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PENANGANAN

HIPERTENSI EMERGENSI
PENYAKIT
KARDIO
HIPERTENSI VASKULAR

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
PENYAKIT
HIPERTENSI KARDIO
VASKULAR
Penurunan berat badan

Poirrier et al. 2006


Tiap Kg Menurunkan TD
Sistolik 1-2 mmHg & Diastolik 1-4 mmHg
HYPERTENSION(JNC-7class.)
SBP-mmHg DBP-mmHg

NORMAL <120 AND<80

PREHYPERTENSION 120-139 or 80-89

STAGE 1 140-159 or 90-99

STAGE 2 >=160 >=100


Excess Reduced Stress Genetic Obesity Endothelium
sodium nephron Alteration derived
intake nunber factor

Renal Decreased Sympathetic Renin Cell Hyper-


sodium filtration Nervous angiotensin membrane insulinemia
retention surface overactivity excess alteration

Fluid Venous
volume Constriction

Preload Contractility Functional Structural


Constriction Hypertrophy

BLOOD PRESSURE = CARDIAC OUTPUT X PERIPHERAL RESISTANCE


Hypertension = Increased CO and/or 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 Acute
Heart Failure Coronary
Syndrome

Eclampsia
Acute Renal
Failure
Severe Hypertension
BP > 180/120 mm Hg

Progressive Target Organ Damage?

Yes No
HT 1st Episode Frequent Episodes
Emergency HT Urgency Uncontrolled HT

Parenteral Rx Oral Rx in ED Refill Rx


Admit to ICU Clinic : 24h 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 0.25-10 ugr/kg/min Immediate 1-2 minutes after


nitroprusside infusion stopped
Nitroglycerin 5-500 ug/min 1-3 minutes 5-10 minutes

Labetolol HCl 20-80 mg every 10-15 min or 5-10 minutes 3-6 minutes
0.5-2 mg/min
Fenoldopan 0.1-0.3 ug/kg/min <5 minutes 30=60 minutes
HCl
Nicardipine 5-15 mg/h 5-10 minutes 15-90 minutes
HCl
Esmolol HCl 250-500 ug/kg/min IV bolus, 1-2 minutes 10-30 minutes
then 50-100 ug/kg/min by
infusion; may repeat bolus after
5 minutes or increase infusion
to 300 ug/min
JNC 7, 2003
CHEST 2007 Recommendation for
Hypertensive Emergency
Acute Pulmonary edema / Nicardipine, fenoldopam, or nitropruside combined with
Systolic dysfunction nitrogliceryn and loop diuretic
Acute Pulmonary edema/ Esmolol, metoprolol, labetalol, verapamil, combined with
Diastolic dysfunction 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 / Nicardipine or fenoldopam
microangiopathic anemia
Sympathetic crises/ cocaine Verapamil, diltiazem, or nicardipine combined with
oveerdose benzodiazepin
Acute postoperative Esmolol, Nicardipine, Labetalol
hypertension
Acute ischemic stroke/ Nicardipine, labetalol, fenoldopam
intracerebral bleeding

CHEST, 2007
AHA / ASA 2007 Recommendation for
Hypertensive Emergency

Drug I.V. Bolus Dose Continous Infus Rate

Labetalol 5 20 mg every 15 2 mg/min (max 300mg/d)


Nicardipine NA 5-15 mg/h
Esmolol 250 ug/kg IVP loading dose 25-300 ug/kg/m
Enalapril 1,25-5 mg IVP every 6 h NA
Hydralazine 5 20 mg IVP every 30 1,5-5 ug/kg/m
Nipride NA 0,1-10 ug/kg/m
NTG NA 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 Penghambat EKA 25- 50 mg


Nitrogliserin Vasodilator 1,25-2,5 mg
Nikardipin Antagonis kalsium 30 mg
Isradipin Antagonis kalsium 1,25-5 mg
Labetalol Penyekat dan 200-1200 mg
Klonidin Agonis 0,1-0,4 mg
Furosemid Diuretik 40-80 mg

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