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TERKINI :
FOKUS PADA JNC 8
WACHID PUTRANTO
Divisi Ginjal Hipertensi
Fakultas Kedokteran UNS/RS.Dr. Moewardi
Surakarta
Prevalensi Hipertensi
70
60
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
Hypertension complication
Eyes
retinopathy
Brain
stroke
Kidneys
renal failure
Heart
ischaemic heart disease
left ventricular hypertrophy
heart failure
1 million adults
12.7 million person-years
2 mmHg
decrease in
mean SBP
7% reduction in risk
of ischaemic heart
disease mortality
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
Scope of topics
Review process
Prior to
Publication
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 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
(<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
DBP90 mmHg . Target DBP<90 mmHg
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
Description
Details
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
CHEP
General (non
elderly)
General elderly
<80 y
General 80 y
DM
CKD (no
proteinemia)
CKD +
proteinemia
<140/90
<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
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
ISHIB
<135/85
<130/80
Diuretic or CCB
JNC 7
General
CKD
DM
<140/90
<130/80
<130/80
130/80
ACEI or ARB
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/
Blocker
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