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HIPERTENSI KRISIS SYAIFUL AZMI SUB BAGIAN GINJAL HIPERTENSI BAG ILMU PENYAKIT DALAM FDOK UNAND / RSUP DR M DJAMIL PADANG.

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Presentasi berjudul: "HIPERTENSI KRISIS SYAIFUL AZMI SUB BAGIAN GINJAL HIPERTENSI BAG ILMU PENYAKIT DALAM FDOK UNAND / RSUP DR M DJAMIL PADANG."— Transcript presentasi:

1 HIPERTENSI KRISIS SYAIFUL AZMI SUB BAGIAN GINJAL HIPERTENSI BAG ILMU PENYAKIT DALAM FDOK UNAND / RSUP DR M DJAMIL PADANG

2 HIPERTENSI KRISIS

3 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

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

5 DEFINISI HIPERTENSI KRISIS Peningkatan tekanan darah mendadak (> 180/120 mmHg) - T.O.D +/- - KELUHAN +/- - PENANGGULANGAN SEGERA

6 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

7 KLASIFIKASI Hipertensi Emergensi -Biasanya tekanan darah > 220/140 mmHg -Keluhan TOD : sesak, nyeri dada, nokturia, disartria, gangguan kesadaran

8 Table 2 : Algorithm for Triage Evaluation Parameter Severe Hypertension (Urgency) Hypertensive Emergency AsymptomaticSymptomatic Blood pressure (mmHg) > 180/110 Usually > 220/140 SymptomsHeadache, anxiety; often asymtomatic Severe headache, shortness of breath Shortness of breath, chest pain, nocturia, dysarthria, weakness, altered consciousness ExaminationNo target organ damage, no clinical cardiovascular disease Target organ damage; clinical cardiovascular disease present, stable Encephalopathy,pulmonary edema, renal insufficiency, cerebrovascular accident, cardiac ischemia TherapyObserve 1-3 hr; initiate, resume medication; increase dosage of inadequte agent Observe 3-6 hr; lower BP with shortacting oral agent; adjust current therapy Baseline laboratory tests; intravenous line; monitor BP, may initiate parenteral therapy in emergency room PlanArrange follow-up within 3-7 days; if no prior evaluation, schedule appointment Arrange follow-up evaluation in less than 72 hr Immediate admission to ICU; treat to initial goal BP, additional diagnostic studies BP, Blood pressure; ICU, Intensive care unit Sumber : Hebert e.j Prim Care (3)

9 DIAGNOSIS ANAMNESIS -Lama menderita hipertensi -Obat-obat yang dimakan -Keluhan TOD -Penyakit penyerta

10 DIAGNOSIS PEMERIKSAAN FISIS -Pengukuran tekanan darah -Perabaan a. radialis, a. karotis -TOD

11 Table 3 : Clinical Characteristics of the Hypertensive Emergency Blood Pressure (mmHg) Funduscopi c Findings Neurologic Status Cardiac Findings Renal Symptoms Gastrointestinal Symptoms Usually >220/140 Hemorrhage s, exudates, papiledema Headache, confusion, somnolence, stupor, visual loss, seizures, focal neurologic deficits, coma Prominent apical pulsation, cardiac eniargement, congestive heart failure Azotemia, proteinuria, oliguria Nausea. vomiting Sumber : Hebert e.j Prim Care (3)

12 Table 4 : Clinical Manifestations of End-Organ Damage From Hypertensive Emergency Central nervous system Dizzness, NV, confusion, weakness, encephalopathy, ICH, SAH, ischemic stroke EyesOcular hemorrhage, exudates, or papiledema on fundoscopic exam, blurred vision, loss of sight HeartAngina, ACS, LVF, PE, aortic dissection, cardiogenic shock KidneysHematuria, 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 (2)

13 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

14 Table 5 : Management of Hypertensive Urgencies AGENTDOSE ONSET/DURATION OF ACTION (AFTER DISCONTINUATION) PRECAUTIONS Captopril25 mg p.o., repeat as needed SL, 25 mg min/6-8 h SL, min/2-6 h Hypotension, renal failure in bilateral renal artery stenosis Clonidine mg p.o., repeat hourly as required to total dose of 0.6 mg min/8-16 hHypotension, drowsiness, dry mouth Labetalol mg p.o repeat every 2-3 h30 min-2 h/2-12 hBronchoconstriction, heart block, orthostatic hypotension Amblodipi n 2,5-5 mg1-2 hr/12-18 hrTachycardia, hypotension Nifedipin5 mg sl5-20 min/2-6 hrTachycardio, hypotension Adapted with permission from Vidt DG. Hypertensive crises: emergencies and urgencies. J Clin Hypertens (Greenwich). 2004;6: Sumber : - Adaptec etc - InaSH - Hebert C.J Hypertensive Crises Prim Care (3)

15 PENGOBATAN Hipertensi Emergensi -Dirawat di ICU -Obat anti hipertensi parenteral -Target :- Penurunan tekanan darah pd jam pertama % - Minimalisir hipoperfusi organ vital -Penurunan tekanan darah selanjutnya dl 24 jam

16 Table 6 : Treatment of Hypertensive Emergencies Agent Parenteral Vasodilators DosageOnset/Duration of Action (after discontinuation) Precautions Sodium Nitroprusside  g/kg/min as IV infusion Immediate/2-3 min after infusion Nausea, vomiting; prolonged use may cause thiocyanate intoxication, methemoglobinemia, acidosis, cyanide poisoning; bags, bottles, delivery sets must be light resistant Nitroglycerin5-100  g as IV infusion 2-5 min/5-10 minHeadache, tachycardia, vomiting; flushing. Methemoglobinemia; requires special delivery system because of drug binding to PVC tubing Nicardipine5-15 mg/hr as IV infusion 1-5 min/15-30 min, but may exceed 12 hr after prolonged infusion Tachycardia, nausea, vomiting, headache, increased intracranial pressure; hypotension may be protracted after prolonged infusions Fenoldopam Mesylate  g/kg/min as IV infusinon <5 min/30 minHeadache, tachycardia, flushing, local phlebitis, dizziness Hydralazine5-20 mg as IV bolus or mg IM; repeat every 4-6 hr 10 min IV/> 1 hr (IV); min IM/4-6 hr (IM Tachycardia, headache, vomiting, aggravation of angina pectoris, sodium and water retension, increased intracranial pressure Sumber : Hebert e.j Prim Care (3)

17 Keadaan khusus 1.Diseksi Aorta - Robekan pd dinding aorta - Klinis : nyeri dada (Spt MCI) : Sinkope - Pemeriksaan : Echo, CT Scan, MRI - Terapi : Target TDS mmHg/dl Waktu menit - Konsul bedah

18 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

19 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

20 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 % dl 1-3 jam Obat : Na nitropruside Labetalol

21 Keadaan khusus 5.Krisis adrenergic - Karena produksi katekolamin  - Terapi :Turunkan tekanan darah % dl 1-2 jam Obat :- Fentolamin - Labetalol

22 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

23 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

24 Keadaan khusus 8.Perdarahan serebral - Biasanya tekanan darah > 240/120 mmHg - Klinis :- penurunan kesadaran - ngorok - tanda-tanda defisit neurologi - Terapi :-  tek darah % jam pertama - 160/90 mmHg dl 24 jam - Obat :Na Nitropruside Nicardipin CCB

25 Keadaan khusus 9.Kehamilan - Keluhan :- Sakit kepala - Sesak nafas - Oliguri - Kejang - Lab. Proteinuria - Terapi :Terminasi kehamilan Obat :- Nicardipin - Labetalol

26 Keadaan khusus 10.Pengguna NAPZA - Obat kokain, amfetamin, metametamin phencyclidine - Obat pilihan CCB

27 Table 7 : Preferred Drugs for Select Hypertensive Emergencies EmergencyDrugs of choiceTarget Blood Pressure Aortic dissection AMI, ischemia Pulmonary edema Renal emergencies Catecholamine excess Hypertensive encphalopathy Subarachnoid hemorrhage Ischemic stroke Nitroprusside + esmolol Nitroglycerin, nitroprusside, nicardipine Nitroprusside, nitroglycerin, labetalol Fenoldopam, nitroprusside, labetalol Phentolamine, labetalol Nitroprusside Nitroprusside, nimodipine, nicardipine Nitroprusside (controversial), nicardipine SBP as soon as possible Secondary to ischemia relief Improve symptoms 10%-15% in 1-2 hr Target BP 20%-25% in 2-3 hr Control paroxysms, 10 %-15% in 1-2 hr 20%-25% in 2-3 hr 0%-20% in 6-12 hr AMI, acute mycardial infarction; SBP, systolic bood pressure Sumber : Hebert e.j Prim Care (3)

28 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

29 TAKE HOME MESSAGE Dokter pada pelayanan primer, dapat memberikan anti hipertensi oral yang bekerja cepat, dalam menatalaksana hipertensi sebelum merujuk ke RS rujukan

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