1. HYPERTENSION ABOUT PATHOGENESIS, THERAPY AND COMPLICATION
PIT PDUI JAWA BARAT 2018
Bandung, 13 – 15 Juli 2018
HYPERTENSION ABOUT PATHOGENESIS, THERAPY AND COMPLICATION
Pudji Rusmono Adi., dr., SpPD. K-KV. FINASIM
Section of cardiovascular of Internal Medicine
IMMANUEL Hospital. Bandung

2. WHAT IS HYPERTENSION ?
A Blood pressure high enough to be a danger to their well-being. - The exact cutoff points to define stages of hypertension are somewhat arbitrary. ¹
- The relationships between arterial pressure and mortality is quantitative; the high the pressure, the worse the prognosis.(Pickering, 1972)²
The operational definition of hypertension is the level at which the
benefits of action exceed those of inaction. (Rose 1980) ²
Hypertension is now considered as a part of a complex syndrome of changes in cardiac and vascular structure and function.³
¹ Lily LS. Pathophysiology of Heart Disease. 5th ed
³ Kalra S, Kalra B, AgrawaNavneet. Combination therapy in hypertension: An update. Diabetology & Metabolic Syndrome 2010, 2:44
² M. Kaplan. Kaplan’s Clinical Hypertension. 9ed, 2006

3. PATHOGENESIS OF HYPERTENSION
Oparil S, Zaman,MA, Calhoun DA. Pathogenesis of Hypertension. Ann Intern Med. 2003;139:

4. Pathophysiologic mechanisms of hypertension.
Oparil S, Zaman,MA, Calhoun DA. Pathogenesis of Hypertension. Ann Intern Med. 2003;139:

5. Blood Pressure Classification
DEFINITION
The Seven Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, NIH Publication, 2004.
Blood Pressure Classification
SBP
mmHg
DBP
Normal
< 120
And <80
Prehypertension
And 80 – 89
Stage 1
Hypertension
And 90 – 99
Stage 2
> 160
> 100
JNC 7.

6. 2013 ESH/ESC Guidelines for the management of arterial hypertension
European Heart Journal (2013) 34, 2159–2219

7. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
Paul K. Whelton et al. Hypertension. 2018;71:

8. MEASUREMENT OF BLOOD PRESSURE.
Paul K. Whelton et al. Hypertension. 2018;71:

9. Hypertension Canada's 2017 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults
Hypertension diagnostic algorithm. ABPM, ambulatory blood pressure measurement; AOBP, automated office blood pressure; BP, blood pressure. ∗If AOBP is used, use the mean calculated and displayed by the device. If non-AOBP (see †) is used, take at least 3 readings, discard the first, and calculate the mean of the remaining measurements. A history and physical exam should be performed and diagnostic tests ordered. †AOBP is performed with the patient unattended in a private area. Non-AOBP is performed using an electronic upper arm device with the provider in the room. ‡Diagnostic thresholds for AOBP, ABPM, and home BP in patients with diabetes have yet to be established (and might be lower than mm Hg). §Serial office measurements over 3-5 visits can be used if ABPM or home measurement is not available. ‖For a home BP series, 2 readings are taken each morning and evening for 7 days (28 total). Discard the first day readings and average the last 6 days. ¶Annual BP measurement is recommended to detect progression to hypertension.
Canadian Journal of Cardiology  , DOI: ( /j.cjca )
Copyright © 2017 Canadian Cardiovascular Society

10. TREATMENT RECOMMENDATION
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

11. Non pharmacology therapy ........
Atherosclerotic cardiovascular Risk Calculator
Non pharmacology therapy

12. Non pharmacology therapy + BP lowering medication (1 medication)

13. Paul K. Whelton et al. Hypertension. 2018;71:1269-1324

14. Detection of white coat hypertension or masked hypertension in patients not on drug therapy
Detection of white coat hypertension or masked hypertension in patients not on drug therapy. Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring.
Paul K. Whelton et al. Hypertension. 2018;71:
Copyright © American Heart Association, Inc. All rights reserved.

15. Choice of initial drug.
Paul K. Whelton et al. Hypertension. 2018;71:

16. Blood Pressure Goal.
Paul K. Whelton et al. Hypertension. 2018;71:

17. JNC 8

18. Diagnosis and management of a hypertensive crisis.
Diagnosis and management of a hypertensive crisis. Colors correspond to Class of Recommendation in Table 1. *Use drug(s) specified in Table 19. †If other comorbidities are present, select a drug specified in Table 20. BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care unit; and SBP, systolic blood pressure.
Paul K. Whelton et al. Hypertension. 2018;71:
Copyright © American Heart Association, Inc. All rights reserved.

19. Paul K. Whelton et al. Hypertension. 2018;71:1269-1324

20. ESH/ESC Guidelines for the management of arterial hypertension, 2013.
European Heart Journal (2013) –2219

21. Cardiovascular Risk Stratification. ESHESC Guidelines 2013
Mancia et al. Eur Heart J 2013;34(28):

22. Possible combination therapy of Hypertensive drugs
2013 ESH/ESC Guidelines for the management of arterial hypertension.
European Heart Journal (2013) –2219

23. Single - drug :
Hypertension (HTN) guidelines recommend antihypertensive drug classes, without detailing specific drugs.¹
Although decreases in BP were overall similar among the different pharmacologic families, the specific analysis of the drugs used in monotherapy showed relevant differences¹.
Most of the drugs achieved mean SBP reductions between
mmHg and 5 -10mm Hg for DBP.¹
Monotherapy normalizes BP in no more than % of
patients, even those with mild hypertension, and it is not fully
effective in patients with high grade hypertension.²
¹ Paz et al. Treatment efficacy of anti-hypertensive drugs in monotherapy or combination. Medicine (2016) 95:30
²Taddei S. Combination Therapy in Hypertension: What Are the Best Options According to Clinical Pharmacology
Principles and Controlled Clinical Trial Evidence? Am J Cardiovasc Drugs

24. Combi – Drug.
In high/very high-risk patients another important goal of antihypertensive treatment is rapid normalization of BP.
Combination therapy can induce a more rapid BP reduction and/or normalization than can monotherapy.
Combination therapy produces a significantly greater reduction in global cardiovascular, coronary, and cerebrovascular events versus mono therapy, independent of BP control.
There is solid evidence that combination therapy offers important advantages over monotherapy.
Taddei S. Combination Therapy in Hypertension: What Are the Best Options According to Clinical Pharmacology
Principles and Controlled Clinical Trial Evidence? Am J Cardiovasc Drugs
DOI /s

25. Good combinations include:
It is important to use a combination of antihypertensive agents characterized by complementary mechanisms of action.
Good combinations include:
- A RAS blockers (ACE inhibitors, ARBs, beta- blockers) +
a drug that stimulates RAS (calcium antagonists,diuretics,
vasodilators)
- An agent activating the sympathetic nervous system
should be combined with one that blocks sympathetic
activity.
Taddei S. Combination Therapy in Hypertension: What Are the Best Options According to Clinical Pharmacology
Principles and Controlled Clinical Trial Evidence? Am J Cardiovasc Drugs
DOI /s

26. Kalra S, Kalra B, Agrawal N
Kalra S, Kalra B, Agrawal N. Combination therapy in hypertension: An update Diabetology & Metabolic Syndrome 2010, 2:44

27. Average no. of antihypertensive medications
Number of Antihypertensive Agents Needed to Reach Blood Pressure (BP) Goal
Average no. of antihypertensive medications
Trial (SBP achieved)
ASCOT-BPLA (136.9 mmHg)
ALLHAT (135 mmHg)
UKPDS (144 mmHg)
HOT (138 mmHg)
AASK (128 mmHg)
Major clinical trials have demonstrated that patients typically needed treatment with multiple antihypertensive agents to get to, and stay at, blood ressure (BP) goal. The number of antihypertensive agents required for BP control in many patients typically averages 24, with co-morbid conditions (such as kidney disease or diabetes mellitus) imposing greater drug requirement.1,2
For example, in the Hypertension Optimal Treatment (HOT) study, an average of 3.3 drugs were required to attain a diastolic BP goal of <80 mmHg, and in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA), most patients were taking at least two antihypertensive agents by the end of the trial.2,3 In the Avoiding Cardiovascular Events Through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial, patients were receiving initial treatment with single-pill combinations (SPCs) of antihypertensive agents. Excellent BP control rates were obtained with both the SPCs used in the study.4
References
Sica DA. Rationale for fixed-dose combinations in the treatment of hypertension. The cycle repeats. Drugs 2002;62:44362.
Bakris GL, et al. The importance of blood pressure control in the patient with diabetes. Am J Med 2004;116(5A):30S–8S.
Dahlöf B, et al. Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 2005;366:895906.
Jamerson K, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med 2008;359:241728.
SBP: systolic blood pressure
Kjeldsen et al Hypertension 1998: 31: ; UKPDS group Lancet, 1998: 352: ; AASK research group Arch Intern Med 168: ; Dahlöf et al. Lancet 2005;366:895–906 ALLHAT research group 2002; 288: :
Valsartan Family Slide Library Item code: XXXXX.XXX; Release Date: XXXXXXXXXXXXXXXXXX 2013

28. Effectiveness of combination therapy in clinical practice: odds ratio values (95 % confidence interval) for nonfatal cardiovascular outcomes overall, coronary heart disease, or cerebrovascular events.
Taddei S. Combination Therapy in Hypertension: What Are the Best Options According to Clinical Pharmacology
Principles and Controlled Clinical Trial Evidence? Am J Cardiovasc Drugs
DOI /s

29. JNC 7

30. ABOUT COMPLICATION.
*WHO. Global brief on hypertension. 2013

33. *WHO. Global brief on hypertension. 2013

34. *WHO. Global brief on hypertension. 2013

35. *WHO. Global brief on hypertension. 2013

36. WHO 2013:*
Globally cardiovascular disease accounts for approximately 17 million deaths a year, nearly one third of the total .
Of these, complications of hypertension account for 9.4 million deaths worldwide every year .
Hypertension is responsible for at least 45% of deaths due to heart disease, and 51% of deaths due to stroke.
*WHO. Global brief on hypertension. 2013

37. SUMMARY Hypertension is now considered as a part of a complex
syndrome of changes in cardiac and vascular structure
and function.
Pathophysiologically there are many that play a role in the development of hypertension.
In mild cases required only single medication, but in the more severe cases requires a combination of two drugs.
If hypertension is not controlled with combination drugs or complication arise it is better referred to a specialist.
The main complication of hypertension are causing high death rates from heart disease and stroke.

38. HATUR NUHUN