Sympo11 1. Dr. Ika - Guideline Hypertension In Indonesia Dr. Ika. Hopecardis 2016.pdf

Dr. Ika Prasetya Wijaya SpPD-KKV, FINASIM, FACP, FICA [email protected] Pendidikan : S1 Spesialis 1 Spesialis 2 FINASIM FACP FICA Pekerjaan:

Samarinda: 5 Januari 1968

: FKUI 1992 : FKUI 2003 : KIPD/FKUI 2011 : PAPDI 2010 : ACP 2015 : ICA 2015

KETUA Divisi Kardiologi, Departemen Ilmu Penyakit Dalam FKUI-RSUPNCM 2014 Editor Acta Medica Indonesiana/Indonesian Journal of Internal Medicine Penulis Buku Ajar Ilmu Penyakit Dalam bidang Kardiologi

Organisasi:

Peminatan: Intervensi Kardiologi Infeksi dan Aterosklerosis Kardiologi dalam Onkologi Kardiologi Klinis

CRE/062/Aug10-Aug11/MF

Wakil Ketua Umum PB PAPDI 2015-sekarang Wakil Ketua PAPDI Cabang Jakarta 2010- sekarang Ketua I PB IKKI 2009-sekarang

Dr. Ika Prasetya Wijaya, SpPD, K-KV, FINASIM, FACP, FICA

HYPERTENSION IS… ◦ Hypertension is defined as a systolic

blood pressure (SBP) of 140 mm Hg or more, or a diastolic blood pressure (DBP) of

90 mm Hg or more, in

repetitive examination

Hypertension in Indonesia Nearly 1 in 4 Adults (25.8%) in the Indonesia Has Hypertension

Why is this important? Individuals with a normal BP at age 55 yo have a 90% lifetime risk of developing hypertension.

Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA. 2002;287:1003-10.

HYPERTENSION IS ASSOCIATED WITH VARIOUS COMPLICATION

Global Leading Risks for Death, 2010 Systolic blood pressure > 115 mmHg

Global Burden of Disease Study 2010 , Lancet 2012; 380: 2224–60

Complications of Hypertension: End-Organ Damage

Hypertension

Hemorrhage, Stroke

Retinopathy CHD = coronary heart disease CHF = congestive heart failure LVH = left ventricular hypertrophy Chobanian AV, et al. JAMA. 2003;289:2560-2572.

LVH, CHD, CHF

Peripheral Vascular Disease

Renal Failure, Proteinuria

WHAT CAN WE DO?

Measuring blood pressure Diagnosing hypertension Assessing CV risk and Target Organ Damage Lifestyle Intervention

Initiating and monitoring antihypertensive drug treatment Choosing antihypertensive drug treatment Patient education and adherence to treatment

Measuring and confirm Blood Pressure

A Statement by the American Society of Hypertension and the International Society of Hypertension2013)

Algorithm hypertension diagnosis

Canadian Hypertension Education Program. The Canadian Recommendation for The Management of Hypertension 2014

Assessing cardiovascular risk and target organ damage: updated recommendations For all people with hypertension offer to: – test urine for presence of protein – take blood to measure glucose, electrolytes, creatinine, estimated glomerular filtration rate and cholesterol – examine fundi for hypertensive retinopathy – arrange a 12-lead ECG.

MANAGEMENT ◦Many guidelines exist for the management of hypertension. Most groups, including the JNC, American Heart Association/ American Stroke Association (AHA/ASA), European Society of Hypertension (ESH) recommend lifestyle modification as the first step in managing hypertension

Lifestyle Intervention Intake of vegetables, fruits, whole grains (DASH dietary pattern) •Low fat dairy products •Poultry, fish •Legume •Limits intake of sweet, sugar sweetened and red meats

Lower sodium intake •No more than 2,400 mg sodium/day •Further reduction of sodium intake to 1,500 mg/day

Physical Activity •Aerobic physical activity 3-4 session a week, lasting 40 min per session; moderate to vigorous intensity

GUIDELINES FOR HYPERTENSION

Algorithm management hypertension in general A Statement by the American Society of Hypertension and the International Society of Hypertension 2013

JNC VIII

Algorithm management of hypertension

JNC VII

Algorithm management of hypertension

BRITISH HYPERTENSION SOCIETY 2004 Drug combination therapy in hypertension

Treatment of hypertension according to the NICE guideline BHS - 2011

EUROPEAN SOCIETY OF HYPERTENSION 2007 Selecting drugs combinations to achieve target of hypertension

Hypertension treatment recommendations adjusted with compelling indication, according to WHO - ISH 2003 ESH - ESC 2007-2009 JNC 7 2003

INDONESIAN GUIDELINES PERHIMPUNAN DOKTER SPESIALIS KARDIOVASKULAR INDONESIA, 2015

SUMMARY ◦ Guidlelines is just a guide, doctor could manage the patient according to clinical manifestation on the patients

Blood Pressure Target

CASES

Case scenario 1 Presentation 38 year old, female, attending for routine appointment about her contraception, for which she uses a IUD

Medical history From her records you notice that Mary’s blood pressure has increased since her last check twelve months ago. She does not smoke, doesn’t drink alcohol, and has no notable medical history. On examination Mary’s first clinic blood pressure measurement is 158/94 mmHg. Her heart rate is 72 beats per minute and regular You are considering a diagnosis of hypertension and therefore take another reading in Mary’s other arm. There is no notable difference between readings.

Case scenario 1: Diagnosis ◦ How to diagnose a hypertension?

2 measurement

BP Classification

Systolic BP

Diastolic BP

< 120

< 80

Pre-hypertension

120-139

80-89

Stage 1 HTN

140-159

90-99

Stage 2 HTN

> 160

> 100

Normal

2 different occasion (usual waking hours)

Case scenario 1: Assessing CV risk & TOD ◦How to assess CV risk and target organ damage? Renal

Metabolic Eyes Heart

• Creatinine clearance • Estimated GFR • Presence of protein in urine • Plasma Glucose • Electrolytes • Serum total Cholesterol; HDL • Funduscopy • ECG • CV risk assessment

Case scenario 1 : Assessing CV risk & TOD ◦The results of the investigations for target organ damage and formal assessment of cardiovascular risk are: • no evidence of target organ damage • 10-year cardiovascular risk less than 20%. ◦Nothing abnormal was detected in the other investigations you organised.

Case scenario 1 : Lifestyle Intervention Before starting pharmacological treatment, what would you advise to the patient about the lifestyle intervention?

Lifestyle Intervention

DASH

Salt Reduction

Physical Exercise

Case scenario 1 : Drug Treatment If the patients had been eligible to receive antihypertensive drug treatment, what should you consider when prescribing antihypertensive drugs for a woman of child-bearing potential?

Case scenario 1 : Consideration? ◦There is an increased risk of congenital abnormalities if women take angiotensin-converting enzyme (ACE) inhibitors or angiotensin III receptor blockers (ARBs) during pregnancy, and it is important that women of childbearing age know this. If the woman is planning a pregnancy she should discuss this with you. ◦ If a woman taking ACE inhibitors or ARBs becomes pregnant, these antihypertensive drugs should be stopped and alternatives offered.

Case scenario 2 Presentation 65 year old male, came to your clinic for the first time. He was diagnosed by his previous doctor with stage 2 hypertension for almost 5 years. His usual blood pressure was 160/100 mmHg. Medical history From history taking you know that he also diagnosed with Diabetes with poor adherence to the diabetes and hypertensive therapy. On examination He is moderately obese with waist circumference 100 cm. Current BP is 170/110. There is no previous laboratory data

Case scenario 2: Assessing CV risk & TOD ◦How to assess CV risk and target organ damage?

Renal

Metabolic Eyes Heart

• Creatinine clearance • Estimated GFR • Presence of protein in urine • Plasma Glucose • Electrolytes • Serum total Cholesterol; HDL • Funduscopy

• ECG • CV risk assessment

Case scenario 2 : Assessing CV risk & TOD ◦The results of the investigations for target organ damage and formal assessment of cardiovascular risk are: • Blood Glucose: 278 •Total cholesterol: 349 •LDL: 233 •HDL: 47 •Triglycerides: 297 •Ur/Creat: 49/2.0 •Urinalysis: •Protein + •Glucose + ◦ECG: Left ventricular hypertrophy

•

Funduscopy: within normal limit

Case scenario 2 Before starting pharmacological treatment, what would you advise to the patient about the lifestyle intervention?

Lifestyle Intervention DASH

Salt Reduction

Physical Exercise

Case scenario 2 : Drug Treatment What do you consider when prescribing anti-hypertensive drugs for a patient with diabetes mellitus and reduced kidney function?