3. 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
4. PROGNOSIS
• Angka kematian tinggi
• Tanpa terapi : 1 year survival
rate 10-20%
• Terapi adekuat : 5 year survival
rate 50-60%
Kaplan, clinical hypertension
6. 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
11. 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)
12. 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)
13. 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
14. 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)
15. 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
16. 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)
18. 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
19. 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
20. 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
21. Keadaan khusus
5. Krisis adrenergic
- Karena produksi katekolamin
- Terapi : Turunkan tekanan darah
10-15 % dl 1-2 jam
Obat : - Fentolamin
- Labetalol
22. 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
23. 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
24. 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
25. Keadaan khusus
9. Kehamilan
- Keluhan : - Sakit kepala
- Sesak nafas
- Oliguri
- Kejang
- Lab. Proteinuria
- Terapi : Terminasi kehamilan
Obat : - Nicardipin
- Labetalol
27. 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)
28. 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
29. TAKE HOME MESSAGE
Dokter pada pelayanan primer,
dapat memberikan anti hipertensi
oral yang bekerja cepat, dalam
menatalaksana hipertensi
sebelum merujuk ke RS rujukan
