Filed under: Kedokteran Ilmiah
Sekedar menyegarkan kembali ingatan sejawat tentang hipertensi, ini adalah manajemen hipertensi menurut JNC VII untuk pasien2 dg komplikasi tertentu: (maaf masih dalam bahasa inggris, belum sempat translate)
Ischemic Heart Disease. Ischemic heart disease is the most common form of target-organ damage associated with hypertension. In patients with hypertension and stable angina pectoris, the first drug of choice is usually a -blocker; alternatively, long-acting CCBs can be used.1 In patients with acute coronary syndromes (unstable angina or myocardial infarction), hypertension should be treated initially with -blockers and ACE inhibitors,49 with addition of other drugs as needed for BP control. In patients with postmyocardial infarction, ACE inhibitors, -blockers, and aldosterone antagonists have proven to be most beneficial.50, 52–53,62 Intensive lipid management and aspirin therapy are also indicated.
Heart Failure. Heart failure, in the form of systolic or diastolic ventricular dysfunction, results primarily from systolic hypertension and ischemic heart disease. Fastidious BP and cholesterol control are the primary preventive measures for those at high risk for HF.40 In asymptomatic individuals with demonstrable ventricular dysfunction, ACE inhibitors and -blockers are recommended.52, 62 For those with symptomatic ventricular dysfunction or end-stage heart disease, ACE inhibitors, -blockers, ARBs, and aldosterone blockers are recommended along with loop diuretics.40–48
Diabetic Hypertension. Combinations of 2 or more drugs are usually needed to achieve the target BP goal of less than 130/80 mm Hg.21–22 Thiazide diuretics, -blockers, ACE inhibitors, ARBs, and CCBs are beneficial in reducing CVD and stroke incidence in patients with diabetes.33, 54, 63 The ACE inhibitor– or ARB-based treatments favorably affect the progression of diabetic nephropathy and reduce albuminuria,55–56 and ARBs have been shown to reduce progression to macroalbuminuria.56–57
Chronic Kidney Disease. In patients with chronic kidney disease, defined by either (1) reduced excretory function with an estimated glomerular filtration rate of less than 60 mL/min per 1.73 m2 (corresponding approximately to a creatinine of >1.5 mg/dL [>132.6 µmol/L] in men or >1.3 mg/dL [>114.9 µmol/L] in women)20 or (2) the presence of albuminuria (>300 mg/d or 200 mg albumin per gram of creatinine), therapeutic goals are to slow deterioration of renal function and prevent CVD. Hypertension appears in the majority of these patients and they should receive aggressive BP management, often with 3 or more drugs to reach target BP values of less than 130/80 mm Hg.59, 64
The ACE inhibitors and ARBs have demonstrated favorable effects on the progression of diabetic and nondiabetic renal disease.55–59,64 A limited increase in serum creatinine of as much as 35% above baseline with ACE inhibitors or ARBs is acceptable and not a reason to withhold treatment unless hyperkalemia develops.65 With advanced renal disease (estimated glomerular filtration rate <30 mL/min per 1.73 m2, corresponding to a serum creatinine of 2.5-3.0 mg/dL [221-265 µmol/L]), increasing doses of loop diuretics are usually needed in combination with other drug classes.
Cerebrovascular Disease. The risks and benefits of acute lowering of BP during an acute stroke are still unclear; control of BP at intermediate levels (approximately 160/100 mm Hg) is appropriate until the condition has stabilized or improved. Recurrent stroke rates are lowered by the combination of an ACE inhibitor and thiazide-type diuretic
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