Manajemen Hipertensi (Update 2014)

Hipertensi telah menjadi masalah utama dalam kesehatan masyarakat yang ada di Indonesia maupun di beberapa negara yang ada di dunia. Hampir > 50% dari orang berusia 60-69 tahun dan sekitar 75% dari orang-orang tua ≥ 70 tahun terjadi hipertensi (Chobanian, et al. 2003).

Klasifikasi :

European Society of Hypertension/European Society of Cardiology (ESH/ESC) 2013.

• optimal - systolic blood pressure (SBP) < 120 mm Hg and diastolic blood pressure (DBP) < 80 mm Hg

• normal - SBP 120-129 mm Hg and/or DPB 80-84 mm Hg

• high normal - SBP 130-139 mm Hg and/or DBP 85-89 mm Hg

• grade 1 hypertension - SBP 140-159 mm Hg and/or DBP 90-99 mm Hg

• grade 2 hypertension - SBP 160-179 mm Hg and/or DBP 100-109 mm Hg

• grade 3 hypertension - SBP ≥ 180 mm Hg and/or DBP ≥ 110 mm Hg
• isolated systolic hypertension - SBP ≥ 140 mm Hg and DBP < 90 mm Hg

Seventh report of Joint National Committee (JNC 7) pada pasien tanpa end target organ damage.

• normal if SBP < 120 mm Hg and DBP < 80 mm Hg; recheck in 2 years
• prehypertension if SBP 120-139 mm Hg or DBP 80-89 mm Hg; recheck in 1 year
• stage 1 hypertension if SBP 140-159 mm Hg or DBP 90-99 mm Hg; confirm within 2 months
• stage 2 hypertension if SBP ≥ 160 mm Hg or DBP ≥ 100 mm Hg; evaluate within 1 month or within 1 week if > 180/110 mm Hg
• definition of high blood pressure not redefined in Eighth Joint National Committee (JNC 8) 2014 guidelines for management of high blood pressure in adults

Isi dari  eight report Joint National Committee (JNC 8) adalah : Terdapat 9 Rekomendasi 

• Rekomendasi 1-5 tentang batas dan target/goal terapi hipertensi
• Rekomendasi 6-8 tentang seleksi pemilihan obat anti hipertensi
• Rekomendasi 9 tentang memulai dan menambah terapi hipertensi 

Terapi Hipertensi :

• Terapi awal hipertensi, diawali dengan 1- 5 golongan obat antihipertensi. 
  • Thiazide-type diuretic - Recommended option for all patients in most guidelines (JNC8 Moderate recommendation; ESH/ESC Class I, Level A; CHEP Grade A) and reduces mortality (level 1 [likely reliable] evidence)
  • Angiotensin-converting enzyme (ACE) inhibitor - Recommended option either for nonblack patients (JNC8 Moderate recommendation; CHEP Grade B) or all patients (ESH/ESC Class I, Level A), and may reduce mortality (level 2 [mid-level] evidence)
  • Angiotensin receptor blocker (ARB) - Recommended option for nonblack patients (JNC8 Moderate recommendation) or all patients (ESH/ESC Class I, Level A; CHEP Grade B), but may not reduce mortality (level 2 [mid-level] evidence)
  • Calcium channel blocker - Recommended option for all patients in most guidelines (JNC8 Moderate recommendation; ESH/ESC Class I, Level A; CHEP Grade B), but limited data for effect on mortality
  • Beta blockers - Recommended option in some guidelines (ESH/ESC Class I, Level A; CHEP Grade B for patients < 60 years old) but not recommended as initial option in American or British guidelines, and may increase risk of adverse cardiovascular events compared to other antihypertensive drugs (level 2 [mid-level] evidence)
• Terapi awal dengan ACE inhibitor atau ARB direkomendasikan pads pasien dengan diabetes, chronic kidney disease(CKD), atau coronary artery disease (CAD)
• ACE inhibitor dan beta blocker direkomendasikan pads pasien dengan gagal jantung(heart failure). (CHEP Grade A) (level 1 [likely reliable] evidence)
• Banyak pasien membutuhkan > 1 obat untuk mencapai terapi.

Thiazide-type diuretics:

• Thiazide-type diuretics and doses used for hypertension in randomized trials supporting JNC8 recommendations include
  • hydrochlorothiazide (HCT, generic) starting dose 12.5-25 mg/day in 1-2 doses, target dose 25-50 mg/day in 1-2 doses
  • indapamide (generic) 1.25 mg once daily, target dose 1.25-2.5 mg once daily.

Angiotensin-converting enzyme (ACE) inhibitors:

• ACE inhibitors and doses used for hypertension in randomized trials supporting JNC8 recommendations include.
• Captopril (generic) starting dose 50 mg once daily, target dose 150-200 mg/day in 2 doses
• enalapril  starting dose 5 mg/day in 1-2 doses, target dose 20 mg/day in 1-2 doses
• lisinopril (generic) starting dose 10 mg once daily, target dose 40 mg once daily
• ramipril (generic)  10 mg once daily reduces rate of cardiovascular death, myocardial infarction, stroke, and heart failure in patients > 55 years old with vascular disease or diabetes (level 1 [likely reliable] evidence), based on HOPE trial

Angiotensin receptor blockers (ARBs):

• ARBs and doses used for hypertension in randomized trials supporting JNC8 recommendations include.
  • candesartan (generic) starting dose 4 mg once daily, target dose 12-23 mg once daily
  • irbesartan  starting dose 75 mg once daily, target dose 300 mg once daily
  • losartan (generic) starting dose 50 mg/day in 1-2 doses, target dose 100 mg/day in 1-2 doses
  • valsartan (Diovan) starting dose 40-80 mg once daily, target dose 160-320 mg once daily

Calcium channel blockers:

Dihydropyridine calcium channel blockers:

• Dihydropyridine calcium channel blockers and doses used for hypertension in randomized trials supporting JNC8 recommendations include
  • amlodipine (generic) starting dose 2.5 mg once daily, target dose 10 mg once daily

Beta blockers:

• Beta blockers and doses used for hypertension in randomized trials supporting JNC8 recommendations include(1)
  • atenolol (generic) starting dose 25-50 once daily, target dose 100 mg once daily
  • metoprolol (generic) starting dose 50 mg/day in 1-2 doses, target dose 100-200 mg/day in 1-2 doses