HIPERTENSI KRISIS

SYAIFUL AZMI

SUB BAGIAN GINJAL HIPERTENSI

BAG 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

Severe Hypertension (Urgency)

Parameter Hypertensive Emergency
Asymptomatic Symptomatic

Blood pressure > 180/110 > 180/110 Usually > 220/140

(mmHg)

Symptoms Headache, anxiety; Severe headache, Shortness of breath, chest pain,

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

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 Funduscopi Neurologic Cardiac Renal Gastrointestinal

Pressure c Findings Status Findings Symptoms Symptoms
(mmHg)

Usually Hemorrhage Headache, Prominent Azotemia, Nausea.

>220/140 s, exudates, confusion, apical proteinuria, vomiting
papiledema somnolence, pulsation, oliguria
stupor, visual cardiac
loss, seizures, eniargement,
focal congestive
neurologic heart failure
deficits, coma

Sumber : Hebert e.j Prim Care 2008. 35 (3)

 Table 4 : Clinical Manifestations of End-Organ Damage From
Hypertensive Emergency

Central nervous Dizzness, NV, confusion, weakness, encephalopathy, ICH, SAH, ischemic
system 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

ONSET/DURATION OF
AGENT DOSE ACTION PRECAUTIONS
(AFTER
DISCONTINUATION)
Captopril 25 mg p.o., repeat as needed SL, 15-30 min/6-8 h SL, Hypotension, renal
25 mg 15-30 min/2-6 h failure in bilateral renal
artery stenosis
Clonidine 0.1-0.2 mg p.o., repeat hourly as 30-60 min/8-16 h Hypotension,
required to total dose of 0.6 mg 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 2,5-5 mg 1-2 hr/12-18 hr Tachycardia,
n 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 Dosage Onset/Duration of Precautions
Action (after
discontinuation)
Parenteral
Vasodilators

Sodium 0.25-10 g/kg/min as Immediate/2-3 min Nausea, vomiting; prolonged use

Nitroprusside IV infusion after infusion may cause thiocyanate
intoxication,
methemoglobinemia, acidosis,
cyanide poisoning; bags, bottles,
delivery sets must be light
resistant
Nitroglycerin 5-100 g as IV 2-5 min/5-10 min Headache, tachycardia,
infusion vomiting; flushing.
Methemoglobinemia; requires
special delivery system because
of drug binding to PVC tubing
Nicardipine 5-15 mg/hr as IV 1-5 min/15-30 min, Tachycardia, nausea, vomiting,
infusion but may exceed 12 headache, increased intracranial
hr after prolonged pressure; hypotension may be
infusion protracted after prolonged
infusions
Fenoldopam 0.1-0.3 g/kg/min as IV <5 min/30 min Headache, tachycardia, flushing,
Mesylate infusinon local phlebitis, dizziness

Hydralazine 5-20 mg as IV bolus or 10 min IV/> 1 hr (IV); Tachycardia, headache,

10-40 mg IM; repeat 20-30 min IM/4-6 hr vomiting, aggravation of angina
every 4-6 hr (IM 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 sakit
Membuka 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
Refrakter
RPK tidak ada
- Pemeriksaan : bising a renalis
- Terapi : Turunkan tekanan darah
20 - 25% dl 1-3 jam
Obat : Na nitropruside
Labetalol
Keadaan khusus

5. Krisis adrenergic
- Karena produksi katekolamin
- Terapi : Turunkan tekanan darah
10-15 % dl 1-2 jam
Obat : - Fentolamin
- Labetalol
 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
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
Nicardipin
CCB
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 Nitroprusside + esmolol 110-120 SBP as soon as possible

AMI, ischemia Nitroglycerin, nitroprusside, nicardipine Secondary to ischemia relief

Pulmonary edema Nitroprusside, nitroglycerin, labetalol Improve symptoms 10%-15% in 1-2 hr

Renal emergencies Fenoldopam, nitroprusside, labetalol Target BP 20%-25% in 2-3 hr

Catecholamine excess Phentolamine, labetalol Control paroxysms, 10 %-15% in 1-2 hr

Hypertensive encphalopathy Nitroprusside 20%-25% in 2-3 hr

Subarachnoid hemorrhage Nitroprusside, nimodipine, nicardipine 20%-25% in 2-3 hr

Ischemic stroke Nitroprusside (controversial), nicardipine 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
30