HIPERTENSI KRISISHIPERTENSI KRISIS

SYAIFUL AZMI

SUB BAGIAN GINJAL HIPERTENSIBAG ILMU PENYAKIT DALAM

FDOK UNAND / RSUP DR M DJAMIL PADANG

•HIPERTENSI KRISIS

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

PROGNOSIS

• Angka kematian tinggi• Tanpa terapi : 1 year survival rate

10-20%• Terapi adekuat : 5 year survival

rate 50-60%

Kaplan, clinical hypertension

DEFINISI

• HIPERTENSI KRISIS• Peningkatan tekanan darah

mendadak (> 180/120 mmHg)- T.O.D +/-- KELUHAN +/-- PENANGGULANGAN SEGERA

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

KLASIFIKASI

Hipertensi Emergensi- Biasanya tekanan darah >

220/140 mmHg- Keluhan TOD : sesak, nyeri dada,

nokturia, disartria, gangguan kesadaran

Table 2 : Algorithm for Triage Evaluation

ParameterSevere Hypertension (Urgency)

Hypertensive EmergencyAsymptomatic 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 Care 2008. 35 (3)

DIAGNOSIS

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

DIAGNOSIS

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

Table 3 : Clinical Characteristics of the Hypertensive Emergency

Blood Pressure (mmHg)

Funduscopic Findings

Neurologic Status

Cardiac Findings Renal Symptoms

Gastrointestinal Symptoms

Usually>220/140

Hemorrhages, 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)

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)

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

Table 5 : Management of Hypertensive Urgencies

AGENT DOSEONSET/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

Amblodipin 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)

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

Table 6 : Treatment of Hypertensive Emergencies

Agent

Parenteral Vasodilators

Dosage Onset/Duration of Action (after discontinuation)

Precautions

SodiumNitroprusside

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

FenoldopamMesylate

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)

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

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 sakitMembuka oklusi koroner

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

Keadaan khusus

4. AKI/CKD- Biasanya hipertensi sekunder (oklusi a. renalis)- Klinis : Usia muda

RefrakterRPK tidak ada

- Pemeriksaan : bising a renalis- Terapi : Turunkan tekanan darah

20 - 25% dl 1-3 jamObat : Na nitropruside

Labetalol

Keadaan khusus

5. Krisis adrenergic- Karena produksi katekolamin - Terapi : Turunkan tekanan darah

10-15 % dl 1-2 jamObat : - Fentolamin

- Labetalol

Keadaan khusus

6. Hipertensi Ensefalopati- Perfusi ke serebral edem serebral progresif- Klinis : kesadaran

Perdarahan retinaPapil edemDefisit neurologi

- Terapi : tekanan darah 20-25% jam pertama Obat : Na Nitropruside

Labetalol

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

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

NicardipinCCB

Keadaan khusus

9. Kehamilan- Keluhan : - Sakit kepala

- Sesak nafas- Oliguri- Kejang

- Lab. Proteinuria- Terapi : Terminasi kehamilan

Obat : - Nicardipin- Labetalol

Keadaan khusus

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

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)

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

TAKE HOME MESSAGE

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

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