ANATOMI JANTUNG

.
.
.
.
.
 .

.
P WAVE : RIGHT AND LEFT ATRIAL DEPOLARISATION
ATRIAL DEPOLARISATION WAS COMPLETED
DELAYED IN AV NODE FOR SECURITY
VENTRICLE DEPOLARISATION
VENTRICLE REPOLARISATION
 SISTEM KONDUKSI
AV NODE : PINTU PENGHUBUNG ATRIAL &
VENTRIKEL [ 0,12 0,22 DT ]
< 0,12 DT : PRE EKSITASI
> 0,22 DT : AV BLOK DERAJAD I

HIS BUNDLE : JALAN RANGSANG INTRAVENTRIKEL

[ < 0,12 DT ]
0,12 DT ATAU LEBIH : BBB KANAN ATAU
KIRI
 .

.
 .

P : ATRIAL DEPOLARISATION

QRS : VENTRICLE DEPOLARISATION

ST : VENTRICLE REPOLARISATION
T : VENTRICLE REPOLARISATION

U : LATE REPOLARISATION
 NOMENKLATUR

GELOMBANG P, T, SEGMEN PR & ST DITULIS

DENGAN HURUF BESAR

GELOMBANG R : < 5 [ KOTAK KECIL ] HURUF : r

S : < 5 DITULIS : s
Q : LEBAR 0,04 DT ATAU LEBIH
DALAM 1/3 R
TERDAPATNYA PADA r
 .

.
 SADAPAN [ LEAD ]

EXTREMITAS: TANGAN KANAN TANGAN KIRI [LEAD I]

TANGAN KANAN KAKI KIRI [LEAD II]
TANGAN KIRI KAKI KIRI [LEAD III]

TANGAN KIRI JANTUNG [LEAD aVL]

TANGAN KANAN JANTUNG [LEAD aVR]
KAKI KIRI - JANTUNG [LEAD aVF]

PRECORDIAL : V1 V2 V3 V4 V5 V6
 .

.
 .

.
 HASIL REKAMAN EKG

ADA 12 PANDANGAN :
6 LEAD EKSTREMITAS : I II III aVR aVL aVF
6 LEAD PRE-KORDIAL : V1 V2 V3 V4 V5 V6

EKSTREMITAS LEAD:
PROYEKSI BIDANG FRONTAL

PRE-KORDIAL LEAD :
PROYEKSI BIDANG HORISONTAL
 .

.
 .

.
.
 URUTAN BACA EKG
IRAMA JANTUNG
FREKUENSI JANTUNG
POSISI ARAH RANGSANG VENTRIKEL
AKSIS ARAH RANGSANG VENTRIKEL
ZONA TRANSISI
INTERVAL: PR
QRS
QT
 .

IRAMA JANTUNG
 .

SA NODE : IRAMA SINUS

AV NODE : IRAMA JUNCTIONAL

ATRIAL : IRAMA ATRIAL

VENTRIKULER : IRAMA VENTRIKULER

VENTRICLE REPOLARISATION
 IRAMA SUPRA-VENTRIKULER
.
 IRAMA SINUS
DI LEAD II GELOMBANG P UPRIGHT
GELOMBANG QRS NORMAL ATAU MELEBAR [ BBB ]

FREKUENSI : > 60 < 100/MENIT

ARITMIA SINUS: BRADIKARDI, TAKHIKARDI,

SINUS ARITMIA, SA ARREST
.
 .

.
.
.
 .

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 IRAMA JUNCTIONAL

JUNCTIONAL ATAS:
P DIDEPAN QRS & INVERTED DI LEAD II

FREKUENSI : 50 - 60/MENIT

PADA LEBIH DARI 60/MNT: ACCELERATED JR

PADA LEBIH DARI 100/MNT: TAKHIKARDI J
.
.
 JUNCTIONAL TENGAH
P TIDAK TERLIHAT DI SEMUA LEAD

FREKUENSI : 50 60/MENIT

> 60 < 100: ACCELERATED JTR

>100/MENIT: TAKHIKARDI JT
IRAMA JUNCTIONAL BAWAH
P INVERTED & DIBELAKANG QRS DI LEAD II

FREKUENSI : 50 - 60/MENIT

60 < 100 : ACCELERATED JBR

>100/MNT : TAKHIKARDI JB
 .

.
 IRAMA ATRIAL
NORMAL TIDAK TERDETEKSI DENGAN EKG

ATRIAL TAKHIKARDI : FREKUENSI > 150/MENIT

ATRIAL FLUTTER : P BENTUK GERGAJI

ATRIAL FIBRILLASI : COARSE & FINE

RESPONSE VENTRIKEL: RAPID, NORMAL

DAN SLOW
 .

.
 .

.
 .

.
 .

.
 IRAMA VENTRIKULER
QRS LEBAR TANPA GELOMBANG P DIDEPANNYA

FREKUENSI : 30 s/d 40 / MENIT

ACCELERATED V RHYTHM : > 40 s/d <100 / MENIT

TACHYCARDI VENTRICULAR: 100 / MENIT / LEBIH

VENTRICULAR FLUTTER : > 250/MENIT

VENTRICULAR FIBRILLASI : TUMPUL

 IRAMA VENTRIKULER
.
 .

.
 .
.
 .

.
 OVER DRIVE
PENGAMBIL ALIHAN RITME SECARA SEMENTARA

PREMATURE BEAT : ATRIAL, JUNTIONAL [A,T,B],

VENTRIKEL

RUN OF: ATRIAL, JUNCTIONAL [A,T,B], VENTRIKEL

BIASANYA TEMPORER KECUALI ATRIAL FLUTTER &

FIBRILLASI BISA TEMPORER ATAU PERMANEN
 .

.
 .

.
 .

.
.
 LATIHAN TENTUKAN IRAMA
IRAMA SINUS : TANDANYA ?
FREKUENSINYA ?

IRAMA JUNCTIONAL : ADA BERAPA TIPE ?

TANDA MASING 2 ?
BEDA DNG SINUS ?

IRAMA ATRIAL :

IRAMA VENTRIKULER : BEDA DNG SUPRA ?

 HEART RATE
RUMUS UMUM : 300 / R R

ATRIAL FLUTTER :
300 / R R RATE VENTRIKEL
1500 / P P RATE ATRIAL

ATRIAL FIBRILLATION :
300 / [ R1 R11 / 10 ] RATE VENTRIKEL

TOTAL AV BLOCK : 300 / R R RATE VENTRIKEL

300 / P P RATE ATRIUM
 .

..
 .

.
 .

.
 LATIHAN RATE
RUMUS NORMAL BAGAIMANA ?

BAGAIMANA PADA ATRIAL FLUTTER ?

BAGAIMANA PADA ATRIAL FIBRILLASI ?

BAGAIMANA PADA AV BLOK TOTAL ?

 .

POSISI & AXIS

 .

.
 VENTRIKEL BIDANG FRONTAL
DILIHAT GELOMBANG KOMPLEKS QRS
POSITIP : R > Q + S
NOL :R=Q+S
NEGATIP : R < Q + S

CARI YANG NOL, AXIS PASTI TEGAK LURUS PADANYA

LIHAT aVL & aVF + I [VERTIKAL] OR + II [HORISONTAL]

 POSISI & AKSIS QRS
aVL + aVF + INTERMEDIATE 30*
aVL ++ aVF + INTERMEDIATE 20*
aVL + aVF ++ INTERMEDIATE 40*

aVL 0 aVF + SEMI VERTICAL 60*

aVL + aVF 0 SEMI HORIZONTAL 0*

aVL aVF + LEAD I 0 AXIS 90*

+ AXIS 80*
AXIS 100* [ LPHB ]
aVL + aVF LEAD II 0 AXIS 30*
+ AXIS 20*
AXIS 40* [ LAHB ]
 .

ZONA TRANSITION
 .

.
 .

NORMAL : V3 V4

COUNTER CLOCK WISE ROTATION :

V1 V2 V2 V2 V3 V3

CLOCK WISE ROTATION :

V4 V4 V5 V5 V5 V6
 .

INTERVAL P QRST
 .

.
 .

PR : 0,12 0, 22 SECOD
SHORT : PRE-EKSITASI
PROLONG : AV BLOK GRADE I

QRS : < 0,12 SECOND

0,12 OR MORE : HIS BUNDLE BLOCK

QT : < 0,40
0,40 OR MORE : LONG QT SINDROM
.
 PEKERJAAN RUMAH
TENTUKAN:

1. IRAMA & FREKUENSI

2. POSISI & AKSIS

3. TRANSISI ZONE

4. INTERVAL : PR QRS QT
 KEMAMPUAN EKG
ARITMIA : SINUS ATRIAL JUNCTIONAL
VENTRIKULER

GANGGUAN KONDUKSI :
AV NODE HIS BUNDLE

HIPERTROFI ATRIUM & VENTRIKEL

PENYAKIT JANTUNG KORONER

PRE EKSITATION : WPW & LGL

 PACEMAKER
.

KONDUKSI

. JANTUNG
 .

.
PACEMAKER .

SA NODE

AV NODE

ATRIAL

VENTRIKEL
KONDUKSI
.
 .

.
 GANGGUAN KONDUKSI
PRE EKSITASI : SINDROMA WPW & LGL

AV NODE :
GRADE I
GRADE II WENCKEBACH [ MOBITZ I ]
MOBITZ TYPE II
GRADE III [ TOTAL ]

HIS BUNDLE : RBBB LBBB

LAHB LPHB
 PRE-EKSITATION
WOLFF PARKINSON WHITE SYNDROME:
SHORT PR
DELTA WAVE
T INVERTION

LOWN GANONG LEVINE SYNDROME:

SHORT PR
NORMAL QRS
T UP-RIGHT
 BLOK PADA KONDUKSI AV
AV BLOK DERAJAD I :
P SELALU DIIKUTI QRS ST & T
INTERVAL PR > 0,22 DETIK

AV BLOK DERAJAD II :
MOBITZ TIPE I INTERVAL PR PROGRESIF
MOBITZ TIPE II INTERVAL PR SAMA
ADA DROB BEAT PADA MOBITZ I & II

AV BLOK DERAJAD III :

P DENGAN PACEMAKER SINUS
QRS DENGAN PACEMAKER JUNCTIONAL
ATAU VENTRIKULER
 .

.
 BLOK PADA SERABUT HIS

RBBB KOMPLET : rSR DI V1

WIDE S DI LEAD I

LBBB KOMPLET : RR DI LEAD I, V5 ATAU V6

RBBB & LBBB INKOMPLET KOMPLEKS QRS

NORMAL

LAHB : AKSIS 40 LPHB : AKSIS + 100

 LATIHAN
PACEMAKER NORMAL SINUS
NORMAL JUNCTIONAL A/T/B
NORMAL VENTRIKULER
ARITMIA SINUS, ATRIAL
JUNCTIONAL & VENTRIKULER

GANGGUAN KONDUKSI :
PRE EKSITASI
BLOK AV NODE
BLOK SEABUT HIS
 .

OTOT JANTUNG

ATRIAL
VENTRIKEL
 OTOT [MIOKARD] ATRIAL .

PEMBESARAN :
ATRIUM KANAN
ATRIUM KIRI
 .

.
 VENTRIKEL
PEMBESARAN :
VENTRIKEL KANAN
VENTRIKEL KIRI
.
 PENYAKIT JANTUNG KORONER
ISKEMIA : DEPRESI ST & INVERSI T
INJURI : ELEVASI ST
INFARK : Q PATHOLOGIS

HARUS DITENTUKAN FASENYA: HIPER AKUT, AKUT

RECENT DAN OLD

HARUS DITENTUKAN LOKASI :

INFERIOR
ANTERIOR : SEPTAL, APIKAL, LATERAL
POSTERIOR
.
 .

.
 .

.
.
 .

.
 HYPO & HYPER - KALEMIA

HYPOKALEMIA :
U WAVE PROMINENT

HYPERKALEMIA
SYMITRICAL TALL T WAVE
 .

LAPORAN EKG
RITME / IRAMA : SINUS, JUNCTIONAL, ATRIAL OR
VENTRIKULER
.

FREKUENSI : SVT ST NSR SB

POSITION & AXIS QRS : LAHB NORMAL LPHB

ZONA TRANSISI : CCWR NORMAL OR CWR

INTERVAL PR : AV BLOCK GRADE I, LGL / WPW

QRS : BUNDLE BRANCH BLOCK
QT : LONG QT SYNDROME

TANDA PEMBESARAN RUANG, ADANYA GELOMBANG FIBRILLASI,

FLUTTER, EKSTRA SISTOLE, RUN OF, DROB BEAT, ST ELEVASI
ATAU DEPRESI, Q PATHOLOGIS, U PROMINEN, T TENDA

KESIMPULAN :
 .

HUBUNGAN ANTARA ATRIUM &

VENTRIKEL
1. ATRIAL & VENTRIKEL SATU PACEMAKER
FREKUENSI ATRIUM & VENTRIKEL SAMA
.

2. ATRIAL IN FLUTTER ATAU FIBRILLASI

PACEMAKER ATRIUM & VENTRIKEL SAMA NAMUN
FREKUENSINYA BERBEDA

3. PRE EKSITASI SATU PACEMAKER ADA 2 JALAN

HIS DAN ASESORIS [KENT]

4. AV BLOK DERAJAD I, SATU PACEMAKER DENGAN

INTERVAL PR PANJANG
5. AV BLOK DERAJAD II SATU PACEMAKER DENGAN
ADANYA DROB BEAT
6. AV BLOCK TOTAL: PACEMAKER ATRIUM DI SA
NODE, VENTRIKEL DI JUNCTIONAL / VENTRIKULER
 .

..
 .

.
.
.
 .

.
 .

.
 .

NADI TAK ADA INTERMITEN

 .

.
 .

.
Ekstra sistole junctional atas.
 GAMBARAN EKG MIRIP
RITME SINUS & RITME JUNCTIONAL ATAS

BUNDLE BRANCH BLOCK & RITME VENTRIKULER

ISKEMIA ANTERO LATERAL & LVH

ATRIAL FIBRILLASI FINE & JUNCTIONAL TENGAH

AV BLOCK GRADE II & III

SINDROMA LGL & RITME JUNCTIONAL ATAS

.
 .

.
 .

.
 .

.
APA YANG HARUS DICARI
ADANYA OVER-DRIVE DI SEMUA LEAD : I S/D V6

TANDA RVH [ V1, V3R ] RBBB [ I, V1 ]

LVH [V1, V5-6 ] LBBB [ I, V5-6 ]

TANDA PENYAKIT JANTUNG KORONER:

II, III, aVF [INFERIOR]
I & aVL [HIGH LATERAL]
V1 V6 [ANTERIOR]
V7 V9 [POSTERIOR]
V3R V5R [DEXTRA]
 EKG YANG HARUS TAHU

IRAMA SINUS

ATRIAL PREMATURE BEAT, TAKHIKARDI, FLUTTER,

FIBRILLASI

VENTRIKEL PREMATURE BEAT, LVH

RBBB COMPLETE & INCOMPLETE

PJK INFERIOR HIGH LATERAL ANTERIOR

.
.
.
 .

.
.
.
 .

.
 .

.
.
 .

.
 ARTI KLINIS NADI YANG HILANG

HAMPIR SELALU DIAKIBATKAN OLEH OVER-DRIVE

PADA AV BLOK ATAU SA ARREST : PJK

INDIKASI TREADMILL TEST

INDIKASI PRIKSA FAKTOR RISIKO

TIDAK MENGGANGGU/TIDAK PERLU TERAPI

 EKG YANG SERING DITEMUI

ATRIAL FLUTTER
ATRIAL FIBRILLASI
SUPRA VENTRIKULER TAKHIKARDI
RAH
LAH
LVH
RBBB
ISKEMIA INFERIOR
AMI HIPER AKUT RECENT OMI
OVER - DRIVE
 ARITMIA SUPRA-VENTRIKULER

ATRIAL TAKHIKARDI, FLUTTER & FIBRILLASI HARUS

DICARI KEMUNGKINAN ADANYA HIPERTIREOID
PASTIKAN ADA TANDA GAGAL JANTUNG /TIDAK
ATRIAL TAKHIKARDI & FLUTTER/FIBRILLASI
DENGAN RAPID VENTRIKULER RESPONS HARUS
DIBERI OBAT KONTROL RATE
ATRIAL TAKHIKARDI TIDAK PERNAH PERMANENT
ATRIAL FLUTTER & FIBRILLASI HARUS DIBERI ANTI
PLATELET
HARUS SELALU DICARI PENYEBAB DASARNYA
 ARITMIA VENTRIKULER

IRAMA VENTRIKULER BAIK SEBAGAI AV BLOK

TOTAL ATAU IDIOVENTRIKULER RITME PERLU
PACEMAKER

RUN VT, VT, VF, R on T, BIGEMINI, BERPASANGAN

PERLU ANTI ARITMIA & KONSULTASI KE
KARDIOLOGIST

TANDA KLINIS YANG SERING: SINKOPE / PINGSAN

 GANGGUAN KONDUKSI

AV BLOK DERAJAD I, II TANPA KELUHAN KLINIS

TIDAK PERLU OBAT TAPI CARI FAKTOR RISIKO
AV BLOK III DENGAN SINKOPE/HR < 45 HARUS
PAKAI PACEMAKER
RBBB, LAHB, LPHB BANYAK YANG NORMAL DAN
TIDAK ADA ARTI KLINIS SAMA SEKALI
LBBB HARUS SELALU DICARI KEMUNGKINAN HHD
DAN PJK
PRE EKSITASI ADA RISIKO SVT
 HIPERTROFI ATRIUM

ATRIUM KIRI HARUS DIPIKIRKAN KEMUNGKINAN

MITRAL STENOSES, INSUFFICIENSI ATAU HHD

ATRIUM KANAN HARUS SELALU DICARI

KEMUNGKINAN PENYAKIT PARU

KEDUA ATRIUM HARUS DIPIKIRKAN ADANYA

GAGAL JANTUNG AKIBAT HHD, STENOSIS
ATAUPUN INSUFFICIENSI MITRAL
 HIPERTROFI VENTRIKEL

VENTRIKEL KANAN HAMPIR SELALU DIAKIBATKAN

OLEH GAGAL JANTUNG KIRI
JARANG TERJADI TANPA HIPERTROFI VENTRIKEL
KIRI
PADA ANAK DAN BAYI GAMBARAN RVH : NORMAL

VENTRIKEL KIRI PALING SERING PADA ATLIT,

HIPERTENSI & PENYAKIT JANTUNG KORONER
HARUS SELALU DICARI PENYEBABNYA
 DIAGNOSA EKG TANPA ARTI
KLINIS
LAHB, LPHB, SEBAGIAN BESAR RBBB

SEBAGIAN EKSTRA SISTOLE ATRIAL/VENTRIKEL

LEFT AXIS DEVIATION, RIGHT AXIS DEVIATION

COUNTER CLOCK-WISE ROTATION DAN CLOCK-

WISE ROTATION

IRAMA JUNCTIONAL, AV BLOK DERAJAD I

 Heart and coronary artery

Plaque formation
 Atherosclerosis and its clinical impact
Cerebrovascular disease
Transient ischaemic attack (TIA)
Stroke

Cardiovascular disease
Angina
Heart attack
Heart failure

Others
Claudicatio intermiten
Gangren

CRE027/Jul07-Jul08/TEP | RTD Master Slide 2nd Semester

Atherosclerosis
 Hyperlipemia

Cholesterol
LDL-Cholesterol
HDL-Cholesterol
Triglyceride
 Arterial wall:
structure and function
Vascular endothelium modification
in atherosclerosis
Plaque formation 1 Fatty streak
Plaque formation 2- Fibrous cap
Plaque formation 3 Lipid core
 Characteristics of the
stable atherosclerotic
plaque
Fibrous cap
(VSMCs and matrix) Intimal VSMCs
Endothelial (repair
cells phenotype)
Lipid core

Adventitia

Medial VSMCs
(contractile
phenotype)
.
.
The vulnerable atherosclerotic
plaque

Lipid core

Adventitia
 Plaque rupture
The main releasing factors
 Atherosclerosis Timeline
Foam Fatty Intermediate Fibrous Complicated
Cells Streak Lesion Atheroma Plaque Lesion/Rupture

Endothelial Dysfunction
From first decade From third decade From fourth decade
Smooth muscle Thrombosis,
Growth mainly by lipid accumulation and collagen hematoma

Stary HC, et al. Circulation. 1995;92:1355-74. Artery wall often gets

larger with increasing plaque-Glagov NEJM 1987
 Severity of Coronary Artery Stenosis
Prior to Acute MI
68%
60

MI
Patients 40
(%)
20 18%
14%

0
<50% 50%70% >70%
% Stenosis
Data constructed from 4 individual trials in approximately 200 MI patients
Falk E et al. Circulation. 1995;92:657-671. 10
The Grip of Angina
 Medical Management

Antiplatelet

ACE inhibitor

Statin

Kontrol faktor risiko

 EKG KEGAWATAN
PADA AKUT MIOKARD INFARK:
VES LEBIH DARI 5/MENIT
VES BERPASANGAN
VES TIPE R ON T
VES MULTIVOKAL
RUN OF VENTRIKEL TAKHIKARDI
VENTRIKEL FLUTTER & FIBRILLASI

SUPRAVENTRIKULER TAKHIKARDI
 APLIKASI EKG SECARA KLINIS

RBBB INKOMPLIT = NORMAL

RBBB KOMPLET BIASANYA JUGA NORMAL
SERING TERDAPAT PADA ASD
IRAMA SINUS ATAU JUNCTIONAL BIASANYA
NORMAL
ATRIAL TAKHIKARDI, FLUTTER & FIBRILASI
PERLU PENGOBATAN
TAK ADA ARTI KLINIS PADA : LAHB, LPHB,
CCWR/CWR, AV BLOK I
 ARITMIA SUPRAVENTRIKULER

SVT SECEPATNYA DIATASI : MASSAGE

KAROTIS, VALSALVA, ATP, AMIODARON,
INFUS DELTIAZEM, DC SHOK

ATRIAL FLUTTER & FIBRILLASI : ASPIRIN

AMIODARON ATAU DIGITALIS PADA YANG
RAPID VENTRIKEL RESPONS

VENTRIKEL FLUTTER & FIBRILLASI DC SHOK

 EKG YANG ADA HUBUNGANNYA DNG
PENYAKIT JANTUNG KORONER
OVER-DRIVE VENTRIKULER

ATRIAL FIBRILLASI, ATRIAL FLUTTER, SA ARREST

LVH, LBBB, RBBB, AV BLOK I, II, III

ISKEMIA, INJURY, INFARK

 Antihypertensive therapy
Antihypertensive therapy should
Lower blood pressure effectively
Have a favourable safety profile
Reduce cardiovascular morbidity and mortality

Five drug categories

Diuretics
Beta-blockers
ACE inhibitors
Calcium channel blockers
Angiotensin-receptor blockers

Third Joint Task Force of European and other Societies on Cardiovascular Disease Prevention in Clinical Practice.
Eur Heart J 2003; 24: 1601-10.
 SUBCLINICAL ORGAN DAMAGE

ECG LVH
ECHOCSRDIOGRSPHY LVH
IMT >0.9 mm OR PLAQUE
SERUM CREATININE
MALE 1.3 1.5 mg/dl
FEMALE 1.2 1.4 mg/dl
eGFR <60 ml/min/1.73 m2
MICROALBUMINURIA 30-300 mg/24h

Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
 BP Reductions as Small as 2 mmHg Reduce the Risk
of CV Events by up to 10%

Meta-analysis of 61 prospective, observational studies

1 million adults

12.7 million person-years

7% reduction in
risk of IHD
2 mmHg mortality
decrease in 10% reduction in
mean SBP risk of stroke
mortality

Prospective Studies Collaboration. Lancet 2002;360:1903-1913.

 Benefit of Treating Hypertension

Antihypertensive therapy has been associated

with 40 percent reduction in stroke; 25 percent in
myocardial infarction; and more than 50 percent
in heart failure

It is estimated that control of hypertension to

below 140/90 mmHg could, in men and women,
prevent 19 and 31 percent of coronary heart
disease events
 NON DRUGS TREATMENT
WEIGHT REDUCTION [ > 10% ]

INCREASED PHYSICAL EXERCISE

DIET: SODIUM [<6GM/DAY] INCREASED

FRUIT, VEGETABLES, KALIUM
HYPERTENSION & PREGNANCY
DIET NORMAL AND LIMIT ACTIVITY
METILDOPA, LABETALOL, CCB
ACE-I & ARB CONTRA-INDICATION
CA SUPPL & OMEGA 3 NO EFFICIENT
ASPIRIN FOR HISTORY PRE-ECLAMPSIA
SBP >170 OR DBP >110 HOSPITALIZED
ALL DRUGS EXCRETED IN BREAST MILK,
EXCEPTION OF PROPRANOLOL & NIFEDIPIN
IN BREAST MILK IS VERY LOW
 ESH 2003 & JNC VII

ESH-ESC BP BP JNC VII

BP Classification Bp Classification
Optimal <120 / <80 <120/<80 Normal

Normal 120-129 / 80-84 120-129 /80-84 Prehypertension

High normal 130-139 / 85-89 130-139 / 85-89 Prehypertension

Grade 1 Hypertension 140-159 / 90-99 140-159 / 90-99 Stage 1

(mild) Hypertension
Grade 2 Hypertension 160-179 /100-109 Stage 2
(moderate) >160 / >100 Hypertension
Grade 3 Hypertension > 180 / >110
(severe)
Isolated Systolic Isolated Systolic
Hypertension > 140 < 90 Hypertension
 CARDIOVASCULAR RISK STRATIFICATION
Blood pressure (mm Hg)

Other risk factor, organ

Normal High normal Grade 1 HT Grade 2 HT Grade 3 HT
damage, or disease

Low added Moderate High added

No other risk factors Average risk Average risk
risk added risk risk

Low added Low added Moderate Hgh added Very high

1-2 risk factors
risk risk added risk risk added risk

3 risk factors, mets,

Moderate High added High added High added Very high
organ damage, or
added risk risk risk risk added risk
diabetes

Established CV or renal Very high Very high Very high Very high Very high
disease added risk added risk added risk added risk added risk

HT: hypertension; mets: metabolic syndrome; CV: cardiovascular

Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
 TO START DRUG TREATMENT DEPEND ON

THE LEVEL OF BLOOD PRESSURE AND OTHER

RISK FACTOR
 Initiation of Antihypertensive Treatment
Other risk
factor, OD, Normal High normal Grade I HT Grade II HT Grade III HT
or disease

Lifestyle changes for Lifestyle changes for

Lifestyle changes
No other risk No BP No BP several months than several weeks than
and immediate
factors intervention intervention drug treatment if BP drug treatment if BP
drug treatment
uncontrolled uncontrolled

Lifestyle changes for Lifestyle changes for

Lifestyle changes
1-2 risk several weeks than several weeks than
Lifestyle changes Lifestyle changes and immediate
factors drug treatment if BP drug treatment if BP
drug treatment
uncontrolled uncontrolled

3 risk Lifestyle changes

factors, MS, Lifestyle changes and consider
or OD drug treatment Lifestyle changes
Lifestyle changes and Lifestyle changes and
and immediate
drug treatment drug treatment
drug treatment
Lifestyle changes
Diabetes Lifestyle changes and drug
treatment

Established Lifestyle changes Lifestyle changes Lifestyle changes and Lifestyle changes and Lifestyle changes
CV or renal and immediate and immediate immediate immediate and immediate
disease drug treatment drug treatment drug treatment drug treatment drug treatment

HT: hypertension; MS: metabolic syndrome; CV: cardiovascular; OD: organ damage
Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
 ESH/ESC: Antihypertensive Treatment Preferred Drug

Compelling - ACE Aldo-

Diuretic ARB CCB
blocker inhibitor antagonist
indication

Heart failure

Post-MI

Angina
pectoris
Diabetes

Renal
dysfunction
Previous
stroke
Any blood pressure lowering agent
Mancia G, et al. 2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007;25:1105-1187
WHEN BLOOD PRESSURE IS 20 mm Hg

ABOVE SYSTOLIC GOAL OR 10 mm Hg ABOVE

DIASTOLIC GOAL, CONSIDERATION SHOULD BE

GIVEN TO INITIATE THERAPY WITH 2 DRUGS,

EITHER AS SEPARATE PRESCRIPTION OR IN

FIXED-DOSE COMBINATION

The JNC VII Report. JAMA 2003;289:2560-2572

Possible combinations of antihypertensive agents

Diuretics

-blockers ARBs

-blockers CCBs

ACE inhibitors

2007 ESH/ESC guidelines for the management of arterial hypertension

 Non Pharmacologic Treatment

Stopping smoking

Losing Excess Weight

Reducing Alcohol Intake

Eating less Salt

Low level exercise

 Total risk management

Lifestyle and risk factor goals

Healthy food choices
Be physically active
Achieve ideal weight
Reduce blood pressure to < 140/90 mmHg
Reduce total cholesterol to < 5.0 mmol/l (190 mg/dl)
Reduce LDL cholesterol to <3.0 mmol/l (115 mg/dl)
Achieve optimal glycaemic and blood pressure
control in patients with diabetes mellitus (HbA level
between 6.2 and 7.5%) and a blood pressure
<130/85 mmHg
 EKG PADA HIPERTENSI

LVH LBBB LAH

SINUS TAKHIKARDI, OVER-DRIVE, SINUS

BRADIKARDI

ISKEMIA, OLD MIOKARD INFARK

ATRIAL TAKHIKARDI, FLUTTER & FIBRILLASI

~10% Weight loss = ~30% Visceral
adipose tissue loss