PENANGANAN HIPERTENSI EMERGENSIDr. Librantoro, SpJP, FIHA

HIPERTENSIPENYAKIT KARDIOVASKULARPrevalensi : 1 milyarMortalitas : + 7.1 jutaMONICA-JAKARTA1993-2000 :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.

HIPERTENSIPENYAKIT KARDIOVASKULARTerapi FarmakologiPerubahan pola hidupPenurunan berat badanPoirrier et al. 2006Tiap Kg Menurunkan TDSistolik 1-2 mmHg & Diastolik 1-4 mmHg MANAJEMEN HIPERTENSI

HYPERTENSION(JNC-7class.)

SBP-mmHgDBP-mmHgNORMAL =100

Beberapa Faktor yang terlibat dalam kontrol tekanan darah (Kaplan, 2002)

PERUBAHAN GAYA HIDUPMANAJEMEN HIPERTENSI

DEFINISIKrisis HipertensiAdalah peningkatan tekanan darah yang sangat tinggi (>180/120 mmHg) dan dapat diklasifikasikan sebagai hipertensi emergensi dan hipertensi urgensi.

Hipertensi emergensiMerupakan suatu keadaan yang jarang dijumpai, yang memerlukan penurunan tekanan darah sesegera mungkin untuk membatasi atau menghindari kerusakan organ target lebih lanjut.

Hipertensi urgensiKeadaan 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 HipertensiNeurologis : Sakit kepala, kejang, penurunan kesadaranMata : retinal bleeding , edema papilJantung : Nyeri dada, edema paruGinjal : Azotemia,proteinuria, oligouriaKebidanan : Preeclampsia

Hypertensive Emergencies Stroke EncephalopathyDecompensated Heart FailureAcute Renal FailureAcute Coronary SyndromeAortic Dissection Eclampsia

Severe HypertensionBP > 180/120 mm HgProgressive Target Organ Damage?

PENANGANAN HIPERTENSI EMERGENSIDi ruang ICU/ICCUBed restMenggunakan antihipertensi intra venaMenurunkan tekanan arteri rata-rata (mean arterial pressure/MAP) tidak lebih dari 25 % dalam beberapa menit sampai 2 jamMenurunkan 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 EmergencyJNC 7, 2003

DrugsDosageOnsetDurationSodium nitroprusside0.25-10 ugr/kg/minImmediate1-2 minutes after infusion stopped Nitroglycerin5-500 ug/min1-3 minutes5-10 minutesLabetolol HCl20-80 mg every 10-15 min or 0.5-2 mg/min 5-10 minutes3-6 minutesFenoldopan HCl0.1-0.3 ug/kg/min

CHEST 2007 Recommendation for Hypertensive Emergency

CHEST, 2007

Acute Pulmonary edema / Systolic dysfunctionNicardipine, fenoldopam, or nitropruside combined with nitrogliceryn and loop diureticAcute Pulmonary edema/ Diastolic dysfunctionEsmolol, metoprolol, labetalol, verapamil, combined with low dose of nitrogliceryn and loop diuretics Acute Ischemia CoronerLabetalol or esmolol combined with diureticsHypertensive encephalopatyNicardipine, labetalol, fenoldopamAcute Aorta DissectionLabetalol or combined Nicardipine and esmolol or combine nitropruside with esmolol or IV metoprololPreeclampsia, eclampsiaLabetalol or nicardipineAcute Renal failure / microangiopathic anemiaNicardipine or fenoldopamSympathetic crises/ cocaine oveerdoseVerapamil, diltiazem, or nicardipine combined with benzodiazepinAcute postoperative hypertensionEsmolol, Nicardipine, LabetalolAcute ischemic stroke/ intracerebral bleedingNicardipine, labetalol, fenoldopam

AHA / ASA 2007 Recommendation for Hypertensive EmergencyAHA/ASA Guideline, 2007 update. Stroke. 2007;38: 2001-2023.)

DrugI.V. Bolus DoseContinous Infus RateLabetalolNicardipineEsmololEnalaprilHydralazineNiprideNTG5 20 mg every 15NA250 ug/kg IVP loading dose1,25-5 mg IVP every 6 h5 20 mg IVP every 30NANA2 mg/min (max 300mg/d)5-15 mg/h25-300 ug/kg/mNA1,5-5 ug/kg/m0,1-10 ug/kg/m20-400 ug/m

Sodium NitroprussideSodium 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 CHFAdverse effects: hypotension.Contraindicated in pregnancy : cross the placenta..

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

CHEST, 2007

NitroglycerinDilator of coronary arteriespromotes 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.

HydralazineIt 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.

NifedipineNifedipine 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 URGENSIRuang perawatan biasaBed restDiet rendah garamTerapi antihipertensi oralPenurunan tekanan darah bertahap 24-48 jam

OBAT-OBAT YANG DIGUNAKAN PADA PENANGANAN HIPERTENSI URGENSINama ObatGolonganDosis

Kaptopril Penghambat EKA 25- 50 mgNitrogliserin Vasodilator 1,25-2,5 mgNikardipin Antagonis kalsium30 mgIsradipin Antagonis kalsium1,25-5 mgLabetalolPenyekat dan200-1200 mgKlonidinAgonis 0,1-0,4 mgFurosemid Diuretik40-80 mg

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