Power point' medis

2. Epidemiology

3. INTRODUCTION
• Hypert ens ion remains the leading cause of death
globally —> 10,4 million deaths/ year
• 1,39 billions of people had hypert ens ion in 2010
• BP trends show a clear shift of the highest BPs from High
income to Low income regions

4. 1:100.000 adult Population

5. Criteria for Hypertension Based on Office-, Ambulatory
(ABPM)-, and Home Blood Pressure (HBPM)
Measurement

6. ISH 2020 Classification of
Hypertension

7. ESC 2018 Classification of
Hypertension

8. BP (Blood Pressure) = CO (Cardiac Output) x TPR (Total Peripheral
Resistance)
Blood Pressure
Regulation
CO = SV (Stroke Volume) x HR (Heart
Rate)

9. Definitions
Hypertensive
Urgency
• Systolic BP >180
or Diastolic BP
>120 in the
absence of end-
organ damage
Hypertensive
Emergency
• SBP >180 OR
DBP>120 in the
presence of
end-organ
damage

10. Hypertensive Emergencies
Definition
The situations in which severe
hypertension (grade 3) is associated with
acute hypertension-mediated organ
damage (HMOD) which is often life-
threatening and requires immediate but
careful intervention to lower BP, usually
with intravenous (i.v.) therapy.

11. HT Eemergensi
1. Hipertensi maligna: hipertensi berat
(umumnya
derajat 3) dengan : perdarahan retina dan
atau papiledema), ensefalopati (terjadi
pada sekitar
15% kasus), gagal jantung akut, penurunan
fungsi
ginjal akut.
2. Hipertensi berat dengan kondisi klinis lain,
dan
memerlukan penurunan tekanan darah
segera,
seperti diseksi aorta akut, iskemi miokard
akut atau gagal jantung akut.
3. Hipertensi berat mendadak akibat
feokromositoma, berakibat kerusakan
organ.
4. Ibu hamil dengan hipertensi berat atau
preeklampsia.

12. Diagnostic workup for
patients with a
suspected hypertension
emergency

13. Pathophysiology
of the
Hypertensive
Crisis
1. Ault NJ, et al. Am J Emerg
Med. 1985;3(6 suppl):10-15. 2.
Wallach R, et al. Am J Cardiol.
1980;46:559-565.
3. Varon J, et al. Chest.
2000;118:214-227. 4. Kincaid-
Smith P. J Hyertens. 1991;9:893-
899.

14. End-Organ Damage
Characterizes Hypertensive
Emergencies
Brain
Hypertensive
encephalopathy
Stroke
Retina
Hemorrhages
Exudates
Papilledema
Cardiovascular
System
Unstable angina
Acute heart failure
Acute myocardial
infarction
Acute aortic dissection
Dissecting aortic
aneurysm
Kidney
Hematuria
Proteinuria
Decreasing renal
function
Adapted from Varon J, Marik PE. Chest. 2000;118:214-227.

15. Hypertensive Emergency : Goals of
Therapy
 Immediate and controlled BP reduction1
 BP ↓ 25% within minutes to 1 hour
 If BP is then stable, target toward 160/100-110
mm Hg over the next 2-6 hours
 If this level of BP is well tolerated and the
patient is clinically stable, further gradual
reductions toward normal BP can be targeted
over the next 24-48 hours
1. The 7th Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. US Dept of HHS; NIH publication No. 03-5233;
2003:54.
2. Adams HP, et al. Stroke. 2005;36:916-923.
Don’t just “treat the number” !!!

16. .
All patients should be provided with
a quiet room BP↓ ≥ 10-20%
mmHg
Tilt the head of the bed 15 degrees up
 decrease BP
If BP remains above 180/100 mmHg
for ≥ 3 hours  antihypertensives
Optional treatment depend on 
previous diagnosis and treated HT
Post observation, & ~ 20-30 mmHg
reduction in BP a longer acting
agent in accordance with treatment
of essential HT.

17. Previously Treated Hypertension
• Restart/resume medications in non-adherent patients
• Increase the dose of current antihypertensive medications
• Add another antihypertensive agent from another class
Untreated Hypertension (Choice treatment depends on
patient and setting (e.g. ER vs doctor’s office)
• Temporary use of fast acting oral antihypertensive (e.g. clonidine,
labetalol, captopril)  gradually BP over several hours, depending on
the condition of the patient
• BP ↓ over 24-48 hours with longer acting agent (e.g. ramipril 10 m,
metoprolol SR (or XL) 100 m, or nifedipine XL 30 mg) is usually
preferred over temporary use of short-acting agents
Adjust & Optimize Hypertensive
Regimen !

18. the follow-up & monitoring
parameters
 Observation for a few hours  confirm stable/improving &
symptomatic condition
 Once stabe, the pts can be sent home with close follow-up
(every 1-2 days) involving :
 Evaluation for signs of hypertension or hypotension
 Attainment of BP with help of antihypertensive and
lifestyles interventions (e.g. low salt diet, increased
physical activity)
 Assessment of medication adherence (consider
simplified dosing schedules, & adherence aides, if
appropriate)
 Pts adherence to follow up  if there is high risk of
cerebrovascular or cardiovascular disease, hospital
admission may be warranted for initial management.

19. Not to Use Sublingual
Nifedipine
 Drug is poorly soluble, not absorbed through buccal mucose
 Sudden uncontrolled and severe reductions in BP, may
precipitate cerebral, renal, and myocardial ischemic events
 Lack of clinical documentation attesting to benefit from it use
 The Cardiorenal Advisory Committee of the FDA has
concluded “that the practice of administering SL/ oral
nifedipine should be abandoned because this agent is not
safe nor efficacious”.
Anaesth Clin North Am. 1999

20. Hypertensive Emergency :
Goals of Therapy
 Goal : Lower Diastolic BP to approximately
100-105 over 2-6 hours; max initial fall not to
exceed 20 – 25%
○ More aggressive decrease can lead to ischemic stroke
and myocardial ischemia
 If focal neurological sx present obtain MRI to
r/o acute stroke (rapid BP correction
contraindicated)
 Parenteral antihypertensives (IV Drip)
recommended over oral agents in hypertensive
emergency

21. What the guideline says?

26. Oral Drug Choice often Based
on Comorbid Condition
Heart failure
• TH, BB, ACEI, ARB, ALDO
Post MI
• BB, ACEI, ARB, ALDO
High CVD Risk
• TH, BB, ACEI, CCB
Diabetes
• TH, BB, ACEI, ARB, CCB
Chronic Renal Failure
• ACEI, ARB
Recurrent stroke prevention
• TH, ACEI KEY: ACEI, angiotensin converting enzyme inhibitor; ALDO, aldosterone antagonist; ARB, angiotensin
receptor blocker; BB, b blocker; CCB, calcium channel blocker; TH, thiazide.

27. Parenteral Medication Used to
Manage Hypertensive
Emergencies
Drug Dosage Onset/
duration
Indications Side Effects
Nitroprusside
sodium
Infusion : 0.25-1.0
mcg/kg/mnt
Immediate/ 3-
5 min
Most emergencies Nausea, vomiting,
sweating,
thiocyanate and
cyanide poisoning
Nitroglycerin Infusion : 5-200
mcg/kg/min
Immediate/ 3-
5 min
Myocardial ischemia,
myocardial infarction,
LV failure
Headache,
methemoglobinemi
a, tolerance with
prolonged infusion
Labetalol Bolus : 20 mg/ 5
min until desire
effect (max 80 mg)
Infusion : 1-2 mg/
min
5-10 min/ 1-8
h
Most emergencies
except those
complicated by LV
failure
Heart block,
orthostatic
hypotension
Nicardipine Infusion : 5-10
mg/h
5-10 min/ 1-4
h
Most emergencies
except those
complicated by LV
failure
Reflex tachycardia,
headache, nausea,
flushing

29. ESC 2018

30. Nitroglycerin (NTG)
 Venodilator, arterial-dilator (at high dose).
 Decreasing preload and afterload.
 Preferred for patients with acute heart
failure, ACS, myocardial ischemia.
 Fast response, safe, well tolerated.
 Onset : 1-2 min, duration 3-5 min.

31. Doses
 Dose: Starting dose; 5 mcg/min, increase
until target BP attained every 5 minutes, no
maximum dose (>200 mcg/min 
hypotensive effect).
 Syringe pump use, recommended.

32. Mechanism of
Nitrates
Effects of nitrates in generating
NO and stimulating guanylate
cyclase to cause a vasodilation
Opie LH & Horowitz JD. Nitrates and
newer antianginals. In: Drugs for the
Heart. 7th ed. Saunders Elsevier.

33. Actions of
Nitrates on
Circulation
The major effect is on
the venous
capacitance vessels,
with additional
coronary and
peripheral arteriolar
vasodilatory benefit
Opie LH & Horowitz JD. Nitrates and newer
antianginals. In: Drugs for the Heart. 7th ed.
Saunders Elsevier. China

34. Nitroglycerin vs isosorbid
dinitrate
Nitroglycerin Isosorbide Dinitrat
Type of Nitrates Trinitrates (glyceryl
trinitrates)
Dinitrates
Onset Fast: 1-2 minutes Delayed due to
bioconversion to
mononitrate in liver
Duration 3-5 minutes 20 min
Half life 1-4 min 10 mins

35. Thomas Münzel et al. Circulation. 2011;123:2

36. Perioperative hypertension
Varon J, Malik PE. Vascular Health and Risk Management 2008:4(3) 615–627

37. Perioperative nitroglycerin
ISDN was successful in treating hypertension in 63% of the events, whereas NTG had an
83% success. NTG has been found to be effective in controlling hypertension

38. Low-dose NTG significantly reduces cardiac filling
pressures and improves microvascular perfusion in
patients admitted for acute heart failure

39. IV Nitroglycerin is highly effective in preventing
adverse ischemic events (reccurent or refractory
angina) in patients with unstable angina secondary to
restenosis

40. European Heart Journal (2020) 00, 179
Intravenous nitrates are
recommended in patients
with ongoing ischemic
symptoms & without
contraindications
Intravenous nitrates are
recommended in patients
with uncontrolled
hypertension or signs of
heart failure

41. J Am Coll Cardiol 2013;61:xxx–xxx, doi:10.1016/j.jacc.2012.11.019

42. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, Circulation. 2013;127:e362-e425

43. European Heart Journal (2016) 37, 2129–2200

44. 2013 ACCF/AHA Guideline for the Management of Heart Failure, Circulation.

45. Take Home Messages
1. Hypertensive emergency should be treated
promptly, and target BP reduction is determined
from type of acute organ damages.
2. Main goal of treatment is optimal BP reduction
without compromising perfusion to vital organs
3. IV continuous vasodilators such as
Nitroglycerine which is titratable, short acting and
safe are recommended therapy for initial
treatment with close monitoring.
4. Don’t treat the number