVE DRUGSdiuretics (including thiazides, chlorthalidone and indapamide), beta-blockers, calcium antagonists, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers are all suitable for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in some combinations

Some drugs should be preferred in specific conditions

Markedly high baseline BP or high CV risk: start two-drug combination may be consideredThe main benefits of antihypertensive treatment are due to lowering of BP per se and are largely independent of the drugs employedMost patients need 2 drugs to achieve target BP.

Only DHP-CCB should normally be combined with beta-blockersPossible combinations of classes of antihypertensive drugsESC/ESH 2013

JAMA. doi:10.1001/jama.2013.284427Report JNC 8

Recommendation 9

The main objective of hypertension treatment is to attain and maintain goal BP.

If goal BP is not reached within a month of treatment: increase the dose of the initial drug OR Add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB).

The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached.

Recommendation 9If goal BP cannot be reached with 2 drugs: Add and titrate a third drug from the list provided.

Do not use an ACEI and an ARB together in the same patient.

If goal BP cannot be reached using the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP: antihypertensive drugs from other classes can be used.

Report JNC 8

For patients in whom goal BP cannot be attained using the above strategy OR

The management of complicated patients for whom additional clinical consultation is needed.

Referral to a hypertension specialist may be indicated

Recommendation 9Report JNC 8

GUIDELINES FOR REFERRALIndication for referral to a higher level of care includedClinical suspicious of secondary hypertensionAll complicated hypertensionsPatient with severe retinopathyFailure to respond to treatment ( Resistant hypertension) or need combination treatmentRaised serum creatininHaematuria, proteinuria or cell in urineSuspicion of white coat hypertension

Pemerikssaan Penunjang :Anamnesa/PD Urin : microalb, eri,gulaDarah: Kreatinin,glukosaEKG & Foto ToraksTIDAK ADAADAterkontrolTidak terkontrol> 3 bulanPemerikssaan Penunjang :Tidak terkontrol3 bulan 3 obatHIPERTENSISEKUNDERADATidak terkontrolPPK 1PPK3PPK2HIPERTENSI KRISISTerapi awalTidak terkontrolRENAL DENERVASIRENAL ANGIOGRAFI(stenting)RujukRujuk Balik

DETECTIONDIAGNOSIS

TARGET ORGANCV RISKS

TERAPIMax 2 obat

RE-EVALUASITERAPI

RE-EVALUASITERAPI

CLINICAL PATHWAY HIPERTENSI

Jenis AktivitasTindakanPPK IAssessmentPenilaian AwalStatus Medical Record lengkapTanda vitalAnamnesis dan pemeriksaan fisik lengkapIdentifikasi :

EtiologiHipertensi esensialHipertensi sekunder

Faktor risiko lain : Diabetes melitusHiperlipidemiaMerokokHiperuricaemia

Kerusakan target organStrokeRetinopatiLVH, PJKPenyakit Ginjal Kronik

CLINICAL PATHWAY HIPERTENSI

Jenis AktivitasTindakanPPK IInvestigationsPemeriksaanUrinalisis : proteinuria, hematuria, glukosuriaKimia Darah : kreatinin, gula darah Rontgen thoraxEKG

CLINICAL PATHWAY HIPERTENSI

Jenis AktivitasTindakanPPK ITreatmentMedicationsModifikasi gaya hidup :Diet : DASH dietAktivitas fisik

FarmakoterapiMonoterapi atau terapi kombinasi

Golongan obat :ACE Inhibitor atau ARBCalcium antagonistBeta blockerDiuretik

CLINICAL PATHWAY HIPERTENSI

Jenis AktivitasTindakanPPK IDietkebutuhan kalori 30-35 kkal/kgBB/hari; protein 1,0 g/kg/hariRendah garam, tinggi seratPenyuluhanEdukasiKonsep terapi hipertensi: modifikasi gaya hidup dan farmakoterapiKerusakan target organ dan konsekuensinya

CLINICAL PATHWAY HIPERTENSI

Jenis AktivitasTindakanPPK IRujuk / konsultasiRujuk ke PPK 2 bila didapatkanFaktor Risiko kardiovaskular lain yang tidak terkontrolAdanya kerusakan target organHipertensi sekunderHipertensi krisisTekanan darah tidak terkontrol dengan 2 macam obat maksimal selama 3 bulanOutcomeHipertensi terkontrolPencegahan kerusakan target organRencana PerawatanRawat jalan

*Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL, and the Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360:1347-1360.Ezzati and coworkers undertook a comprehensive review of the published literature and other sources, including government reports and international data bases, to obtain data on the prevalence of risk-factor exposure and hazard size for 14 epidemiologic regions of the world.The slide shows the estimated mortality for each of 8 leading risk factors, considered individually.**Initiation of lifestyle changes and antihypertensive drug treatment. Targets of treatment are also indicated. Colours are as in Figure 1. Consult Section 6.6 for evidence that, in patients with diabetes, the optimal DBP target is between 80 and 85 mmHg. In the high normal BP range, drug treatment should be considered in the presence of a raised out-of-office BP (masked hypertension). Consult section 4.2.4 for lack of evidence in favour of drug treatment in young individuals with isolated systolic hypertension.Possible combinations of classes of antihypertensive drugs. Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well-tested combinations; red continuous line: not recommended combination. Although verapamil and diltiazem are sometimes used with a beta-blocker to improve ventricular rate control in permanent atrial fibrillation, only dihydropyridine calcium antagonists should normally be combined with beta-blockers.**