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Elian Devina G99162151

Parada Jiwanggana G99161072


Ayati Jauharotun N G99162137
Aulia Zhafira G99161022

Pembimbing:
dr. Agus Jati, Sp.PD
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
DEFINISI
HIPERTENSI KRISIS
Peningkatan tekanan darah mendadak (> 180/120 mmHg)
KLASIFIKASI
HIPERTENSI URGENSI
TANPA GEJALA
- Biasanya tekanan darah > 180/120 mmHg
- Tanpa disertai kerusakan organ
KLASIFIKASI
Hipertensi Emergensi
-hipertensi emergensi adalah keadaan di mana tekanan darah sistolik
> 180 mmHg dan diastolic > 120 mmHg
-disertai dengan tanda dan gejala kerusakan organ.
Etiologi
Hipertensi kronis
Hipertensi sekunder hiperaldosteron
Obat antihipertensi klonidin dan phencyclidine
Komplikasi kehamilan
Pemakaian cocaine, monoamine oxidase inhibitors
(MAOIs)
Hiperkapnia
Renal artery stenosis
Pheochromocytomas
Hyperthyroidism dan Hypothyroidism
Bakris GL dan Sorrentiono M, 2013; Devicaesaria A, 2014;
Pollack JC dan Rees JC, 2008; Kotchen T, 2017
?
Autoregulasi pada Hipertensi
From: Regulation of Cerebral Autoregulation by Carbon Dioxide
Anesthes. 2015;122(1):196-205. doi:10.1097/ALN.0000000000000506

Date of download: 10/8/2017 Copyright 2017 American Society of Anesthesiologists. All rights reserved.
Pengobatan Depresi dengan MAOIs
Target Organ Damage

Stroke
Atherosclerosis*
Vasoconstriction
Vascular hypertrophy Hypertension
Endothelial dysfunction

LV hypertrophy
Fibrosis Heart failure DEATH
Remodeling MI
Apoptosis

GFR
Proteinuria
Renal failure
Aldosterone release
Glomerular sclerosis
*preclinical data
LV = left ventricular; MI = myocardial infarction; GFR = glomerular filtration rate

Adapted from Willenheimer R et al Eur Heart J 1999; 20(14): 9971008, Dahlf B J Hum Hypertens 1995; 9(suppl 5):
S37S44, Daugherty A et al J Clin Invest 2000; 105(11): 16051612, Fyhrquist F et al J Hum Hypertens 1995; 9(suppl 5):
S19S24, Booz GW, Baker KM Heart Fail Rev 1998; 3: 125130, Beers MH, Berkow R, eds. The Merck Manual of
Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories 1999: 16821704, Anderson S
Exp Nephrol 1996; 4(suppl 1): 3440, Fogo AB Am J Kidney Dis 2000; 35(2): 179188
Tekanan darah Hipertensi kronis Urgensi Emergency

Gejala Sakit kepala, kecemasan, Sakit kepala berat, Sesak napas, nyeri
sering asimptomatik. sesak napas. dada, nokturia,
disarteria, kelemahan
umum sampai dengan
penurunan kesadaran.

Pemeriksaan Tidak dijumpai keruskan Kerusakan organ target Encefalopati, edema


organ target, tidak ada minimal atau tidak ada, pulmonum, insufisiensi
penyakit kardiovascular penyakit kardivascular ginjal, cerebrovascular
secara klinis. yang stabil accident, iskemik cardiac
TABLE 2 : ALGORITHM FOR TRIAGE EVALUATION

Severe Hypertension (Urgency)


Parameter Hypertensive Emergency
Asymptomatic Symptomatic

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)


PROGNOSIS
Angka kematian tinggi
Tanpa terapi : 1 year survival rate 10-20%
Terapi adekuat : 5 year survival rate 50-60%

Kaplan, clinical hypertension


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
KESIMPULAN
Hipertensi urgensi perlu dibedakan dengan hipertensi emergensi
agar dapat memilih pengobatan yang memadai bagi penderita.
Pada hipertensi emergensi peningkatan tekanan darah disertai
dengan kerusakan organ target, sedangkan pada hipertensi urgensi
tidak ada kerusakan organ sasaran/kerusakan minimal.
Dalam memberikan terapi perlu diperhatikan beberapa faktor:
Apakah penderita dengan hipertensi emergensi atau urgensi.
Cepatnya tekanan darah diturunkan, tekanan darah yang diinginkan,
dan lama kerja dari obat.
Autoguralsi dan perfusi dari vital organ (otak, jantung, dan ginjal)
bila tekanan darah diturunkan.
Besarnya penurunan tekanan umumnya kira-kira 25% dari MAP
ataupun tidak lebih rendah dari 160/100 mmHg.
Pemakaian obat parenteral untuk hipertensi emergensi lebih aman
karena tekanan dapat diatur sesuai dengan keinginan, sedangkan
dengan obat oral kemungkinan penurunan tekanan darah melebihi
yang diinginkan sehingga dapat terjadi hipoperfusi organ.
TAKE HOME MESSAGE
Dokter pada pelayanan primer, dapat memberikan anti hipertensi oral
yang bekerja cepat, dalam menatalaksana hipertensi sebelum merujuk
ke RS rujukan