This document discusses guidelines for managing hypertension in patients with stroke. It defines hypertension and classifies it based on stages and etiology. For patients with acute stroke, the guidelines recommend controlling blood pressure within certain ranges to balance risks of further stroke, rebleeding, and maintaining cerebral perfusion. For ischemic stroke patients, blood pressure should be lowered if significantly elevated. For intracerebral hemorrhage, blood pressure needs to be carefully controlled to reduce risks. For subarachnoid hemorrhage from aneurysm, blood pressure control can help prevent rebleeding until the aneurysm is treated. Choice of antihypertensive medications should consider the patient's condition and comorbidities.

1. TATALAKSANA HIPERTENSI
PADA PASIEN STROKE

2. DEFINISI
Hipertensi adalah bila TDS ≥140
mmHg dan/atau TDD ≥90
mmHg pada pengukuran di
klinik atau fasilitas layanan
kesehatan.1
Hypertension is defined as a
systolic blood pressure (SBP) of
140 mm Hg or more, or a
diastolic blood pressure (DBP) of
90 mm Hg or more, or taking
antihypertensive medication.2
1Kosasih adrianus et al. consensus penatalksanaan hipertensi 2019. perhimpunan dokter hipertensi Indonesia
2Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. Hypertension. 2003 Dec. 42(6):1206-52.

3. DEFINISI
JNC VII 2003. ESH-ESC 2013. NICE 2011
Tekanan darah sistol ≥ 140 mmHg ATAU
Tekanan darah diastol ≥ 90 mmHg
Umur > 18 tahun
Tidak menggunakan obat anti hipertensi

4. TEKANAN DARAH
Lily S. L. 2016. “Hypertension”. Pathophysiology of heart disease 6th

5. Pengaturan
tekanan darah
secara ringkas
dapat
dikelompokka
n menjadi 2
yakni jangka
Panjang dan
pendek.
REGULASI TEKANAN DARAH

6. DEFINISI
ESC/ESH, 2013

7. KLASIFIKASI ETIOLOGI
PRIMER
(80-95%)
IDIOPATI
K
GENETIK
SEKUNDER
(5-20%)
PENYAKIT DASAR YANG
JELAS
Onset usia muda (< 30 tahun)
Onset usia sangat tua (> 70 tahun)
TD tiba-tiba sangat tinggi (TDS > 180, TDD >110
HT sulit untuk dikendalikan dengan terapi
Kaplan’s Clinical Hypertension, 2006

8. KLASIFIKASI STADIUM
JNC VII 2003, ASH-ISH 2013 WHO 2003, ESC-ESH, 2013

9. NICE 2011
Klasifikasi Stadium

10. CLASSIFICATION
1Chopra HK et al: Recent Guidelines for Hypertension. Circulation Research. 2019;124:984–986 At https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.119.314789

11. OTHER TERMINOLOGY
Terminology
Resistant
hypertension:
blood pressure above goal despite adherence to a combination of at least
3 optimally dosed antihypertensive medications with different
mechanisms of action.1
Refractory
hypertension:
blood pressure above goal despite adherence to a combination of at least
5 optimally dosed antihypertensive medications with different
mechanisms of action including spironolactone.1
Hypertensive urgency a subset of hypertensive crises, are characterized by acute, severe
elevations in blood pressure, often greater than 180/110 mm Hg (typically
with systolic blood pressure [SBP] greater than 200 mm Hg and/or
diastolic blood pressure [DBP] greater than 120 mm Hg) but are not
associated with target-organ dysfunction.2
Hypertensive
emergency
a subset of hypertensive crises, are characterized by acute, severe
elevations in blood pressure, often greater than 180/110 mm Hg (typically
with systolic blood pressure [SBP] greater than 200 mm Hg and/or
diastolic blood pressure [DBP] greater than 120 mm Hg) associated with
the presence or impendence of target-organ dysfunction2
1. Scott at al. Hypertension Emergencies. CCSAP
2Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. Hypertension. 2003 Dec. 42(6):1206-52.

12. OTHER TERMINOLOGY
Terminology
White coat
hypertension:
refers to the untreated condition in which BP is elevated in the office, but
is normal when measured by ABPM, HBPM, or both.2
Masked hypertension refers to untreated patients in whom BP is normal in the office but is
elevated when measured by HBPM or ABPM2
Pseudo-resistant
hypertension
Individuals with elevated office BPs due to white-coat hypertension,
improper BP measurement or medication nonadherence do not have true
resistant hypertension but have so-called2
Pre-existing
hypertension
(hipertensi kronik)
Onset dimulai sebelum kehamilan atau sebelum minggu ke-20 kehamilan,
dan biasanya menetap selama lebih dari 6 minggu pasca persalinan dan
dapat disertai proteinuria.1
Hipertensi gestasional Terjadi setelah minggu ke-20 kehamilan dan biasanya membaik dalam 6
minggu pasca persalinan.1
Hipertensi kronik plus
superimposed
Ahipertensi gestasional dengan proteinuria1
1Kosasih adrianus et al. consensus penatalksanaan hipertensi 2019. perhimpunan dokter hipertensi Indonesia
2Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. Hypertension. 2003 Dec. 42(6):1206-52.

13. TERMINOLOGY
Dubenbostel et al. Refractory Hypertension: A novel phenotype of antihypertensive treatment failure. Hypertension.2016 jun;67(6):1085-92

14. DEFINISI STROKE
Gejala defisit neurologis akut baik fokal atau global yang mendadak
Berkurangnya atau hilangnya aliran darah pada parenkim otak,
retina, atau medulla spinalis
Disebabkan penyumbatan atau pecahnya arteri atau vena (vaskular)
yang dibuktikan dengan imaging dan/atau patologi

15. KLASIFIKASI (MODIFIKASI
MARSHALL)
Patologi Anatomi dan
Penyebab
•Stroke Iskemik (85%)
•Transient Ischemic
Attack
•Cerebral Thrombosis
•Cerebral Emboli
•Stroke Hemorragik (15%)
•Pendarahan
Intraserebral (ICH)
•Pendarahan
Subarakhnoid (SAH)
Stadium
•Transient Ischemic
Attack
•Stroke-in-evolution
•Completed Stroke
Sistem Pembuluh Darah
•Sistem Karotis
•Sistem Vertebro-basilar

16. ETIOLOGI DAN PATOGENESIS
STROKE
Etiologi:
 Global: Pendarahan sistemik yang masif, AF berat, syok ireversible karena
henti jantung
 Fokal:
 Hemoragik
 Hipertensi Arterial
 AMV
 Sumbatan lumen pembuluh darah
 Trombus
 Emboli
 Peningkatan viskositas darah
TIA (<24 jam)  RIND (24-48 jam)  Partial + Non-progressive Stroke 
Progressing Stroke (Stroke in evolution)  Completed Stroke

17. TATALAKSANA HIPERTENSI PADA
PASIEN STROKE BERDASARKAN
GUIDELINE AHA/ASA

18. STROKE ISKEMIK

19. PATOGENESIS STROKE ISKEMIK
Indikator Ischemic-
Core
Penumbra Luxury
Perfusion
Morfologi Sangat pucat Pucat Kemerahan
dan Edema
CBF Paling
rendah
Rendah Sangat tinggi
PO2 Rendah Rendah Tinggi
PCO2 Tinggi Tinggi
Asam Laktat Tinggi Meningkat
Neuron Degenerasi Functional
Paralysis
• Therapeutic Window  Reversibilitas
neuron penumbra
• Tx : Resusitasi
• Iskemia berkepanjangan  Apoptosis

20. 3.2. BLOODPRESSURE

24. MANAGEMEN STROKE
KEDARURATAN MEDIK STROKE AKUT:
TEKANAN DARAH (HIPOTENSI)
Hipotensi arterial berhubungan dengan buruknya keluaran
neurologis, terutama bila TDS < 100mmHg dan TDD <70mmHg 
Harus dicari etiologi dan diatasi
Vasopresor (Fenileprin, dopamin, dan norepinefrin)
Diawali dengan dosis kecil dan dipertahankan pada TDS 140 mmHg
pada kondisi akut stroke

25. MECHANICAL THROMBECTOMY

26. IN-HOSPITAL MANAGEMENT OF AIS: GENERAL
SUPPORTIVE CARE

27. 4.4. Blood Pressure

28. INTRACEREBRAL
HEMORRHAGE

30. SUBARACHNOID
HEMORRHAGE

31. RISK FACTORS FOR AND PREVENTION OF ASAH RECOMMENDATIONS
31
Treatment of high blood pressure with antihypertensive medication is recommended
to prevent ischemic stroke, intracerebral hemorrhage, and cardiac, renal, and other
end-organ injury (Class I; Level of Evidence A).
Hypertension should be treated, and such treatment may reduce the risk of aSAH
(Class I; Level of Evidence B).

32. MEDICAL MEASURES TO PREVENT REBLEEDING AFTER ASAH
32
Between the time of aSAH symptom onset and aneurysm
obliteration, blood pressure should be controlled with a titratable
agent to balance the risk of stroke, hypertension-related
rebleeding, and maintenance of cerebral perfusion pressure
(Class I; Level of Evidence B). (New recommendation)
The magnitude of blood pressure control to reduce the risk of
rebleeding has not been established, but a decrease in systolic
blood pressure to <160 mm Hg is reasonable (Class IIa; Level of
Evidence C). (New recommendation)
Acute hypertension should be controlled after aSAH and until
aneurysm obliteration, but parameters for blood pressure control
have not been defined

33. MANAGEMEN STROKE
KEDARURATAN MEDIK STROKE AKUT: TEKANAN DARAH
(HIPERTENSI)
73,9% hipertensi dengan 22,5-27,6% memiliki TDS > 180mmHg
Iskemik
 Diturunkan sekitar 15% dlm 24 jam pertama stlh onset apabila TDS > 220 mmHg
atau TDD > 120
 Jika akan diberi rtPA, diturunkan hingga TDS <185 mmHg dan TDD < 110 mmHg
 Setelah pemberian rtPA, harus dipantau hingga TDS < 180 dan TDD < 105 selama
24 jam pertama
 Labetalol, nitroprusid, nikardipin.
Hemorragik Intraserebral
 TDS > 200 atau MAP > 150, diturunkan dengan antihipertensi IV secara kontinu
dengan pemantauan setiap 5 menit
 TDS 150 – 220, dapat diturunkan dengan cepat hingga 140 mmHg
 Setelah kraniotomi, target MAP 100 mmHg
Hemoragik SAH Aneurisma
 Diturunkan hingga TDS 140 – 160 untuk mencegah SAH berulang
 Mencegah risiko vasospamse, target TDS 160-180 (tergantung usi, berat ringan
risiko, komorbiditas)

34. PILIHAN TERAPI
CHEP 2013

35. PILIHAN TERAPI
CHEP 2013

36. PILIHAN TERAPI
CHEP 2013

37. PILIHAN TERAPI
CHEP 2013

38. KESIMPULAN PERBANDINGAN TAGET DAN
OBAT INISAL DARI BERBAGAI GUIDELINE

39. PILIHAN OBAT BERDASARKAN
PENYAKIT
ESC/ESH, 2013

40. TERIMA KASIH