08 October 2009

Pedoman Tata Laksana Penyakit Hipertensi

Dalam menangani penyakit hipertensi, banyak organisasi kesehatan di dunia membuat suatu pedoman dalam tata laksana hipertensi. Pada intinya pedoman-pedoman tersebut berisikan cara mengatasi penyakit hipertensi dengan perubahan gaya hidup atau terapi non farmakologi, obat yang digunakan dalam terapi farmaklogi dan target tekanan darah yang ingin dicapai serta penanganan pada penderita hipertensi dengan keadaan khusus. Berikut ini pedoman tata laksana hipertensi :
1. Pedoman WHO dan International Society of Hypertension Writing Group (ISWG) tahun 2003, berisikan :
  • Pasien hipertensi dengan tekanan darah sistole >= 140 mmhg dan diastole >= 90 mmhg diawali dengan terapi non farmakologi seperti penurunan berat badan bagi penderita yang obese/kegemukan, olahraga yang teratur, mengurangi konsumsi alkohol dan garam, tidak merokok dan mengkonsumsi lebih banyak sayur dan buah.
  • Terapi farmakologi : untuk penderita tanpa komplikasi pengobatan dimulai dengan diuretik tiazid dosis rendah dan untuk penderita dengan komplikasi menggunakan lebih dari satu macam obat hipertensi.


2. Joint National Committee (JNC) berisikan :

  • Perubahan gaya hidup dan terapi obat memberikan manfaat yang berarti bagi pasien hipertensi
  • Target tekanan darah < 140/90 bagi hipertensi tanpa komplikasi dan target tekanan darah < 130/80 bagi hipertensi dengan komplikasi
  • Diuretik tiazid merupakan obat pilihan pertama untuk mencegah komplikasi kardiovaskular.
  • Hipertensi dengan komplikasi pilihan pertama diuretik tiazid tapi juga bisa digunakan penghambat ACE (captopril,lisinopril,ramipril dll), ARB (valsartan, candesartan dll), beta bloker (bisoprolol) dan antagonis kalsium (nifedipin, amlodipin dll) bisa juga dipertimbangkan.
  • Pasien hipertensi dengan kondisi lain yang menyertai seperti gagal ginjal dan lain-lain, obat anti hipertensi disesuaikan dengan kondisinya.
  • Monitoring tekanan darah dilakukan 1 bulan sekali sampai target tercapai dilanjutkan setiap 2 bulan, 3 bulan atau 6 bulan. Semakin jauh dari percapaian target tekanan darah, semakin sering monitoring dilakukan.


3. British Hypertensive Society (BHS)

  • Terapi non farmakologi dilakukan pada pasien hipertensi dan mereka yang keluarganya ada riwayat hipertensi
  • Pengobatan dimulai pada tekanan darah sistole >=140 dan diastole >= 90
  • Target yang ingin dicapai setelah pengobatan, sistol =< 140 dan diastole =< 85
  • obat piliha pertama tiazid atau beta bloker bila tidak ada kontraindikasi.

4. National Heart Lung Blood Institute (NHLBI)

  • Modifikasi gaya hidup sebagai penanganan menyeluruh, dapat dikombinasi dengan terapi obat
  • Menerapkan pola makan DASH (Diet Approach to Stop Hypertension) untuk penderita hipertensi
  • Hipertensi tanpa komplikasi harus dimulai dengan diuretik atau beta bloker
  • Hipertensi dengan penyakit penyerta, pemilihan obat harus berdasarkan masing-masinghambat individu dan berubah dari mono terapi ke terapi kombinasi yang fleksibel

5. European Society of Hypertension (ESH)

  • Fokus diberikan pada paien individual dan risiko kardiovaskularnya.
  • Penderita hipertensi dapat menerima satu atau lebih macam obat selama tujuan terapi tercapai
  • Penatalaksanaan harus difokuskan pada pencapaian target pengobatan kardiovaskular dengan perubahan gaya hidup atau dengan terapi obat
  • Kombinasi obat yang digunakan untuk mencapai target tekanan darah harus ditetapkan secara individual pada masing-masing pasien
  • Penghambat ACE dan ARB tidak boleh digunakan pada kehamilan.

6. UK's NICE

  • Penghambat ACE sebagai lini pertama bagi penderita hipertensi usia < 55 tahun dan antagonis kalsium atau diuretika bagi penderita hipertensi > 55 tahun
  • ARB direkomedasikan jika penghambat ACE tidak dapat ditoleransi
  • Penggunakan beta bloker sebagai lini keempat.

7. PEDOMAN  HIPERTENSI (KONSENSUS PERHIMPUNAN HIPERTENSI INDONESIA)
Hasil konsensus Pedoman Penanganan Hipertensi di Indonesia tahun 2007 berisikan :

  • Penanganan hipertensi ditujukan untuk menurunkan morbiditas dan mortalitas kardiovaskular (termasuk serebrovaskular) serta perkembangan penyakit ginjal dimulai dengan upaya peningkatan kesadaran masyarakat dan perubahan gaya hidup ke arah yang lebih sehat.
  • Penegakan diagnosis hipertensi perlu dilakukan dengan melakukan pemeriksaan tekanan darah minimal 2 kali dengan jarak 1 minggu bila tekanan darah <160/100 mmhg
  • Sebelum bertindak dalam penanganan hipertensi, perlu dipertimbangkan adanya risiko kardiovaskular, kerusakan organ target dan penyakit penyerta. Penanganan dengan obat dilakukan pada penderita dengan banyaknya faktor risiko 3 atau lebih  atau dengan adanya kerusakan organ target,diabetes, penyakit penyerta, di samping perubahan gaya hidup.
  • Penanganan dengan obat dilakukan bila upaya perubahan gaya hidup belum mencapai target tekanan darah (masih >= 140/90 atau >= 130/80 bagi penderita diabetes/ penyakit ginjal kronis).
  • Pemilihan obat didasarkan ada tidaknya indikasi khusus. Bila tidak ada indikasi khusus, obat tergantung pada derajat hipertensi (derajat 1 atau derajat 2 JNC7)


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