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
PROGNOSIS
Angka kematian tinggi
Tanpa terapi : 1 year survival
rate 10-20%
Terapi adekuat : 5 year
survival rate 50-60%
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
Parameter
Hypertensive Emergency
Asymptomatic
Symptomatic
Blood pressure
(mmHg)
> 180/110
> 180/110
Symptoms
Headache, anxiety;
often asymtomatic
Severe headache,
shortness of breath
Examination
No target organ
damage, no clinical
cardiovascular
disease
Therapy
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
Plan
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
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
Eyes
Heart
Kidneys
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
AGENT
Captopril
DOSE
ONSET/DURATION OF
ACTION
(AFTER
DISCONTINUATION)
15-30 min/6-8 h SL,
15-30 min/2-6 h
Clonidine
30-60 min/8-16 h
Labetalol
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
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
Nicardipine
5-15 mg/hr as IV
infusion
Fenoldopam
0.1-0.3 g/kg/min as IV
infusinon
5-20 mg as IV bolus or
10-40 mg IM; repeat
every 4-6 hr
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.
Keadaan khusus
3.
Edem Paru
- Klinis :
- Terapi :
- Obat :
- 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
Emergency
Drugs of choice
Aortic dissection
Nitroprusside + esmolol
AMI, ischemia
Pulmonary edema
Renal emergencies
Catecholamine excess
Phentolamine, labetalol
Hypertensive encphalopathy
Nitroprusside
20%-25% in 2-3 hr
Subarachnoid hemorrhage
20%-25% in 2-3 hr
Ischemic stroke
Nitroprusside (controversial),
nicardipine
0%-20% in 6-12 hr
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
31