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HIPERTENSI KRISIS

SYAIFUL AZMI
SUB BAGIAN GINJAL HIPERTENSI
BAG ILMU PENYAKIT DALAM
FDOK UNAND / RSUP DR M DJAMIL
PADANG

HIPERTENSI
KRISIS

PREVALENSI
HIPERTENSI KRISIS
1 % dari populasi hipertensi dewasa
Hipertensi Emergensi
- > 50% penderita di ICU
- karena terapi tak adekuat

Pergolini MS. Clinter 160/2/2009


Mark PE Chest 131/6/2007

PROGNOSIS
Angka kematian tinggi
Tanpa terapi : 1 year survival
rate 10-20%
Terapi adekuat : 5 year
survival rate 50-60%

Kaplan, clinical hypertension

DEFINISI
HIPERTENSI KRISIS
Peningkatan tekanan darah
mendadak (> 180/120 mmHg)
- T.O.D +/- KELUHAN +/- PENANGGULANGAN SEGERA

KLASIFIKASI
HIPERTENSI URGENSI
TANPA GEJALA
- Biasanya tekanan darah > 180/120 mmHg
- Tanpa keluhan (sakit kepala/cemas)
- TOD Akut tidak ada
DGN GEJALA
- Biasanya tekanan darah > 180/120 mmHg
- Keluhan sakit kepala hebat, nafas
pendek, kardiovaskuler stabil
- TOD akut tidak ada

KLASIFIKASI
Hipertensi Emergensi
- Biasanya tekanan darah >
220/140 mmHg
- Keluhan TOD : sesak, nyeri dada,
nokturia, disartria, gangguan
kesadaran

Table 2 : Algorithm for Triage Evaluation

Parameter

Severe Hypertension (Urgency)

Hypertensive Emergency

Asymptomatic

Symptomatic

Blood pressure
(mmHg)

> 180/110

> 180/110

Usually > 220/140

Symptoms

Headache, anxiety;
often asymtomatic

Severe headache,
shortness of breath

Examination

No target organ
damage, no clinical
cardiovascular
disease

Therapy

Observe 1-3 hr;


initiate, resume
medication; increase
dosage of inadequte
agent
Arrange follow-up
within 3-7 days; if no
prior evaluation,
schedule appointment

Target organ
damage; clinical
cardiovascular
disease present,
stable
Observe 3-6 hr;
lower BP with
shortacting oral
agent; adjust
current therapy
Arrange follow-up
evaluation in less
than 72 hr

Shortness of breath, chest pain,


nocturia, dysarthria, weakness,
altered consciousness
Encephalopathy,pulmonary
edema, renal insufficiency,
cerebrovascular accident, cardiac
ischemia

Plan

Baseline laboratory tests;


intravenous line; monitor BP, may
initiate parenteral therapy in
emergency room
Immediate admission to ICU; treat
to initial goal BP, additional
diagnostic studies

BP, Blood pressure; ICU, Intensive care unit


Sumber : Hebert e.j Prim Care 2008. 35 (3)

DIAGNOSIS
ANAMNESIS
- Lama menderita hipertensi
- Obat-obat yang dimakan
- Keluhan TOD
- Penyakit penyerta

DIAGNOSIS
PEMERIKSAAN FISIS
- Pengukuran tekanan darah
- Perabaan a. radialis, a. karotis
- TOD

Table 3 : Clinical Characteristics of the Hypertensive Emergency

Blood
Pressure
(mmHg)

Funduscopi
c Findings

Neurologic
Status

Cardiac
Findings

Renal
Symptoms

Gastrointestinal
Symptoms

Usually

Hemorrhage
s, exudates,
papiledema

Headache,
confusion,
somnolence,
stupor, visual
loss, seizures,
focal
neurologic
deficits, coma

Prominent
apical
pulsation,
cardiac
eniargement,
congestive
heart failure

Azotemia,
proteinuria,
oliguria

Nausea.
vomiting

>220/140

Sumber : Hebert e.j Prim Care 2008. 35 (3)

Table 4 : Clinical Manifestations of End-Organ Damage From Hypertensive


Emergency
Central nervous
system

Dizzness, NV, confusion, weakness, encephalopathy, ICH, SAH, ischemic


stroke

Eyes

Ocular hemorrhage, exudates, or papiledema on fundoscopic exam,


blurred vision, loss of sight

Heart

Angina, ACS, LVF, PE, aortic dissection, cardiogenic shock

Kidneys

Hematuria, proteinuria, pyelonephritis, elevated SCr and BUN, ARF

ACS; acute coronary syndrome; ARF: acute renal failure: BUN: blood urea nitrogen: ICH: intracranial
hemorrhage; LVF: left ventricular failure; NV: nausea and vomiting: PE: pulmonary edema: SAH:
subarachnoid hemorrhage; SCr, serum creatinine

Pergolini MS. The Management of hypertensive crises. Clin Ter 2009. 160 (2)

PENGOBATAN
Hipertensi Urgensi
- Tidak memerlukan penurunan
tekanan darah segera sp normal
dalam waktu observasi
- Oral anti hipertensi bekerja cepat
- Target tidak tercapai, tingkatkan
dosis
- Target tercapai dalam 3-7 hari

Table 5 : Management of Hypertensive Urgencies

AGENT

Captopril

DOSE

25 mg p.o., repeat as needed SL,


25 mg

ONSET/DURATION OF
ACTION
(AFTER
DISCONTINUATION)
15-30 min/6-8 h SL,
15-30 min/2-6 h

Clonidine

0.1-0.2 mg p.o., repeat hourly as


required to total dose of 0.6 mg

30-60 min/8-16 h

Labetalol

200-400 mg p.o repeat every 2-3 h

30 min-2 h/2-12 h

Amblodipi
n

2,5-5 mg

1-2 hr/12-18 hr

Nifedipin

5 mg sl

5-20 min/2-6 hr

PRECAUTIONS

Hypotension, renal
failure in bilateral renal
artery stenosis
Hypotension,
drowsiness, dry mouth
Bronchoconstriction,
heart block, orthostatic
hypotension
Tachycardia,
hypotension
Tachycardio,
hypotension

Adapted with permission from Vidt DG. Hypertensive crises: emergencies and urgencies. J Clin Hypertens (Greenwich).
2004;6:520-525

Sumber :

- Adaptec etc
- InaSH
- Hebert C.J Hypertensive Crises Prim Care 2008. 35 (3)

PENGOBATAN
Hipertensi Emergensi
- Dirawat di ICU
- Obat anti hipertensi parenteral
- Target : - Penurunan tekanan darah pd jam
pertama 20-25 %
- Minimalisir hipoperfusi organ vital
- Penurunan tekanan darah selanjutnya dl 24 jam

Table 6 : Treatment of Hypertensive Emergencies


Agent

Dosage

Onset/Duration of
Action (after
discontinuation)

Precautions

0.25-10 g/kg/min as
IV infusion

Immediate/2-3 min
after infusion

5-100 g as IV
infusion

2-5 min/5-10 min

Nausea, vomiting; prolonged use


may cause thiocyanate
intoxication,
methemoglobinemia, acidosis,
cyanide poisoning; bags, bottles,
delivery sets must be light
resistant
Headache, tachycardia, vomiting;

Nicardipine

5-15 mg/hr as IV
infusion

1-5 min/15-30 min,


but may exceed 12
hr after prolonged
infusion

Fenoldopam

0.1-0.3 g/kg/min as IV
infusinon

<5 min/30 min

5-20 mg as IV bolus or
10-40 mg IM; repeat
every 4-6 hr

10 min IV/> 1 hr (IV);


20-30 min IM/4-6 hr
(IM

Parenteral
Vasodilators

Sodium

Nitroprusside

Nitroglycerin

Mesylate
Hydralazine

flushing. Methemoglobinemia;
requires special delivery system
because of drug binding to PVC
tubing
Tachycardia, nausea, vomiting,
headache, increased intracranial
pressure; hypotension may be
protracted after prolonged
infusions
Headache, tachycardia, flushing,
local phlebitis, dizziness
Tachycardia, headache,
vomiting, aggravation of angina
pectoris, sodium and water
retension, increased intracranial
pressure
Sumber : Hebert e.j Prim Care 2008. 35 (3)

Keadaan khusus
1. Diseksi Aorta
- Robekan pd dinding aorta
- Klinis
: nyeri dada (Spt MCI)
: Sinkope
- Pemeriksaan : Echo, CT Scan, MRI
- Terapi : Target TDS 110-120 mmHg/dl
Waktu 10-20 menit
- Konsul bedah

Keadaan khusus
2.

Sindroma koroner akut


- Angina pektoris tak stabil, STEMI/Non STEMI
- Klinis : nyeri dada khas
- Pemeriksaan : EKG, CKMB, Troponin T
- Terapi :
- obat
: - Nitrogliserin
- Na Nitropruside
- C.C.B (Nicardipin)
- Target : 10-20% dl 1-3 jam pertama
: jaga TDD > 60 mmHg
- Obat : Penghilang rasa sakit
Membuka oklusi koroner

Keadaan khusus
3.

Edem Paru
- Klinis :

- Terapi :
- Obat :

- sesak nafas hebat, tiba-tiba


- ronkhi, bendungan
- gallop rythem

- Na Nitropruside
- Fenoldopam
- Obat-obat diuretik
- Target : TDS turun 30 mmHg dl beberapa
menit
: 130/80 mmHg dl 3 jam

Keadaan khusus
4. AKI/CKD
- Biasanya hipertensi sekunder (oklusi a.
renalis)
- Klinis :
Usia muda
Refrakter
RPK tidak ada
- Pemeriksaan : bising a renalis
- Terapi :
Turunkan tekanan darah
20 - 25% dl 1-3 jam
Obat : Na nitropruside
Labetalol

Keadaan khusus
5. Krisis adrenergic
- Karena produksi katekolamin
- Terapi : Turunkan tekanan
darah
10-15 % dl 1-2 jam
Obat : - Fentolamin
- Labetalol

Keadaan khusus
6. Hipertensi Ensefalopati
- Perfusi ke serebral edem serebral
progresif
- Klinis :
kesadaran
Perdarahan retina
Papil edem
Defisit neurologi
- Terapi : tekanan darah 20-25% jam pertama
Obat : Na Nitropruside
Labetalol

Keadaan khusus
7. Stroke Iskemi
- Penurunan tekanan darah masih
kontroversi
- tekanan darah tiba-tiba iskemi
cerebri bertambah
- tekanan darah bila awal > 220/120
mmHg, tdk lebih 10% pd jam I, 20%
pada 6-12 jam berikut
- Obat
:
- Na Nitropruside
- Nicardipin

Keadaan khusus
8. Perdarahan serebral
- Biasanya tekanan darah > 240/120 mmHg
- Klinis :
- penurunan kesadaran
- ngorok
- tanda-tanda defisit neurologi
- Terapi :
- tek darah 20-25 % jam
pertama
- 160/90 mmHg dl 24 jam
- Obat :
Na Nitropruside
Nicardipin
CCB

Keadaan khusus
9. Kehamilan
- Keluhan :
- Sakit kepala
- Sesak nafas
- Oliguri
- Kejang
- Lab. Proteinuria
- Terapi : Terminasi kehamilan
Obat :
- Nicardipin
- Labetalol

Keadaan khusus
10.Pengguna NAPZA
- Obat kokain, amfetamin,
metametamin phencyclidine
- Obat pilihan CCB

Table 7 : Preferred Drugs for Select Hypertensive Emergencies

Emergency

Drugs of choice

Target Blood Pressure

Aortic dissection

Nitroprusside + esmolol

110-120 SBP as soon as possible

AMI, ischemia

Nitroglycerin, nitroprusside, nicardipine

Secondary to ischemia relief

Pulmonary edema

Nitroprusside, nitroglycerin, labetalol

Improve symptoms 10%-15% in 1-2 hr

Renal emergencies

Fenoldopam, nitroprusside, labetalol

Target BP 20%-25% in 2-3 hr

Catecholamine excess

Phentolamine, labetalol

Control paroxysms, 10 %-15% in 1-2 hr

Hypertensive encphalopathy

Nitroprusside

20%-25% in 2-3 hr

Subarachnoid hemorrhage

Nitroprusside, nimodipine, nicardipine

20%-25% in 2-3 hr

Ischemic stroke

Nitroprusside (controversial),
nicardipine

0%-20% in 6-12 hr

AMI, acute mycardial infarction; SBP, systolic bood pressure

Sumber : Hebert e.j Prim Care 2008. 35 (3)

KESIMPULAN
1. Hipert. Krisis
: tek darah mendadak
dgn atau tanpa TOD
2. Hipert. Urgensi :
- berobat jalan
- oral anti hipertensi
3. Hipert. Emergensi : - rawat di ICU
- obat anti hipertensi
parenteral

TAKE HOME MESSAGE


Dokter pada pelayanan primer,
dapat memberikan anti hipertensi
oral yang bekerja cepat, dalam
menatalaksana hipertensi
sebelum merujuk ke RS rujukan

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