PENATALAKSANAAN HIPERTENSI

TERKINI :

FOKUS PADA JNC 8

WACHID PUTRANTO

Divisi Ginjal Hipertensi

Fakultas Kedokteran UNS/RS.Dr. Moewardi

Surakarta

Suatu keadaan klinis dimana tekanan darah seseorang lebih tinggi daripada tekanan darah normal

Epidemiologi :

Jumlah penderita hipertensi di seluruh dunia :

1 milyar

USA : 65 juta

Indonesia ? : belum ada data resmi

Conlin PR, Int J Clin Pract 2005; 59(2):214-24

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

0

10

20

30

40

50

60

70

18-29 30-39 40-49 50-59 60-69 70-79 80+

SBP > 140 mm Hg DBP > 90 mm Hg

age (yrs)

pre

vale

nce

of

hyp

ert

en

sio

n (

%)

4 11

21

44

54

64 65

Prevalensi Hipertensi

Hypertension complication

Damages depend on:

How high of the blood pressures

How long the uncontrolled and

untreated high blood

presure

Target Organ damage!! Eyes retinopathy

Kidneys renal failure

Brain stroke

Heart ischaemic heart disease

left ventricular hypertrophy heart failure

Peripheral arterial disease

Blood Pressure Reduction Of 2 mmHg Reduces The Risk Of CV Events by 710%

Meta-analysis of 61 prospective, observational studies

1 million adults

12.7 million person-years

Lewington et al. Lancet 2002;360:190313

2 mmHg decrease in mean SBP

10% reduction in risk of stroke mortality

7% reduction in risk of ischaemic heart disease mortality

HYPERTENSION GUIDELINES

ASH/ISH

CLASSIFICATION HYPERTENSION

BP SBP DBP

Normal

Topic JNC 7 2014 Hypertension Guidelin

Methodology Non systematic literature review by Critical questions and review criteria defined by expert expert committee including a range panel with input from methodology team of study design Initial systematic review by methodologist restricted to Recommendation based on consensus RCT evidence Subsequent review of RCT evidence and recommendations by the panel according to a standardized protocol Definitions Defined hypertension and prehypertension Definision of hypertension and prehypertension not addressed, but tresholds for pharmacologic treatment were defined Treatments Separate treatmen goals defined for Similar treatment goals defined for all hypertensive Goals uncomplicated hypertension and for populations except when evidence review supports subsets with various comorbid condition different goals for a particular subpopulation Lifestyle Recommended lifestyle modifications Lifestyle recommendations recommended by endorsing Recommendation based on literature review and expert the evidence based recommendations of the Lyfestyle opinion Work Group Drug therapy Recommended 5 classes to be considered Recommended selection among 4 specific medications as initial therapy for most patients without classes ( ACEI or ARB, CCB or Diuretics) and doses based compelling indication for another class on RCT evidence Specified particular antihypertensive Recommended specific medication classes based on medication classes for patients with evidence review for racial, CKD, and diuretics sub group compelling indication,ie,diabetes,CKD,heart Panel created a table of drugs and doses used in the failure,myocardial infarction,stroke,high outcome trials CVD risk

Included a comprehensive table oral Antihypertensive drugs including names and usual dose ranges Scope of topics Addressed multiple issues ( blood pressure Evidence review of RCTS addressed a limited measurements methods,patients evaluation number of questions,those judge by the panel components,secondary hypertension, to be of highest priority adherence to regimens,resistant hypertension, and hypertension in special populations) based on literature review and expert opinion Review process Reviewed by the National High Blood pressure Reviewed by experts including those affiliated Prior to Education Program Coordinating Committee, with professional and public organizations and Publication a coalition of 39 major professional,public, and federal agencies; no official sponsorship by any voluntary organizations and 7 federal agencies organization should be inferred

The Process

Literature review 1/1/1966 12/31/2009

Inclusion Criteria (1) HTN (2) 2000 participants (3) multisenter (4) Kriteria inklusi/eksklusi.

9 Recommendations

A

C

B

N

D

E

Recommendation

Strength of Recommendation

Recommendation 1 Populasi berusia 60 yrs,mulai terapi farmakologi SBP150 mmHg, DBP90 mmHg

Grade A

HYVET, Sys-Eur, SHEP, JATOS, VALISH, CARDIO-SIS

Corollary Recommendation Populasi usia 60 yrs, jika terapi farmakologi mengakibatkan penurunan TD lebih rendah (

Recommendation

Strength of Recommendation

Recommendation 3 Populasi usia

Recommendation

Strength of Recommendation

Recommendation 6 Pada populasi non black , termasuk dg DM, initial anti HTN treatment : a thiazide type diuretic, CCB, ACEI or ARB

Grade B

VA-cooperative, HDFP, SHEP

Recommendation 7 Populasi kulit hitam, termasuk dg DM, initial anti HT: thiazide-type diuretic or CCB

Grade B ( No DM)

Grade C ( DM)

ALLHAT

Recommendation 8 Populasi usia 18 dg CKD dan HTN, initial (or add on) anti HTN : ACEI or ARB utk memperbaiki kidney outcomes. Tanpa melihat ras atau status DM

Grade B

IDNT, AASK

Recommendation Strength of Recommendation

Recommendation 9 Tujuan treatment HTN adalah untik mencapai dan

mempertahankan target BP Jika target BP tidak tercapai dlm 1 bl, naikkan dosis

atau tambahkan 2nd 1 obat dr rekomendasi 6 (thiazide-type diuretic, CCB, ACEI, or ARB)

Jika target BP tidak tercapai dg 2 obat, tambah dan titrasi obat 3rd . Do not use an ACEI and an ARB together

Jika target BP tidak dapat tercapai dg obat-obat pada recommendasi 6 krn kontraindikasi atau butuh >3 obat, obat antiHT dari kelas lain bias digunakan.

Referral kepada hypertension specialist jika BP tidak tercapai atau untuk management komplikasi.

Grade E

Strategies to Dose Antihypertensive Drugs

Strategies Description Details

A Mulai 1 obat naikan sp dosis maksimum,kemudian tambahkan obat ke-2

Jika target BP blm tercapai naikkan dosis obat 1 sp dosis maksimum sblm menambahkan obat ke-2 dan ke-3.

B Mulai 1 obat kemudian tambahkan obat ke-2 sblm dosis maksimum

Tambahkan obat ke-2 sblm obat 1 mencapai dosis maks.Jk Target BP blm tercapai,tambahkan obat ke-3 dan titrasi sp dosis maks.

C Mulai dengan 2 obat (separate or single combination)

Mulai dg 2 obat Bbrp committee merekomendasi: 2 obat SBP >160 dan/atau DBP

>100, atau SBP >20 mmHg diatas target dan/atau DBP >10 mmHg

Jika target BP tdk tercapai (2 drugs), tambahkan obat ke-3 dan titrasi.

Lifestyle Modification

JNC 8

JNC 7

Guideline Population Goal BP Initial drugs

2014 HT Guideline

General 60 y General

Guideline Population Goal BP Initial drugs

ADA DM

Important Variables For HTN Recommendations

BP NICE ESC/ESH ASH/ISH AHA/ACC/CDC

JNC 7 JNC 8

Definition HTN

140/90 and

daytime ABPM

135/85

140/90 140/90 140/90 Pre HT 120-139 or 80-89 Stg 1 HT

140-159 or 90-99

Stg 2 HT 160 or 100

Not addressed

Drug th/ in low risk pts after non pharm th/

160/100 or daytime ABPM 150/95

140/90 140/90 140/90 140/90

NICE ESH/ESC ASH/ISH AHA/ACC/CDC

JNC 7 JNC 8

Diuretic Chorthali-done (CTD)

Indapami- de (IND)

Thiazides (THZ), CTD ND

THZ CTD IND

THZ THZ THZ CTD IDP

Initiate th/ with 2 drugs

Not mentio-

ned

Pts w/ markedly

elevated BP

160/90 160/100 160/100 Not mentioned

BP target

Under JNC 8, in all cases, targets BP should be reached within a month of starting treatment either by increasing the dose or by using a combination drugs

In patients 60 yrs who do not have DM or CKD, the goal BP level is

Under the JNC 8 guidelines, patients would receive a dosage adjustment and combinations of the 4 first-line & later line therapies ACEI/ARB, CCB, and thiazide-type diuretic

The JNC 8 does not recommend -blockers and -blockers as 1st therapy due to 1 trial that showed a higher rate of CV events with use of B compared with use of an ARB, and another trial in which B resulted in inferior CV outcomes compared with use of a diuretic

JNC 8 also recommend lifestyle interventions include use of the DASH eating plan, weight loss, reduction in sodium intake to

When initiating therapy, patients of African descent without CKD should use CCBs and thiazides instead of ACE inhibitors

ACE inhibitors and ARBs should not be used in the same patient simultaneously