HIPERTENSI KRISIS

Dr widyastuti
Puskesmas Tanggulangin
•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; often Severe headache, shortness of Shortness of breath, chest pain, nocturia,
asymtomatic breath dysarthria, weakness, altered consciousness

Examination No target organ damage, no Target organ damage; clinical Encephalopathy,pulmonary edema, renal
clinical cardiovascular disease cardiovascular disease insufficiency, cerebrovascular accident, cardiac
present, stable ischemia

Therapy Observe 1-3 hr; initiate, resume Observe 3-6 hr; lower BP with Baseline laboratory tests; intravenous line; monitor
medication; increase dosage of shortacting oral agent; adjust BP, may initiate parenteral therapy in emergency
inadequte agent current therapy room

Plan Arrange follow-up within 3-7 Arrange follow-up evaluation Immediate admission to ICU; treat to initial goal
days; if no prior evaluation, in less than 72 hr BP, additional 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 Pressure Funduscopic Neurologic Status Cardiac Findings Renal Symptoms Gastrointestinal
(mmHg) Findings Symptoms

Usually Hemorrhages, Headache, confusion, Prominent apical Azotemia, Nausea. vomiting

>220/140 exudates, somnolence, stupor, pulsation, cardiac proteinuria, oliguria
papiledema visual loss, seizures, eniargement,
focal neurologic congestive 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 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

ONSET/DURATION OF ACTION
AGENT DOSE (AFTER DISCONTINUATION) PRECAUTIONS

Captopril 25 mg p.o., repeat as needed SL, 25 mg 15-30 min/6-8 h SL, Hypotension, renal failure in
15-30 min/2-6 h bilateral renal artery stenosis

Clonidine 0.1-0.2 mg p.o., repeat hourly as required to 30-60 min/8-16 h Hypotension, drowsiness, dry
total dose of 0.6 mg 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 Dosage Onset/Duration of Action (after Precautions
discontinuation)
Parenteral Vasodilators

Sodium 0.25-10 g/kg/min as IV infusion Immediate/2-3 min after Nausea, vomiting; prolonged use may cause
Nitroprusside infusion 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 Tachycardia, nausea, vomiting, headache,
exceed 12 hr after prolonged increased intracranial pressure; hypotension may
infusion be protracted after prolonged infusions

Fenoldopam 0.1-0.3 g/kg/min as IV infusinon <5 min/30 min Headache, tachycardia, flushing, local phlebitis,
Mesylate dizziness

Hydralazine 5-20 mg as IV bolus or 10-40 mg 10 min IV/> 1 hr (IV); 20-30 min Tachycardia, headache, vomiting, aggravation of
IM; repeat every 4-6 hr IM/4-6 hr (IM 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 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
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