Prinsip Pengobatan Hipertensi

Emergensi
Goal: cegah progresivitas kerusakan organ
Harus menggunakan obat intravena
Utamakan keuntungan pengobatan terhadap perfusi
jaringan terutama otak, miokardium dan ginjal

MIMS Cardiovascular Guide, 2005

PENANGGULANGAN HIPERTENSI
EMERGENSI :
Bila diagnosa hipertensi emergensi telah
ditegakkan maka TD perlu segera diturunkan.
Langkah-langkah yang perlu diambil adalah :
Rawat di ICU, pasang femoral intraarterial line
dan pulmonari arterial catether (bila ada
indikasi ). Untuk menentukan fungsi
kordiopulmonair dan status volume intravaskuler.

Anamnese singkat dan pemeriksaan fisik.

tentukan penyebab krisis hipertensi
singkirkan penyakit lain yang menyerupai krisis
hipertensi
tentukan adanya kerusakan organ sasaran
Tentukan TD yang diinginkan didasari dari
lamanya tingginya TD sebelumnya, cepatnya
kenaikan dan keparahan hipertensi, masalah
klinis yang menyertai dan usia pasien.

Tujuan pengobatan Hipertensi emergency

adalah
-memperkecil kerusakan organ target akibat tingginya
tekanan darah dan menghindari pengaruh buruk akibat
pengobatan.
Berdasarkan prinsip ini maka obat antihipertensi pilihan
adalah yang bekerja cepat, efek penurunan tekanan
darah dapat dikontrol dan dengan sedikit efek samping.
-Tujuan pengobatan menurunkan tekanan arteri rata-rata
(MABP) sebanyak 25 % atau mencapai tekanan darah
diastolik 100 110 mmHg dalam waktu beberapa menit
sampai satu atau dua jam.
-Kemudian tekanan darah diturunkan menjadi 160/100
mmHg dalam 2 sampai 6 jam. Tekanan darah diukur
setiap 15 sampai 30 menit.
- Penurunan tekanan darah yang terlalu cepat dapat
menyebabkan iskemia renal, cerebral dan miokardium.

Pengobatan Hipertensi Emergensi

Name

Dosing

Onset of
Action

Duration
of Action

Preload

Afterload

Cardiac
Output

Renal
perfusion

Sodium
nitroprusside

IV 0.25-10 mg/kg/min

Within
seconds

1-2 min

decreased

decreased

no effect

decreased

Labetolol

IV (20-to 80-mg
bolus/10 min)

5-10 min

2-6 hr

no effect

decreased

decreased

no effect

Fenoldopam

IV 0.1-0.6 mg/kg/min

10-15 min

10-15 min

no effect

decreased

increased

increased

Nicardipine

IV 2-10 mg/hr

5-10 min

2-4 hr

no effect

decreased

increased

no effect

Esmolol

IV 80-mg bolus over 30

second, followed by 150
mg/kg/min infusion

6-10 min

20 min

no effect

no effect

decreased

no effect

Methyldopa

IV (250-to 1000-mg
bolus every 6 hr)

3-6 hr

up to 24
hr

no effect

decreased

decreased

no effect

Hydralazine

IV bolus (10-20 mg)

10 min

no effect

decreased

Increased

no effect

2-6 hr

Pengobatan Hipertensi Emergensi

Name

Comments

Major Side Effects

Sodium nitroprusside

Need to measure thiocyanate

levels, caution in renal
insufficiency
Alpha and beta blocker,
contraindicated in acute
heart failure
Safe in coronary bypass
patients
Short-acting beta blocker,
contraindicated in acute
heart failure
Safe in pregnancy needs
renal dosing
Safe in pregnancy

Cyanide toxicity: nausea, vomiting,

altered mental status, lactic
acidosis, death
Bradycardia, bronchospasm, nausea

Labetolol
Nicardipine
Esmolol
Methyldopa
Hydralazine

Reflex tachycardia, flushing

Bradycardia bronchospasm
Drowsiness, fever, jaundice
Reflex tachycardia, lupus-like
syndrome

Pengobatan Hipertensi Emergensi

Modes of
comparison

Hypertensive encephalopathy,
cardiovascular accident,
intracranial hemorrhage

Acute congestive heart

failure or pulmonary
edema

Acute myocardial
infarction or acute
coronary syndrome

Aortic dissection

Acute cocaine or
sympathomimetic
intoxication

Therapeutic goal

First do no harm, avoid

hypoperfusion
Do not exceed 20%
reduction of BP

Reduction of BP,
especially by
vasodilatation
Promote diuresis

Redution of BP
Decrease
myocardial oxygen
demand

Reduction of
shear orces by
reduction of BP
and tachycardia

Reduction of
excessive
sympathomimetic
drive

Suggested agents

Nicardipine: reduces,
cerebral ischemia
Consider ultra short acting
agents (esmolol or
nitroprusside)

IV nitroglycerin
Morphine
IV angiotensin
converting enzyme
inhibitor
IV diuretic

IV blocker
IV nitroglycerin

IV labetalol
IV blocker
Nitroprusside

Benzodiazepine
IV nitroglycerin
IV labetalol

Risk of therapy

Cerebral autoregulation is
disrupted in the ischemic
brain
Patients demonstrate
marked lability of BP with
any agent, and
hypoperfusion of the brain
can occur

Diuretics and
angiotensin converting
enzyme inhibitor can
exacerbate renal
dysfunction

Blocker can
exacerbate left
ventricular failure

Nitroprusside is
extremely potent
and requires
continuous intraarterial BP
monitoring

Unopposed blockade
can cause alpha
storm and increase
cocaine toxicity

Pearls

There is no clear evidence of

benefit with intensive control
of BP in the setting of stroke

Diuretics are slow to

work
Angiotensin converting
enzyme inhibitor has
rapid onset of action
IV nitrates dilate
capacitance vessels at
low doses, higher
doses dilate arterioles
and lower BP

Blockade also
reduces mortality
associated with
ventricular
arrhythmia

Avoid volume
depletion in
patients requiring
IV dye or going
for general
anesthesia

Measure core
temperature and treat
hyperthermia if
present
Consider the
possibility of
multidrug use