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
Prevalensi Hipertensi
prevalence of hypertension (%)
70 60
SBP > 140 mm Hg DBP > 90 mm Hg
64
65
70-79
80+
54
50
44
40 30 20
21 4
11
18-29
30-39
10 0 age (yrs)
40-49
50-59
60-69
Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36
Hypertension complication Eyes retinopathy
Brain stroke
Target Organ damage!! Damages depend on:
Kidneys renal failure
Heart ischaemic heart disease left ventricular hypertrophy heart failure
Peripheral arterial disease
• How high of the blood pressures
• How long the uncontrolled and untreated high blood presure
Blood Pressure Reduction Of 2 mmHg Reduces The Risk Of CV Events by 7–10% • Meta-analysis of 61 prospective, observational studies
• 1 million adults • 12.7 million person-years 2 mmHg decrease in mean SBP
7% reduction in risk of ischaemic heart disease mortality
10% reduction in risk of stroke mortality
Lewington et al. Lancet 2002;360:1903–13
ASH/ISH
HYPERTENSION GUIDELINES
CLASSIFICATION HYPERTENSION BP
BP
SBP
Optimal
<120
DBP and
<80
SBP
DBP
Normal
<120 and
<80
High Normal
130-139
85-89
80-89
HT stg 1
140-159
90-99
Stg 1
120-139 or 140-159 or
90-99
HT stg 2
160-179
100-109
Stg 2
≥160 or
≥100
HT stg 3
≥180
≥110
ISH
≥140
<90
Normal Pre HT
BP
SBP
Optimal
<120
and
<80
Normal
<130
and
<85
High Nml
130-139
or
85-89
HT stg 1
140-159 or
90-99
HT stg 2
160-179 or
100-109
HT stg 3
≥180
120-129and./or 80-84
and
DBP
or
≥110
JNC 8 No definition of HT
Topic Methodology
JNC 7 Non systematic literature review by expert committee including a range of study design Recommendation based on consensus
2014 Hypertension Guidelin
Critical questions and review criteria defined by expert panel with input from methodology team Initial systematic review by methodologist restricted to 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
Scope of topics
Review process Prior to Publication
Included a comprehensive table oral Antihypertensive drugs including names and usual dose ranges Addressed multiple issues ( blood pressure Evidence review of RCT’S 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 Reviewed by the National High Blood pressure Reviewed by experts including those affiliated Education Program Coordinating Committee, with professional and public organizations and 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 B C
D E N
Recommendation
Strength of Recommendation
Recommendation 1 Populasi berusia ≥60 yrs,mulai terapi farmakologi SBP≥150 mmHg, DBP≥90 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 (<140/90) dan pengobatan ditoleransi dengan baik tanpa efek samping, teruskan pengobatan. Usia ini TD <140 tidak lebih baik disbanding 140-160
Grade E
Recommendation 2 Populasi usia <60 yrs, terapi farmacologi bila DBP≥90 mmHg . Target DBP<90 mmHg
Grade A (30-59 yrs) Grade E (18-29 yrs) HDFP, HT-Stroke Cooperative, MRC, ANBP, VA cooperative
Recommendation
Strength of Recommendation
Recommendation 3 Populasi usia <60 yrs, terapi farmacologi bila SBP ≥140 mmHg.Target SBP<140 mmHg
Grade E
Recommendation 4 Populasi usia ≥18 yrs dengan CKD, terapi farmacologi bila SBP ≥140 mmHg or DBP ≥90 mmHg . Target SBP <140 mmHg dan DBP <90 mmHg
Grade E AASK, MDRD, REIN-2
Recommendation 5 Populasi usia ≥18 dengan DM, terapi Grade E farmacologi bila SBP ≥140 mmHg atau DBP ≥ 90 mmHg. Target SBP<140 and DBP <90 SHEP, Syst-Eur, UKPDS, ACCORD, ADVANCE, HOT
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
G U I D E L I N E C 0 M P A R I S O N GOAL BP INITIAL TX
Guideline 2014 HT Guideline
ESH/ESC
Population
Goal BP
Initial drugs
General ≥60 y
<150/90
General <60 y DM
<140/90 <140/90
CKD
<140/90
Non Black: thiazide type diuretic, ACEI, ARB or ARB Black: thiazide type-diuretic or CCB Thiazide type diuretic, ACEI, ARB or CCB ACEI or ARB
• • • • • •
CHEP
General (non elderly) General elderly <80 y General ≥ 80 y DM CKD (no proteinemia) CKD + proteinemia
<140/90
βBocker, diuretic, CCB, ACEI, ARB
<150/90 <150/90 <140/85 <140/90
ACEI or ARB ACEI or ARB
<130/90
General <80 y
<140/90
General >80 y DM
<150/90 <130/80
CKD
<140/90
Thiazide, βBlocker (<60y), ACEI (nonblack) or ARB Add CVD risk: ACEI or ARB No CVD risk: ACEI/ARB/Thiazide/DHPCCB ACEI or ARB
Guideline
Population
Goal BP
Initial drugs
ADA
DM
<140/80
ACEI or ARB
KDIGO
• DM and CKD alb exc <30 mg/d • DM and CKD alb exc >30 mg/d
≤140/90
ACEI or ARB
NICE
General <80 y General ≥80 y
<140/90 <150/90
<55 y; ACEI or ARB ≥55 y or black; CCB
ISHIB
Black, lower risk TOD or CVD risk
<135/85 <130/80
Diuretic or CCB
JNC 7
General CKD DM
<140/90 <130/80 <130/80
≤130/80
ACEI or ARB
Important Variables For HTN Recommendations BP
NICE
ESC/ESH
ASH/ISH AHA/AC C/CDC
Definition HTN
≥140/90 and daytime ABPM ≥135/85
≥140/90
≥140/90
Drug th/ in low risk pts after non pharm th/ βBlocker as 1st line
≥160/100 ≥140/90 or daytime ABPM ≥150/95
No
Yes
≥140/90
No
≥140/90
≥140/90
No
JNC 7
JNC 8
Pre HT 120-139 or 80-89 Stg 1 HT 140-159 or 9099 Stg 2 HT ≥160 or ≥100
Not addressed
≥140/90
• <60 y, ≥140/90 • ≥60 y, ≥150/90
No
No
NICE
ESH/ESC
ASH/ISH
AHA/ACC /CDC
JNC 7
JNC 8
Diuretic
Chorthalidone (CTD) Indapamide (IND)
Thiazides (THZ), CTD ND
THZ CTD IND
THZ
THZ
THZ CTD IDP
Initiate th/ with 2 drugs
Not mentioned
Pts w/ markedly elevated BP
≥160/90
≥160/100
≥160/100
Not mentioned
<140/90
<160/90 (<60 y)
BP target
<140/90 ≥80 y, <150/90
<140/90 <140/90 • Elderly <80 ≥80 y, SBP 140<150/90 150, in fit pts SBP <140 • Elderly ≥80 y SBP 140150
<140/90
≥60 y, <150/90
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 <150/90 mm Hg
In pts 18 - 59 yrs without major comorbidities target BP <140/90, and in patient ≥ 60 yrs without DM, CKD, or both, the new goal BP is <150/90 mm Hg
JNC 8 panel recommended thiazide-type diuretics as initial therapy for most patients (include newly diagnosed HTN)
JNC 8 also recommend lifestyle interventions include use of the DASH eating plan, weight loss, reduction in sodium intake to <2.4 gr/day, and at least 30 minutes of aerobic activity most days of the week 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 β-blockers and α-blockers as 1st therapy due to 1 trial that showed a higher rate of CV events with use of βB compared with use of an ARB, and another trial in which αB resulted in inferior CV outcomes compared with use of a diuretic
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
