KRISIS HIPERTENSI

Dr. Linda Armelia, SpPD-KGH

Bag. Penyakit Dalam
FK Univ YARSI
 TOPIK
• Hipertensi krisis
• Sesak nafas
 Kasus 1
• Seorang laki-laki, 52 tahun, datang ke IGD RS dengan keluhan sakit kepala
sekali sejak 3 jam yl disertai penglihatan kabur sejak 12 jam yl
• Riw: TD tinggi ada sejak 3 tahun yang lalu, tidak teratur minum obat dan
dislipidemia
• KU: CM lemah, TD 210/110 mmHg, nadi 90 x/menit, pernafasan 20 x/menit.
• EKG: LVH, tidak ada ST elevasi
• Lab: Hb 10 g%, ureum 70 mg/dL, kreatinin 2.3 mg/dL, K 3.2 mEq/L, Na 140
mEq/L, Cl 101 mEq/L

Pertanyaan:
• Apa diagnosis pada pasien ini?
• Apa terapi yang dapat diberikan untuk mengatasi keadaan ini?
• Berapa target TD yang kita harapkan?
 Kasus 2
• Seorang laki-laki, 45 tahun, datang dengan keluhan sesak nafas. Sesak
timbul saat pasien beristirahat, diikuti dengan batuk dan nyeri dada
kanan atas. Sesak saat beraktifitas tidak ada. Riwayat asma (-), merokok
(+) 1 bungkus per hari, riwayat DM disangkal
• PF: CM lemah, TD 140/90 mmHg, nadi 102 x/menit, RR 34 x/menit,
cepat dalam, suhu 380 C
• EKG: SR
• Lab: Hb 14 g%, leukosit 21.000/mm3, ureum 50 mg/dL, kreatinin 1.3
mg/dL, GDS 350 g/dl
Pertanyaan:
• Apa diagnosis pada pasien ini?
• Apa yang menyebabkan sesak nafasa pada pasien ini?
• Apa terapi yang dapat diberikan untuk mengatasi keadaan ini?
 Pendahuluan
• Hipertensi ↓31,7 % (2007)  25,8 % (2013)
RISKESDAS • Berdasarkan wawancara (apakah pernah didiagnosis
nakes, gejala dan minum obat):
2013 • Prevalensi hipertensi ↑ 7,6% (2007)  9,5% (2013)
• Stroke ↑ 8,3/1000 (2007)  12,1/1000 (2013)

Hipertensi • 1% dari populasi hipertensi

krisis dewasa

Hipertensi • > 50% penderita di ICU karena

emergensi pengobatan yang tidak adekuat
RISKESDAS 2013
Pergolini MS. Clinter 2009
Mark PE. Chest 2007
Faktor-faktor yang mengontrol Tekanan Darah
Definisi Hipertensi menurut JNC VII

Klasifikasi TD TDS (mmHg) TDD (mmHg)

Normal < 120 Dan < 80

Prehipertensi 120 – 139 Atau 80 – 89

Stage 1 140 – 159 Atau 90 - 99

Stage 2 >= 160 Atau >= 100

 Definisi hipertensi krisis

Peningkatan TD mendadak (>180/120

mmHg) yang disertai dengan:

Ada/tidaknya Memerlukan
Ada/tidaknya
kerusakan target penanggulangan
keluhan
organ segera
 Klasifikasi Hipertensi krisis

HIPERTENSI
URGENSI HIPERTENSI
TANPA GEJALA EMERGENSI B
TD >180/120 mmHg
Tanpa keluhan TD >220/140 mmHg
TOD akut tidak ada dg kel TOD
Mata  Funduskopi
DENGAN GEJALA
Neurologi
TD >180/120 mmHg
Kel sakit kepala hebat, Jantung
nafas pendek, KV stabil Ginjal
TOD akut tidak ada
Gastro intestinal
 Patofisiologi
Sudden increase in Systemic
Vascular Resistance
Mechanical Stress with endothelial
injury, increased permeability, Coag/Plt
activation, fibrin deposition

BP
1) Fibrinoid necrosis
2) Ischemia
3) Activation of RAA
4) Proinflammatory
cytokines
Vaughan and Delanty Lancet 2000; 356:411
 Etiologi yang mendasari

• Tidak jelas, kemungkinan dikarenakan:

– ACE DD genotype
– Tidak adanya subunit b dan g ENaC
– Peningkatan kadar adrenomedullin
– Peningkatan kadar natriuretic peptide
– Abnormalitas dari penanda stress oxidative dan
disfungsi endotel
Penyebab Hipertensi
Identifikasi Penyebab Hipertensi
 Kerusakan organ target
 Ensefalopati hipertensi
 Perdarahan intraserebral
 Stroke
 Trauma kepala
 Penyakit iskemia jantung
 Miokard infark akut
 Kegagalan ventrikel kiri dengan edema paru
 Angina pektoris tidak stabil
 Diseksi aorta
 Perdarahan arterial
 Eklampsia

Colgan R, Prim Care Clin, 2006

 Complications of Hypertension:
End-Organ Damage

Hypertension

Hemorrhage, LVH, CHD, CHF

Stroke

Peripheral
Vascular
Disease Renal Failure,
Retinopathy
Proteinuria
CHD = coronary heart disease
CHF = congestive heart failure
LVH = left ventricular hypertrophy Slide Source
Hypertension Online
Chobanian AV, et al. JAMA. 2003;289:2560-2572. www.hypertensiononline.org
 Diagnosis
• Lama menderita hipertensi
• Obat-obat yang dimakan
Anamnesis • Keluhan TOD
• Penyakit penyerta

• Pengukuran TD (kedua lengan)

Pemeriksaan • Perabaan arteri radialis dan
karotis
Fisik • TOD
 Pemeriksaan penunjang

Laboratorium Pemeriksaan lain

• Darah lengkap • EKG
• Elektrolit • Foto toraks
• Ureum, kreatinin • CT scan
• AGD
• Urinalisis
 Evaluasi di Triage
Blood Pressure Group I - High BP
> 180/110
Symptom Headache
Anxiety
Often asymptomatic
Exam No target organ damage
No clinical CVD
Therapy Observed 1-3 hour
Initiati/resume medication
Increases dosage of
inadequate agent
Plan Arrange follow up < 72 hour
If no prior evaluation,
schedulle appoitment
Group II - Urgency
> 180/110
Severe headache
Shortness of breath
Edema
Target organ damage
Clinical CVD present/stable
Observe 3-6 hour
Lower BP with short acting
oral agent
Arrange folloe up
evaluation <24 hour
Group III – Emergency
Usually > 220/140
Shortness of breath
Chest pain
Nocturia
Dysathria
Weakness
Altered convusioness
Encephalopathy
Pulmonary edema
Renal insufficiency
Cerebrovascular accident
Cardiac ischemic
Baseline lab
Intravenous line
Monitor BP
May initiate parenteral therapy
in emergency room
Immediate admission to ICU
Treat to initiate goal BP
Additional diagnostic studies
Vidt, DG. J of Clin Hyper. 2001
 Pengobatan
Tidak memerlukan penurunan
TD segera sampai normal Oral anti hipertensi bekerja
dalam waktu observasi (target cepat
MAP lk 25% dlm 24 jam)

HIPERTENSI
URGENSI

Oral anti hipertensi bekerja

Target tercapat dalam 3-7 hari
cepat
 Perhatian khusus

• Mulai OAH dg dosis kecil

• Jangan turunkan TD terlalu cepat pada orang dg risiko besar
tjd komplikasi hipotensi spt orang tua, penyakit pembuluh
darah perifer berat, kelainan arterosklerosis berat dan
intrakranial
• Target TD awal sampai 160/110 mmHg dlm bbrp jam – hari dg
terapi konvensional
• MAP jangan lebih dari 25% dlm 24 jam
 Pengobatan hipertensi urgensi dengan preparat oral

Obat Dosis Onset kerja Efek samping

Captopril 25 mg p.o, bila diperlukan 15-30 min/6-8 jam SL Hypotension, Gagal ginjal
bs diulangi scr SL 25 mg 15-30 min/2-6 jam karena tjd stenosis arteri
renalis
Clonidine 0.1-0.2 mg p.o, dapata 30-60 min/8-16 jam Hypotension, drowsiness,
diulangi dlm hitungan mulut kering
jam sampai dosis total
0.6 mg
Labetalol 200-400 mg p.o, ulangi 30 min – 2 jam/2-12 jam Bronchoconstriction,
tiap 2-3 jam heart block, orthostatic
hypotension
Prazosin 1-2 mg p.o, bila 1-2 jam/8-12 jam Syncope (first dose),
diperlukan dapat diulangi palpitation, tachycardia,
dalam hitungan jam orthostatic hypotension
• Bisa juga ditambahkan obat lain:
Obat Dosis Onset Efek samping
Amlodipin 2,5-5 mg 1-2 hr/12-18 hr Takikardi
Hipotensi
Nifedipin 5 mg SL 5-20 min/2-6 hr Takikardi
Hipotensi

Adaptec ets
InaSH
Hebert. C J Hypertensive Crises Prim Care 2008
 Pengobatan

HIPERTENSI EMERGENSI

Target:
Dirawat di ICU MAP 10% pada jam
pertama dan 15% 2-3 P↓ TD selanjutnya dlm
Obat anti hipertensi jam kmd 24 jam
parenteral
Minimalisir hipoperfusi
organ vital
 Pengobatan hipertensi emergensi

PARENTERAL VASODILATORS
Obat Dosis ONSET Efek Samping
Sodium 0.25-10 ug.kg/min as Immediate/2-3 min after Nausea, vomiting, prolonged use may cause
Nitroprusside IV infusion infusion thiocyanate intoxication,
methemoglobilinemia, acidosis, cyanide
poisoning, bags, bottles, delivery sets must
be lght resistant
Nitroglycerin 5-100 ug as iv infusion 2-5 min/5-10 min Headache, tachycardia, vomiting, flushing,
methemoglobulinemia, requires special
delivery system because of drug binding to
PVC tubung

Nicardipine 5-15 mg/hr as IV 1-5 min/15-30 min but may Tachycardia, nausea, vomiting, headache,
infusion exceed 12 hr after increased intracranial pressure, hypotension
may be protracted after prolonged infusion
prolonged infusion
Fenolam Mesylate 0.1-0.3 ug/kg/min as < 5 min/30 min Headache, tachycardia, flushing, local
IV infusion phlebitiss, dizzines

Hydralazine 5-20 mg as IV bolus or 10 min iv/>1 hr (IV); 20-30 Tachycardia, headache, vomiting,
10-40 mg IM; repeat min im/4-6 hr (IM) aggravation of angina pectoris, sodium and
water retension, increasedintracroanil
every 4-6 hr
pressure
 Sumber
• Hypertensive Urgency and Emergency, Hospital Physician, 2007
• Hypertensive crises challenges and management, Chest 2007
 Sesak nafas
• Keadaan tubuh yang tidak bisa bernafas dengan baik
• Penyebab:
– Saluran pernafasan
– Jantung
– Saluran pencernaan
– Anemia
– Gangguan metabolik
– Reaksi histeria
 Questions Your Doctor May Ask

• When you visit your doctor, she will take a careful history and do a
physical exam. Some of the questions she may ask include:
• When did you first experience shortness of breath and how did it first
begin?
• Do your symptoms occur at rest or only with activity? If you only feel
short of breath with activity, which activities seem to cause your
symptoms?
• Do you feel more winded when you are sitting up or lying down?
• Do you have any other symptoms, such as chest pain, a cough,
whezzing, fever, leg pain, unexplained weight loss or fatigue?
• Do you have a personal of family history of any heart or lung problems?
• Have you ever smoked? If so, for how long?
• Have you traveled recently by car or by plane?
 Causes of Unexplained Weight Loss
• There are many reasons for unexplained weight loss, some serious, and some more of a nuisance. In older adults
(over the age of 65) the most common cause is cancer, followed by gastrointestinal and psychiatric conditions. An
overview of some causes include:
• Endocrine conditions – Such as hyperthyroidism (overactive thyroid), hypothyroidism (underactive thyroid),
diabetes and Addison’s disease.
• Infections – Such as HIV/AIDS, tuberculosis, endocarditis (infection of the heart valves), and parasitic infections.
• Cancer – Weight loss may be the first signs of cancers such as lung cancer (especially adenocarcinoma of the lung),
colon cancer, ovarian cancer and pancreatic cancer.
• Intestinal problems – Such as peptic ulcer disease, celiac disease, Crohn's disease, ulcerative colitis, and
pancreatitis.
• Heart failure
• Kidney failure.
• Chronic obstructive pulmonary disease - (COPD) – Such as emphysema.
• Oral concerns – Such as gum disease, tooth decay, mouth sores, or braces.
• Smoking.
• Eating disorders – For example anorexia nervosa and bulimia.
• Poor nutrition – Due to poor food choices, or finances that limit the purchase of food (starvation).
• Psychological conditions - Such as depression and anxiety.
• Medications – Nearly any medication may have weight loss as a consideration. Medications may cause weight
loss directly, or cause nausea and loss of appetite leading to weight loss.
• Drug abuse – Not only street drugs such as methamphetamine, but prescription medications like Adderall and
over-the-counter drugs like laxatives may be abused.
• Neurological conditions – Such as Parkinson’s disease and Alzheimer's disease