HIPERTENSI KRISIS SYAIFUL AZMI SUB BAGIAN GINJAL HIPERTENSI BAG ILMU PENYAKIT DALAM FDOK UNAND / RSUP DR M DJAMIL PADANG •HIPERTENSI KRISIS 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 PROGNOSIS • Angka kematian tinggi • Tanpa terapi : 1 year survival rate 10-20% • Terapi adekuat : 5 year survival rate 50-60% Kaplan, clinical hypertension DEFINISI • HIPERTENSI KRISIS • Peningkatan tekanan darah mendadak (> 180/120 mmHg) - T.O.D +/- KELUHAN +/- PENANGGULANGAN SEGERA 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 KLASIFIKASI Hipertensi Emergensi - Biasanya tekanan darah > 220/140 mmHg - Keluhan TOD : sesak, nyeri dada, nokturia, disartria, gangguan kesadaran Table 2 : Algorithm for Triage Evaluation Parameter Severe Hypertension (Urgency) Hypertensive Emergency Asymptomatic Symptomatic Blood pressure (mmHg) > 180/110 > 180/110 Usually > 220/140 Symptoms Headache, anxiety; often asymtomatic Severe headache, shortness of breath Shortness of breath, chest pain, nocturia, dysarthria, weakness, altered consciousness Examination No target organ damage, no clinical cardiovascular disease Target organ damage; clinical cardiovascular disease present, stable Encephalopathy,pulmonary edema, renal insufficiency, cerebrovascular accident, cardiac ischemia Therapy Observe 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 Plan Arrange 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 2008. 35 (3) DIAGNOSIS ANAMNESIS - Lama menderita hipertensi - Obat-obat yang dimakan - Keluhan TOD - Penyakit penyerta DIAGNOSIS PEMERIKSAAN FISIS - Pengukuran tekanan darah - Perabaan a. radialis, a. karotis - TOD 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 2008. 35 (3) Table 4 : Clinical Manifestations of End-Organ Damage From Hypertensive Emergency Central nervous system Dizzness, NV, confusion, weakness, encephalopathy, ICH, SAH, ischemic stroke Eyes Ocular hemorrhage, exudates, or papiledema on fundoscopic exam, blurred vision, loss of sight Heart Angina, ACS, LVF, PE, aortic dissection, cardiogenic shock Kidneys Hematuria, 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 2009. 160 (2) 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 Table 5 : Management of Hypertensive Urgencies AGENT DOSE ONSET/DURATION OF ACTION (AFTER DISCONTINUATION) Captopril 25 mg p.o., repeat as needed SL, 25 mg 15-30 min/6-8 h SL, 15-30 min/2-6 h Hypotension, renal failure in bilateral renal artery stenosis Clonidine 0.1-0.2 mg p.o., repeat hourly as required to total dose of 0.6 mg 30-60 min/8-16 h Hypotension, drowsiness, dry mouth Labetalol 200-400 mg p.o repeat every 2-3 h 30 min-2 h/2-12 h Bronchoconstriction, heart block, orthostatic hypotension Amblodipi n 2,5-5 mg 1-2 hr/12-18 hr Tachycardia, hypotension Nifedipin 5 mg sl 5-20 min/2-6 hr Tachycardio, hypotension PRECAUTIONS Adapted with permission from Vidt DG. Hypertensive crises: emergencies and urgencies. J Clin Hypertens (Greenwich). 2004;6:520-525 Sumber : - Adaptec etc - InaSH - Hebert C.J Hypertensive Crises Prim Care 2008. 35 (3) PENGOBATAN Hipertensi Emergensi - Dirawat di ICU - Obat anti hipertensi parenteral - Target : - Penurunan tekanan darah pd jam pertama 20-25 % - Minimalisir hipoperfusi organ vital - Penurunan tekanan darah selanjutnya dl 24 jam Table 6 : Treatment of Hypertensive Emergencies Agent Dosage Onset/Duration of Action (after discontinuation) Precautions Sodium Nitroprusside 0.25-10 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 Nitroglycerin 5-100 g as IV infusion 2-5 min/5-10 min Headache, tachycardia, vomiting; flushing. Methemoglobinemia; requires special delivery system because of drug binding to PVC tubing Nicardipine 5-15 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 0.1-0.3 g/kg/min as IV infusinon <5 min/30 min Headache, tachycardia, flushing, local phlebitis, dizziness Hydralazine 5-20 mg as IV bolus or 10-40 mg IM; repeat every 4-6 hr 10 min IV/> 1 hr (IV); 20-30 min IM/4-6 hr (IM Tachycardia, headache, vomiting, aggravation of angina pectoris, sodium and water retension, increased intracranial pressure Parenteral Vasodilators Sumber : Hebert e.j Prim Care 2008. 35 (3) Keadaan khusus 1. Diseksi Aorta - Robekan pd dinding aorta - Klinis : nyeri dada (Spt MCI) : Sinkope - Pemeriksaan : Echo, CT Scan, MRI - Terapi : Target TDS 110-120 mmHg/dl Waktu 10-20 menit - Konsul bedah 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 Keadaan khusus 3. Edem Paru - Klinis : - Terapi : - Obat : - sesak nafas hebat, tiba-tiba - ronkhi, bendungan - gallop rythem - Na Nitropruside - Fenoldopam - Obat-obat diuretik - Target : TDS turun 30 mmHg dl beberapa menit : 130/80 mmHg dl 3 jam 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 20 - 25% dl 1-3 jam Obat : Na nitropruside Labetalol Keadaan khusus 5. Krisis adrenergic - Karena produksi katekolamin - Terapi : Turunkan tekanan darah 10-15 % dl 1-2 jam Obat : - Fentolamin - Labetalol 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 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 Keadaan khusus 8. Perdarahan serebral - Biasanya tekanan darah > 240/120 mmHg - Klinis : - penurunan kesadaran - ngorok - tanda-tanda defisit neurologi - Terapi : - tek darah 20-25 % jam pertama - 160/90 mmHg dl 24 jam - Obat : Na Nitropruside Nicardipin CCB Keadaan khusus 9. Kehamilan - Keluhan : - Sakit kepala - Sesak nafas - Oliguri - Kejang - Lab. Proteinuria - Terapi : Terminasi kehamilan Obat : - Nicardipin - Labetalol Keadaan khusus 10.Pengguna NAPZA - Obat kokain, amfetamin, metametamin phencyclidine - Obat pilihan CCB Table 7 : Preferred Drugs for Select Hypertensive Emergencies Emergency Drugs of choice Target Blood Pressure Aortic dissection Nitroprusside + esmolol 110-120 SBP as soon as possible AMI, ischemia Nitroglycerin, nitroprusside, nicardipine Secondary to ischemia relief Pulmonary edema Nitroprusside, nitroglycerin, labetalol Improve symptoms 10%-15% in 1-2 hr Renal emergencies Fenoldopam, nitroprusside, labetalol Target BP 20%-25% in 2-3 hr Catecholamine excess Phentolamine, labetalol Control paroxysms, 10 %-15% in 1-2 hr Hypertensive encphalopathy Nitroprusside 20%-25% in 2-3 hr Subarachnoid hemorrhage Nitroprusside, nimodipine, nicardipine 20%-25% in 2-3 hr Ischemic stroke Nitroprusside (controversial), nicardipine 0%-20% in 6-12 hr AMI, acute mycardial infarction; SBP, systolic bood pressure Sumber : Hebert e.j Prim Care 2008. 35 (3) 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 TAKE HOME MESSAGE Dokter pada pelayanan primer, dapat memberikan anti hipertensi oral yang bekerja cepat, dalam menatalaksana hipertensi sebelum merujuk ke RS rujukan 31