Oleh Admin Kalbe Medical pada September 14, 2017 07:30

Target TD Optimal pada Pasien Risiko Tinggi Kejadian Kardiovaskular Tanpa Diabetes

Hipertensi merupakan penyakit yang sering dijumpai pada populasi dewasa, terutama pada individu berusia lebih dari 60 tahun. Di antara individu berusia ≥50 tahun, hipertensi sistolik terisolasi merupakan jenis tersering hipertensi yang dijumpai, dan tekanan darah sistolik (TDS) pada kasus ini menjadi lebih penting dibandingkan tekanan darah diastolik sebagai prediktor risiko independen untuk kejadian koroner, stroke, gagal jantung, dan end-stage renal disease (ESRD). Namun, target penurunan TDS tidak pasti. Menurut guideline JNC 8 yang banyak digunakan sebagai pedoman dalam tatalaksana hipertensi, target tekanan darah untuk populasi umum berusia ≥60 tahun adalah <150/90 mmHg, sedangkan untuk populasi umum berusia <60 tahun, menderita diabetes atau gagal ginjal kronik, adalah <140/90 mmHg.

Terdapat hipotesis yang dikemukakan oleh National Heart, Lung, and Blood Institute (NHLBI) expert panel pada tahun 2007 bahwa target TDS yang lebih rendah (<120 mmHg) dapat menurunkan kejadian klinis lebih dari target standar yang ditetapkan. Hipotesis ini merupakan usaha mencegah komplikasi terkait-hipertensi di antara pasien tanpa diabetes. Systolic blood pressure intervention trial (SPRINT) membandingkan manfaat terapi TDS ke target <120 mmHg dibandingkan terapi ke target <140 mmHg. Studi SPRINT melibatkan 9.361 subjek dengan TDS ≥130 mmHg dan peningkatan risiko kardiovaskular, namun tanpa diabetes. Secara acak subjek-subjek ini mendapat terapi intensif (target TDS <120 mmHg) atau terapi standar (target TDS <140 mmHg). Luaran komposir primer yang digunakan adalah infark miokard, sindrom koroner akut lainnya, stroke, gagal jantung, atau kematian karena kardiovaskular.

Pada pengamatan 1 tahun, rerata TDS pada kelompok terapi intensif sebesar 121,4 mmHg dan 136,2 mmHg pada kelompok terapi standar. Intervensi dihentikan dini setelah median follow-up selama 3,26 tahun karena penurunan luaran komposit primer signifikan pada kelompok terapi intensif dibandingkan pada kelompok terapi standar (1,65% per tahun vs. 2.19% per tahun; hazard ratio dengan terapi intensif 0,75; 95% confidence interval [CI], 0,64 s/d 0,89; P<0,001). Mortalitas semua penyebab juga lebih rendah secara signifikan pada kelompok terapi intensif (hazard ratio 0,73; 95% CI, 0,60 s/d 0,90; P = 0,003). Sedangkan angka kejadian tidak dinginkan serius seperti hipotensi, sinkop, abnormalitas elektrolit, dan cedera atau gagal ginjal akut, namun tidak termasuk kejadian jatuh-cedera, lebih tinggi pada kelompok terapi intensif dibandingkan pada kelompok terapi standar.

Kesimpulan dari studi SPRINT menemukan bahwa di antara pasien dengan risiko tinggi kejadian kardiovaskular namun tanpa diabetes, menargetkan TDS ke <120 mmHg, dibandingkan dengan <140 mmHg, menghasilkan angka yang lebih rendah untuk kejadian kardiovaskular mayor fatal ataupun non-fatal dan kematian karena semua penyebab, meskipun disertai dengan peningkatan signifikan kejadian efek yang tidak diinginkan pada kelompok terapi intensif. (JCH)


Image : Ilustrasi
Referensi:
1.Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A randomized trial og intensive versus standard blood-pressure control. N Engl J Med. 2015;373:2103-16.
2.James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: (JNC 8). JAMA. 2014;311(5):507-20.

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