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1. Kuliah Blok Kardiologi
Krisis Hipertensi
Hebat &
Smart
Humanistic Excellence
Beneficient Accountable
Transparan Digitalisasi
Modern dan Terintegrasi
FakultasKedokteran
UniversitasHasanuddin
Program Pendidikan S1 Kedokteran
Fakultas Kedokteran Universitas Hasanuddin

2. DAFTAR KOMPETENSI

3. DAFTAR KOMPETENSI

4. DAFTAR KOMPETENSI

5. DAFTAR KOMPETENSI

6. Faculty
of
Medicine
Universitas
Hasanuddin
Sasaran Pembelajaran

7. Krisis Hipertensi (Kompetensi 3B)
• Mampu mengaplikasikan pengetahuan dasar patomekanisme dalam menjelaskan
timbulnya tanda dan gejala pada kasus krisis hipertensi
• Mampu mengidentifikasi faktor resiko yang berhubungan dengan kasus krisis hipertensi
• Mampu menentukan pemeriksaan penunjang yang relevant untuk menunjang diagnosis
• Mampu menentukan diagnosis dan diagnosis banding berdasarkan analisis anamnesis,
pemeriksaan fisis dan pemeriksaan penunjang
• Mampu menentukan penatalaksanaan awal dan definitif pada kasus krisis hipertensi
• Mampu menjelaskan komplikasi krisis hipertensi
• Mampu menjelaskan pencegahan krisis hipertensi
• Mampu memberikan konseling, informasi dan edukasi (KIE) terkait penyakit dan
penatalaksanaannya

10. –HIPERTENSI KRISIS

11. 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

12. PROGNOSIS
• Angka kematian tinggi
• Tanpa terapi : 1 year survival rate
10-20%
• Terapi adekuat : 5 year survival rate
50-60%
Kaplan, clinical hypertension

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

14. 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

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

16. 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
Shortness of breath, chest pain,
nocturia, dysarthria, weakness,
altered consciousness
Examination No target organ
damage, no clinical
cardiovascular
disease
Target organ
damage; clinical
cardiovascular
disease present,
stable
Encephalopathy,pulmonary
edema, renal insufficiency,
cerebrovascular accident, cardiac
ischemia
Therapy Observe 1-3 hr;
initiate, resume
medication; increase
dosage of inadequte
agent
Observe 3-6 hr;
lower BP with
shortacting oral
agent; adjust
current therapy
Baseline laboratory tests;
intravenous line; monitor BP, may
initiate parenteral therapy in
emergency room
Plan Arrange follow-up
within 3-7 days; if no
prior evaluation,
schedule appointment
Arrange follow-up
evaluation in less
than 72 hr
Immediate admission to ICU;
treat to initial goal BP, additional
diagnostic studies
BP, Blood pressure; ICU, Intensive care unit
Sumber : Hebert e.j Prim

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

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

19. Table 3 : Clinical Characteristics of the Hypertensive Emergency
Blood
Pressure
(mmHg)
Funduscopi
c Findings
Neurologic
Status
Cardiac
Findings
Renal
Symptoms
Gastrointestinal
Symptoms
Usually
>220/140
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
Sumber : Hebert e.j Prim Care
2008. 35 (3)

20. 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)

21. 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

22. Table 5 : Management of Hypertensive Urgencies
AGENT DOSE
ONSET/DURATION OF
ACTION
(AFTER
DISCONTINUATION)
PRECAUTIONS
Captopril 25 mg p.o., repeat as needed SL,
25 mg
15-30 min/6-8 h SL,
15-30 min/2-6 h
Hypotension, renal
failure in bilateral renal
artery stenosis
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 Hypotension,
drowsiness, dry mouth
Labetalol 200-400 mg p.o repeat every 2-3 h 30 min-2 h/2-12 h Bronchoconstriction,
heart block, orthostatic
hypotension
Amblodipi
n
2,5-5 mg 1-2 hr/12-18 hr Tachycardia,
hypotension
Nifedipin 5 mg sl 5-20 min/2-6 hr 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)

23. 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

24. Table 6 : Treatment of Hypertensive Emergencies
Agent
Parenteral
Vasodilators
Dosage Onset/Duration of
Action (after
discontinuation)
Precautions
Sodium
Nitroprusside
0.25-10 g/kg/min as
IV infusion
Immediate/2-3 min
after infusion
Nausea, vomiting; prolonged use
may cause thiocyanate
intoxication,
methemoglobinemia, acidosis,
cyanide poisoning; bags, bottles,
delivery sets must be light
resistant
Nitroglycerin 5-100 g as IV
infusion
2-5 min/5-10 min Headache, tachycardia,
vomiting; flushing.
Methemoglobinemia; requires
special delivery system because
of drug binding to PVC tubing
Nicardipine 5-15 mg/hr as IV
infusion
1-5 min/15-30 min,
but may exceed 12
hr after prolonged
infusion
Tachycardia, nausea, vomiting,
headache, increased intracranial
pressure; hypotension may be
protracted after prolonged
infusions
Fenoldopam
Mesylate
0.1-0.3 g/kg/min as IV
infusinon
<5 min/30 min Headache, tachycardia, flushing,
local phlebitis, dizziness
Hydralazine 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
Tachycardia, headache,
vomiting, aggravation of angina
pectoris, sodium and water
retension, increased intracranial
pressure
Sumber : Hebert e.j
Prim Care 2008. 35 (3)

25. 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

26. 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

27. Keadaan khusus
3. Edem Paru
- Klinis : - sesak nafas hebat, tiba-tiba
- ronkhi, bendungan
- gallop rythem
- Terapi :
- Obat : - Na Nitropruside
- Fenoldopam
- Obat-obat diuretik
- Target : TDS turun 30 mmHg dl beberapa menit
: 130/80 mmHg dl 3 jam

28. 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

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

30. 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

31. 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

32. 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

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

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

35. Table 7 : Preferred Drugs for Select Hypertensive Emergencies
Emergency Drugs of choice Target Blood Pressure
Aortic dissection
AMI, ischemia
Pulmonary edema
Renal emergencies
Catecholamine excess
Hypertensive encphalopathy
Subarachnoid hemorrhage
Ischemic stroke
Nitroprusside + esmolol
Nitroglycerin, nitroprusside, nicardipine
Nitroprusside, nitroglycerin, labetalol
Fenoldopam, nitroprusside, labetalol
Phentolamine, labetalol
Nitroprusside
Nitroprusside, nimodipine, nicardipine
Nitroprusside (controversial), nicardipine
110-120 SBP as soon as possible
Secondary to ischemia relief
Improve symptoms 10%-15% in 1-2 hr
Target BP 20%-25% in 2-3 hr
Control paroxysms, 10 %-15% in 1-2 hr
20%-25% in 2-3 hr
20%-25% in 2-3 hr
0%-20% in 6-12 hr
AMI, acute mycardial infarction; SBP, systolic bood pressure
Sumber : Hebert e.j Prim
Care 2008. 35 (3)

36. 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

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