PENANGANAN

HIPERTENSI EMERGENSI

Dr. Librantoro, SpJP, FIHA

PENYAKIT
KARDIO
VASKULAR

HIPERTENSI

Prevalensi : 1 milyar
Mortalitas : + 7.1 juta
MONICA-JAKARTA
1993-2000 :
16.9 % 17.9 %

 Peningkatan TD sistolik sebesar 20 mm Hg

atau 10 mm Hg TD diastolic) 2 X mortalitas
kardiovaskular.

High normal blood pressure (BP)

meningkatkan risiko terjadinya hipertensi
sebesar 5 X.

MANAJEMEN HIPERTENSI

Perubahan pola hidup

Terapi Farmakologi
HIPERTENSI
Penurunan berat badan

PENYAKIT
KARDIO
VASKULAR

Poirrier et al. 2006

Tiap Kg Menurunkan TD
Sistolik 1-2 mmHg & Diastolik 1-4 mmHg

HYPERTENSION(JNC-7class.)
SBP-mmHg
NORMAL
PREHYPERTENSION

<120

DBP-mmHg
AND<80

120-139

or 80-89

STAGE 1

140-159

or 90-99

STAGE 2

>=160

>=100

Excess
sodium
intake

Reduced
nephron
nunber

Renal
sodium
retention

Fluid
volume

Stress

Decreased
filtration
surface

Sympathetic
Nervous
overactivity

Genetic
Alteration

Renin
angiotensin
excess

Obesity

Cell
membrane
alteration

Endothelium
derived
factor

Hyperinsulinemia

Venous
Constriction

Preload

Contractility

Functional
Constriction

BLOOD PRESSURE = CARDIAC OUTPUT

Hypertension
= Increased CO

X
and/or

Structural
Hypertrophy

PERIPHERAL RESISTANCE
Increased PVR

Autoregulation

Beberapa Faktor yang terlibat dalam kontrol tekanan darah

(Kaplan, 2002)

MANAJEMEN HIPERTENSI
PERUBAHAN GAYA HIDUP

DEFINISI
Krisis Hipertensi
Adalah peningkatan tekanan darah yang sangat tinggi
(>180/120 mmHg) dan dapat diklasifikasikan sebagai
hipertensi emergensi dan hipertensi urgensi.
Hipertensi emergensi
Merupakan suatu keadaan yang jarang dijumpai, yang
memerlukan penurunan tekanan darah sesegera
mungkin untuk membatasi atau menghindari kerusakan
organ target lebih lanjut.

Hipertensi urgensi
Keadaan dimana tidak terdapat tanda-tanda kerusakan
organ target dan memerlukan penurunan tekanan darah
secara bertahap dengan terapi oral dalam 24-48 jam.

Keadaan-keadaan yang dapat timbul pada

hipertensi emergensi :

Hipertensi ensefalopati
Kejadian intrakranial akut
Diseksi aorta akut
Sindroma koroner akut (angina tidak
stabil/infark miokard akut)
Gagal jantung akut
Eklamsia

Manifestasi Klinis
Krisis Hipertensi
Neurologis : Sakit kepala, kejang,
penurunan kesadaran
Mata : retinal bleeding , edema papil
Jantung : Nyeri dada, edema paru
Ginjal : Azotemia,proteinuria, oligouria
Kebidanan : Preeclampsia

Hypertensive Emergencies
Stroke
Encephalopathy

Aortic
Dissection

Decompensated
Heart Failure

Eclampsia

Acute
Coronary
Syndrome
Acute Renal
Failure

Severe Hypertension
BP > 180/120 mm Hg
Progressive Target Organ Damage?
No

Yes
HT
Emergency

1st Episode
HT Urgency

Frequent Episodes
Uncontrolled HT

Parenteral Rx
Admit to ICU

Oral Rx in ED
Clinic : 24h

Refill Rx
Clinic in 72h

PENANGANAN HIPERTENSI EMERGENSI

Di ruang ICU/ICCU
Bed rest
Menggunakan antihipertensi intra vena
Menurunkan tekanan arteri rata-rata (mean
arterial pressure/MAP) tidak lebih dari 25 %
dalam beberapa menit sampai 2 jam
Menurunkan tekanan darah sampai + 160/100
mm Hg dalam 2-6 jam

Ideal Pharmacologic Agents for

Hypertensive Crises
- Fast acting, stable
- Rapidly reversible
- Titratable without significant effect
- Parenteral administration

JNC 7, 2003

JNC 7 Recommendation for

Hypertensive Emergency
Drugs

Dosage

Onset

Duration

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

<5 minutes

30=60 minutes

Nicardipine
HCl

5-15 mg/h

5-10 minutes

15-90 minutes

Esmolol HCl

250-500 ug/kg/min IV bolus,

1-2 minutes
then 50-100 ug/kg/min by
infusion; may repeat bolus after
5 minutes or increase infusion
to 300 ug/min

10-30 minutes

JNC 7, 2003

CHEST 2007 Recommendation for

Hypertensive Emergency
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 combined Nicardipine and esmolol or combine

nitropruside with esmolol or IV metoprolol

Preeclampsia, eclampsia

Labetalol or nicardipine

Acute Renal failure /

microangiopathic anemia

Nicardipine or fenoldopam

Sympathetic crises/ cocaine

oveerdose

Verapamil, diltiazem, or nicardipine combined with

benzodiazepin

Acute postoperative
hypertension

Esmolol, Nicardipine, Labetalol

Acute ischemic stroke/

intracerebral bleeding

Nicardipine, labetalol, fenoldopam

CHEST, 2007

AHA / ASA 2007 Recommendation for

Hypertensive Emergency
Drug

I.V. Bolus Dose

Continous Infus Rate

Labetalol
Nicardipine
Esmolol
Enalapril
Hydralazine
Nipride
NTG

5 20 mg every 15
NA
250 ug/kg IVP loading dose
1,25-5 mg IVP every 6 h
5 20 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: 2001-2023.)

Sodium Nitroprusside
Sodium nitroprusside is the treatment of choice for
hypertensive encephalopathy.
Both an arterial and venous dilator.
IV administration and lowers BP within one or two
minutes.
Short half-life: 2 minutes. Initial dose: 0.5ug/kg/min.
Disadvantages: increased coronary steal.
Therefore, sodium nitroprusside is not the drug of
choice in hypertensive emergencies that manifest as
AMI or CHF
Adverse effects: hypotension.
Contraindicated in pregnancy : cross the placenta..

Nicardipine
Nicardipine is a second generation
dihydropyridine derivative Calcium Channel
Blocker with high vascular selectivity and
strong cerebral and coronary vasodilatory
activity
Onset of actions : 1 to 5 min,
Duration of actions of 4 to 6 h
CHEST, 2007

Nitroglycerin
Dilator of coronary arteries
promotes redistribution of blood flow to
all areas of the myocardium.
Drug of choice for hypertensive
emergencies associated with
myocardial ischemia or CHF.
Half-life: four minutes.
Disadvantages: hypotension and reflex
tachycardia.

Hydralazine
It is not recommended in hypertensive
emergencies involving the CNS because it
increases CBF and intracranial pressure.
It is unsuitable for CV-related hypertensive
emergencies because of reflex tachycardia
and increased myocardial oxygen
consumption.
It is routinely used for eclampsia because it
had no apparent effect on the fetal circulation.

Nifedipine
Nifedipine is a calcium antagonist that
produces a coronary and peripheral
vasodilation.
10 to 30 minutes onset of action.
Adverse effects: neurologic sequelae, fetal
distress, MI, and decreased renal
perfusion.

The biggest mistake in treating

hypertensive emergencies is
over-correction of BP.

Catatan :
- Nifedipin sublingual tidak digunakan lagi sebagai
terapi hipertensi emergensi/urgensi, karena
penurunan tekanan darah yang tiba-tiba dapat
menimbulkan iskemia pada ginjal, otak dan
pembuluh darah koroner.

PENANGANAN HIPERTENSI URGENSI

Ruang perawatan biasa

Bed rest
Diet rendah garam
Terapi antihipertensi oral
Penurunan tekanan darah bertahap 24-48 jam

OBAT-OBAT YANG DIGUNAKAN PADA

PENANGANAN HIPERTENSI URGENSI

Nama Obat

Golongan

Dosis

Kaptopril
Nitrogliserin
Nikardipin
Isradipin
Labetalol
Klonidin
Furosemid

Penghambat EKA
Vasodilator
Antagonis kalsium
Antagonis kalsium
Penyekat dan
Agonis
Diuretik

25- 50 mg
1,25-2,5 mg
30 mg
1,25-5 mg
200-1200 mg
0,1-0,4 mg
40-80 mg