Pembimbing : dr. Reddy Ramundito, Sp. JP Oleh : Raysella Khaulla M. ( ) HIPERTENSI SMF JANTUNG RSU HAJI SURABAYA FAKULTAS KEDOKTERAN UMM 2018

 Suatu keadaan dimana tekanan sistolik berada pada 140 mmHg atau lebih dan tekanan diastolik berada pada 90 mmHg atau lebih (JNC VIII, 2003)  Tekanan darah yang sama atau melebihi 140 mmHg sistolik dan atau sama atau melebihi 90 mmHg diastolik pada seseorang yang tidak sedang mengkonsumsi antihipertensi. (Standar Pelayanan Medik, PAPDI, 2005) 2

Tekanan darah sistolik ≥ 140 mmHg dan atau tekanan darah diastolik ≥ 90 mmHg, pada pemeriksaan yang berulang (Pedoman Tatalaksana Hipertensi pada Penyakit Kardiovaskular, PERKI, 2015) 3

 Prevalensi Hipertensi pada  umur >75 tahun adalah 63.8%  umur tahun adalah 57.6%  umur tahun adalah 45.9%  umur tahun adalah 35.6%  umur tahun adalah 24.8%  umur tahun adalah 14.7%  umur tahun adalah 8.7% (Kemenkes, 2016) 4

FAKTOR RESIKO (JNC VII) JNC VII Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:

Etiologi  Essential (95%)  Sekunder  5%-10% kasus -Renal : renal artery stenosis ; parenchymal disease -Endocrine : Pheochromocytoma; Hyperaldosteronism; hyperthyroidsm ; Cushing syndr; Exogenous agent -Vascular: Coarctation of aorta, Aortic insufficiency -Toxemia of pregnancy

7

TARGET KERUSAKAN ORGAN 8 Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:

CLASSIFICATION (JNC VII) 10 Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:

11 The Canadian Recommendation for The Management of Hypertension 2014

12

Tanda vital ( Tensi, Nadi, RR, Suhu) Cardiovascular Paru, abdomen Neurologic 13

Gula darah dan kolesterol Natrium dan Kalium Thyroid function tests Kidney function tests 14

15 Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:

 Reduce cardiac output   -adrenergic blockers  Ca 2+ Channel blockers  Dilate resistance vessels  Ca 2+ Channel blockers  Renin-angiotensin system blockers   1 adrenoceptor blockers  Reduce vascular volume  Diuretics  Direct vasodilators 16

17 JNCVIII

ANTI HYPERTENSION DRUGS (JNC VII)

Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:

COMBINATION THERAPY

FOLLOW UP dan MONITORING Monitor tekanan darah Monitor serum kalium dan kreatinin Setelah target tek darah dicapai dan stabil, pasien dapat kembali tiap 3-6 bulan Risiko kardiovaskular lainnya harus diterapi Menyarankan pasien untuk berhenti merokok 25

K O N D I S I Kehamilan Coronary heart disease Congestive heart failure O B A T Y A N G D I A N J U R K A N Nifedipine, labetalol, hydralazine, beta-blockers, methyldopa, prazosin Beta-blockers, ACE inhibitors, Calcium channel blockers ACE inhibitors, diuretik beta-blockers WHO-ISH

Krisis Hipertensi Hipertensi Gawat (Emergency) Hipertensi Daurat (Urgency) 27

Hipertensi Emergensi

Penatalaksanaan HT Emergensi  TD harus turun dalam hitungan menit, ok ada ancaman kerusakan target organ  Obat parenteral (i.v): - sodium nitroprussid - nitrogliserin - diltiazem HCl - hidralazin

Hypertensive Emergency DrugDoseOnset (min) Duratio n (min) Adverse EffectsSpecial Indications Sodium nitroprussid e 0.25–10 mcg/kg/min intravenous infusion (requires special delivery system) Immediat e 1–2Nausea, vomiting, muscle twitching, sweating, thiocyanate and cyanide intoxication Most hypertensive emergencies; caution with high intracranial pressure, azotemia, or in chronic kidney disease Nicardipine hydrochlori de 5–15 mg/h intravenous 5–1015–30; may exceed 240 Tachycardia, headache, flushing, local phlebitis Most hypertensive emergencies except acute heart failure; caution with coronary ischemia Clevidipine butyrate 1-2 mg/h intravenous infusion; may double dose every 90 sec initially; maximum: 32 mg/h; typical maintenance dose: 4 to 6 mg/h Headache, syncope, dyspnea, nausea, vomiting Most hypertensive emergencies except severe aortic stenosis; caution with heart failure Fenoldopa m mesylate 0.1–0.3 mcg/kg/min intravenous infusion < 530Tachycardia, headache, nausea, flushing Most hypertensive emergencies; caution with glaucoma 30

Hypertensive Emergency DrugDoseOnset (min) Duratio n (min) Adverse EffectsSpecial Indications Nitroglycerin5–100 mcg/min intravenous infusion 2–55–10Headache, vomiting, methemoglobinemia, tolerance with prolonged use Coronary ischemia Hydralazine hydrochlorid e 12–20 mg intravenous 10–50 mg intramuscular 10–20 20–30 60– – 360 Tachycardia, flushing, headache vomiting, aggravation of angina Eclampsia Labetalol hydrochlorid e 20–80 mg intravenous bolus every 10 min; 0.5– 2.0 mg/min intravenous infusion 5–10180– 360 Vomiting, scalp tingling, bronchoconstriction, dizziness, nausea, heart block, orthostatic hypotension Most hypertensive emergencies except acute heart failure Esmolol hydrochlorid e 250–500 mcg/kg/min intravenous bolus, then 50–100 mcg/kg/min intravenous infusion; may repeat bolus after 5 min or increase infusion to 300 mcg/min 1–210–20Hypotension, nausea, asthma, first-degree heart block, heart failure Aortic dissection; perioperative 31

Hipertensi Urgensi Bersifat mendesak dengan TD Diastolik > 120 mmHg, tetapi dengan minimal atau tanpa kerusakan organ sasaran dan tidak dijumpai keadaan pada hipertensi emergensi Hipertensi post operasi. Hipertensi tak terkontrol / tanpa diobati pada perioperatif.  Penanganan - dalam hitungan jam - Obat HT diberikan secara per oral, sublingual

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 Clonidin e mg p.o., repeat hourly as required to total dose of 0.6 mg min/8-16 hHypotension, drowsiness, dry mouth Labetalo l mg p.o repeat every 2-3 h 30 min-2 h/2-12 hBronchoconstriction, heart block, orthostatic hypotension Amblodi pin 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:

Memperbaiki atau melindungi organ target. Obat yang bekerja cepat dengan pilihan tergantung kerusakan organ target. Diturunkan secepat dan seoptimal mungkin tanpa mengganggu perfusi organ target (tidak perlu sampai normal). Penurunan tekanan darah sekiar 20-30% dalam 1 jam untuk untuk hipertensi gawat darurat, 24 jam hipertensi gawat. 34

DAFTAR PUSTAKA American Society of Hypertension and the International Society of Hypertension2013 DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:A Pathophysiologic Approach, 7th Edition: James PA, Ortiz E, et al evidence-based guideline for the management of high blood pressure in adults: (JNC8). JAMA Feb 5;311(5): Kasper, Braunwald, Fauci, et al. Harrison’s principles of internal medicine 17 th edition. New York: McGrawHill:2008 McPhee SJ, Ganong WF: Pathophyisiology of Disease: An Introduction to Clinical Medicine, 5th edition. Pedoman Tatalaksana Hipertensi pada Penyakit Kardiovaskular, Edisi Pertama, PERKI The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289: World Health Organization International Society of Hypertension stastement on management of hypertension 2013 Vidt, DG. Hypertensive crises: emergencies and urgencies. J Clin Hypertens (Greenwich), 2004;6;