dr. al rasyid, sps (k) - hypertensive emergency agt 06. 13-2-13

7/21/2019 Dr. Al Rasyid, SpS (K) - Hypertensive Emergency Agt 06. 13-2-13

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The Role of Perdipine in The

Management of HypertensiveEmergency

dr. Al Rasyid, Sp.S(K)

Dept. Neurologi FKUI/RSCM

Jakarta


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Epidemiology of HypertensiveEmergency (HE)

First described by Volhard and Fahr (1914),who saw patients with severe hypertensionaccompanied by signs of vascular injury to the

heart, brain, retina, and kidney. Prior to the introduction of antihypertensive

medications, 7% of hypertensive pts had HE.

Currently, 1 to 2% of pts with hypertension will

have a HE at some time in their life.

Marik Paul E, Varon Joseph, CHEST 2007;131:1949-62

2InaSH-2009


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Definitions

Hypertensive CrisisBP > 180/120

Hypertensive EmergencyHypertensive Urgency

Markedly elevated BPwithout severe symptoms or

progressive target organ damage.BP should be reduced within hours.

Oral agents.

Markedly elevated BPwith acute or progressing

target organ damage.BP should be reduced immediate.

Parenteral agents.

Kaplan NM ,Hypertensive Crises in : Clinical hypertension 9th Ed,

Lippincott Williams & Wilkins 2006:609-630


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Definitions

Accelerated malignant hypertensionrepresentsmarkedly elevated BP with papiledema (grade 4Keith-Wagener retinopathy) and/or hemorrhagesand exudates (grade 3 Keith-Wagener retinopathy).The Clinical features and prognosis are similar withgrade 3 or 4 retinopathy (Ahmed et al., 1986)

Hypertensive encephalopatyis a sudden, markedelevation of BP with severe headache and alteredmental status, reversible reduction of BP.

Kaplan NM ,Hypertensive Crises in : Clinical hypertension 9th Ed,

Lippincott Williams & Wilkins 2006:609-630

4InaSH-2009


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Clinical Presentation

25%

5%

16%

23%

14%

12%

2%

0%

5%

10%

15%

20%

25%

30%

Cerebral

Infarction

ICH or SAH Hypertensive

encephalopathy

Acute

pulmonary

edema

Acute CHF AMI or UAP Aortic

dissection

Zampaglione B, Pascale C et al. Hypertension1996;27:144-7


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HypertensiveEmergency

History of HT

Anti HT drug noncompliance

Diabetes Mellitus

Alcoholism

Smoking

Obesity

Tisdalea, 2004Xin, 2001Teo, 2006

Critchley, 2003

Cerebrovascular

lesions

Cardiovasculardisease

Renal failure

50-58 %

Ellenga, 2011Bisognano, 2011

Previous

stroke

Indonesia : RSCM 2011


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PATHOPHYSIOLOGY

Hypertensive emergency occur inassociation with target organ

complications Caucasians : 20 30 %

African-Americans : 80 %


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cardeneiv.com


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ALTERED MECHANISMS INHYPERTENSION AND

HYPERTENSIVE EMERGENCY


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TRIGGERS

NORMAL HIPERTENSIVE

EMERGENCY


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TRIGGERS

ENDOTHELIAL

DYSFUNCTIONNO

MECHANICALSTRETCH INFLAMATION

INCREASED :

CYTOKINES

ENDOTHELIAL ADHESIVES MOLECULES

ENDOTHELIN-1


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Initial Evaluation of Patientswith a Hypertensive Emergency

History : Prior diagnosis and treatment of HT Intake of pressor agents : street drugs,

sympathomimetics Symptoms of cerebral, cardiac, and visual

dysfunction

Physical exam.

BP Funduscopy Neurologic status Cardiopulmonary status Body fluid volume assessment

Peripheral pulses 12InaSH-2009


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Management ofHypertensive Emergency (general)

Patients should be admitted to an Intensive CareUnit for continuous monitoring of BP and parenteraladministration of an appropriate agent

The initial goal therapy is to reduce mean arterial BPby no more than 25% (within minutes to 1 hour).

Then if stable, to 160/100 to 110 mmHg within the

next 2 to 6 hours.

Excessive falls in pressure that may precipitate renal,cerebral, or coronary ischemia should be avoided.

Chobanian AV et al, The JNC 7 report, JAMA 2003;389: 2560-70
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Management ofHypertensive Emergency (general)

If this level of BP is well tolerated and thepatients is clinically stable , further gradual

reductions toward a normal BP can beimplemented in the next 24 to 48 hours.

Exceptions :

1. Patients with ischemic stroke

2. Aortic dissection SBP should < 100mmHg

3. Patients whom BP is lowered to

enable the use of thrombolyticChobanian AV et al, The JNC 7 report, JAMA 2003;389: 2560-70

P t l D f T t t f


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Parenteral Drugs for Treatment ofHypertensive Emergencies based onJNC 7

Drugs Dose Onset Duration ofAction

Sodium

nitroprusside

0.25-10 ugr/kg/min Immediate 1-2 minutes after

infusion stopped

Nitroglycerin 5-500 ug/min 1-3 minutes 5-10 minutes

Labetolol HCl 20-80 mg every 10-15 min

or 0.5-2 mg/min

5-10 minutes 3-6 minutes

Fenoldopan HCl 0.1-0.3 ug/kg/min


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Drug I.V. Bolus Dose Continous Infus

Rate

LabetalolNicardipine

Esmolol

Enalapril

Hydralazine

Nipride

NTG

520 mg every 15NA

250 ug/kg IVP loading dose

1,25-5 mg IVP every 6 h

520 mg IVP every 30

NA

NA

2 mg/min (max 300mg/d)5-15 mg/h

25-300 ug/kg/m

NA

1,5-5 ug/kg/m

0,1-10 ug/kg/m

20-400 ug/m

AHA/ASA Guideline, 2007 update. Stroke. 2007;38: 2001-2

Parenteral Drugs for Treatment ofHypertensive Emergencies based on

ASA Guideline

This parenteral drugs are approved for hypertensive

emergency in acute ischemic stroke and intracerebralhemmorha e

P t l D f T t t f


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Parenteral Drugs for Treatment ofHypertensive Emergencies based on CHEST2007

Acute Pulmonary edema /

Systolic dysfunction

Nicardipine, fenoldopam, or nitropruside combined with

nitrogliceryn and loop diuretic

Acute Pulmonary edema/

Diastolic dysfunction

Esmolol, metoprolol, labetalol, verapamil, combined with

low dose of nitrogliceryn and loop diuretics

Acute Ischemia Coroner Labetalol or esmolol combined with diuretics

Hypertensive encephalopaty Nicardipine, labetalol, fenoldopam

Acute Aorta Dissection Labetalol or combinedNicardipineand esmolol or combine

nitropruside with esmolol or IV metoprolol

Preeclampsia, eclampsia Labetalol ornicardipine

Acute Renal failure /

microangiopathic anemia

Nicardipineor fenoldopam

Sympathetic crises/ cocaine

oveerdose

Verapamil, diltiazem, ornicardipinecombined with

benzodiazepin

Acute postoperative

hypertension

Esmolol,Nicardipine, Labetalol

Acute ischemic stroke/

intracerebral bleeding

Nicardipine,labetalol, fenoldopam

Marik Paul E, Varon Joseph, CHEST 2007;131:1949-62

Nitroglycerin


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Nitroglycerin

Nitroglycerin is a potent venodilator and only at high doses affect

arterial tone. It reduces BP by reducing cardiacouput and preload which are undesirable effects in patient withcompromised cerebral and renal perfusion

NifedipineNifedipine has been widely used via oral or sublingualadministration in the management of hypertensiveemergencies. This mode of administration has not been

approved by FDA and since JNC VI because it may causesudden uncontrolled and severe reductions in blood pressuremay precipitate cerebral, renal, and myocardial ischemia thathave been associated with fatal outcomes


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Nicardipine :

. Dihydropiridine class of CCB

Reduce peripheral resistance --- bloodpressure

water soluble, light insensitive, -- can be

parenteraly used (deference with nifedipine /

sodium nitroprusid)

USE OF NICARDIPINE


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DOSIS PERDIPINE

0.5 6Hypertensive emergencies

10 302 - 10Acute hypertensive crises during surgery

Bolus

(g/kg)DIV

(g/kg/min)

(g/kg/min)0.5 1 2 6 10

Hypertensive emergencies

Acute hypertensive crises during surgery


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Dosage and AdministrationStart with the lowest dose.

Eg 0.5 mcg/BW/min 15 drops monitoring, if in 5-15minutes theres no significant blood pressure reducing

Increasing drip until 20 drop , and then can be increaseduntil desirable blood pressure achieved ( about 3-5 dropseach after monitoring)

Monitoring blood pressure and heart rate frequently

Before choose to switch to oral, 1 hour before Perdipine isstopped, give oral drugs and Perdipine is tappered of


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The 1st line treatment of Hypertensive Emergency

Sodium Chloride / NaCl

( OTSU-NS : 100/250/500 ml )

Dextrose 5%

( OTSU-D5 : 100 / 250 / 500 ml )

Glucose 5%

Potacol

R

Ringer Asetat

KN 1A / 1B / 4A

PERDIPINE

Could be used : Couldnt be used :

Sodium bicarbonat

Ringer Laktat
http://images.google.co.id/imgres?imgurl=http://www.medgadget.com/archives/img/61234232.jpg&imgrefurl=http://medgadget.com/archives/2006/04/the_medfusion_3.html&h=252&w=466&sz=38&hl=id&start=8&um=1&tbnid=j3R8XCeYR1CS4M:&tbnh=69&tbnw=128&prev=/images%3Fq%3Dsyringe%2Bpump%26um%3D1%26hl%3Did


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Kasus

Seorang laki-laki 31 tahun datang diantar

keluarga dalam keadaan tidak sadar sejak 3jam yll. Pasien saat mau ke kamar mandimendadak mengeluh sakit kepala hebat,

kemudian diikuti kejang-kejang danselanjutnya tidak sadar.

Dari pemeriksaan kesadaran sopor, TD

210/110; HR 104x/menit, febris (-). Kakukuduk (-), gerakan tangan dan kaki kanankurang aktif dibandingkan kiri. BB 75 kg

Stroke?26


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Kasus

Seorang laki-laki, 70 th, pagi hari saat ke kamar

mandi mengeluh tungkai kiri terasa lemah. Ia masihdapat berjalan, beberapa saat kemudian kakibertambah lemah disertai dengan kelemahan padatangan kiri dan bicara pelo.

Dari pemeriksaan kesadaran composmentis, TD200/110; HR 104x/menit, febris (-). Kaku kuduk (-),ekstremitas kanan lebih lemah dibandingkan kiri.BB 61 kg

Sebulan yang lalu pasien mengalami hal yang samatapi pulih kembali dalam beberapa menit.


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SUMMARY Hypertensive Crises is an urgent situation that need rapid

management to prevent organ damage

Antihypertensive agent that preffered in this condition

should be fast action, parenteral, and titratable

Nicardipine is the only Calcium Antagonist recommended by

JNC 7, AHA, 2007, CHEST 2007 to manage hypertensive

emergency

Nicardipine has favorable antiischemic profile because of

an increase myocardial , brain, and kidney oxygen supply


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dr. al rasyid, sps (k) - hypertensive emergency agt 06. 13-2-13

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