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Definitions Pathophysiology and Clinical Manifestation Parenteral Agents for Hypertensive Emergencies Management of Spesific Hypertensive Emergencies
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Definition
Hypertensive
Hypertensive Crisis
JNC VII 2003 180/110 Recognition of hypertensive crisis depends on the clinical state of the patients, not on the absolute level of blood pressure Included Hypertensive Emergency and Hypertensive Urgency
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A severe elevation in blood pressure (BP), such as a diastolic BP above 120 to 130 mmHg, and is classified as either an emergency or urgency
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Dwi Lestari
Elevated BP associated / manifested clinically with retinal hemorrhages, exudates and papilledema (grade 3 Keith-Wagener retinopathy and grade 4 KW retinopathy) Most often occur in patients with long-standing uncontrolled hypertension Maybe difficult to detect, subject to observer interpretation
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Failure of the normal autoregulatory function Abrupt increases in systemic vascular resistant
End organ damage and severity of BP elevation Fibrinoid necrosis Activation of endothelial vasoactive systems: endothelin, oxidative stress, RAS
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Severe hypertension
Endothelial damage
Endothelial permeability
Severe blood pressure elevation Tissue ischemia End-organ dysfunction Dwi Lestari
Intravascular hemolysis
Fibrinoid necrosis and intimal proliferation
hypovolemia
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Withdrawl of antihypertensive medications: clonidine rebound (methyldopa,reserpine), nifedipine, propanolol Phenylpropanolamine (cold preparations) Sympathomimetics amines Oral contraceptive, erythropoieten Corticosteroids, anabolic steroids NSAIDS, Cox2 inhibitors Cocaine, amphetamine, ethanol NaCl
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4 3 2
1
1950s Dwi Lestari 1990s Zampaglione, et al. AHA ; 27 (1) : 144
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Fundoscopic appearance of grade IV hypertensive retinopathy, papilloedema (1), arteriovenous nipping (2), flame-shaped hemorrhages (3), soft (4) and hard (5) exudates
Hypertensive encephalopathy Dissecting (acute) aortic aneurysm Acute left ventricular failure with pulmonary edema Acute myocardial infarction & acute coronary syndrome Eclampsia, HELLP sndrome, Pre-eclampsia severe Acute renal failure Symptomatic microangiopathic hemolytic anemia
Haas, Seminars in Dialysis 2006
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Evaluation
Initial evaluation for patients with HTN emergency History Prior diagnosis & treatment of HTN Intake of pressor agents; street drugs, sympathomimetics Symptoms of cerebral, cardiac, pulmonal, and visual dysfunction Physical examination Blood pressure Funduscopy Neurologic status Cardiopulmonary status Blood fluid volume assessment Peripheral pulses
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Laboratory evaluation Hematocrit and blood smear Urine analysis Automated chemistry : creatinin, glucose, electrolytes ECG Plasma renin activity & aldosterone (if primary aldosteronism is suspected) Plasma renin activity before & 1 h after 25 mg captopril (if renovascular HTN issuspected) Spot urine or plasma for metanephrine (if pheochromocytoma is suspected) Chest radiograph (if heart failure or aortic dissection is suspected)
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URGENCY
Identify the cause In panic attacks or anxiety use analgesic, anxiolytics Otherwise use oral antihypertensive agents recheck in 6-24 hours
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Dwi Lestari
Harus dilakukan di rumah sakit Pengobatan secara parenteral baik bolus atau infus. Tekanan darah diturunkan dalam hitungan menit jam.
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Konsensus InaSH
5-120 menit pertama tekanan darah arteri rata-rata (Mean Arterial Pressure, MAP) diturunkan 20-25 % 2 s/d 6 jam berikutnya tekanan darah diturunkan sampai 160 / 100 mm Hg 6-24 jam berikutnya lagi sampai 140 / 90 mmHg. (tidak boleh ada tanda-tanda iskemia organ) Target penurunan tekanan darah tergantung faktor risiko krisis hipertensi.
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Clonidine
Centrally acting -2 Agonist Good oral bioavailability, a relatively rapid onset of oral action. Disadvantage : acute use parogressive sedation, dry mouth, somnolence, rebound hypertension Use oral, transdermal (FDA) 0.1 0.2 po repeat hourly as required Dose 0.150.3 mg over a period of 5 minutes . Reduced MAP in 25% within minutes to 1 hour
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Dwi Lestari
Nitroglycerin
A venous dilator and slight arteriolar dilatation Most useful in patients with symptomatic coronary disease and in those with hypertension following coronary bypass. Initial dose 5 g/min, max dose 100 g/min. Onset 2 to 5 minutes, duration action 5 to 10 minutes Side effect : headache and tachycardia
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Diltiazem
Inhibit the influx Ca during membran depolarization of cardiac and smooth muscle cell Contra indication : sick sinus syndrome, second and third degree AV block
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Nicardipine
Dihydropyridine CCB Initial dose :5 mg/h to a maximum 15 mg/h Increased by 2.5 mg/h Limitation : longer half life time (precludes rapid titration) Side effect : reduced both cerebral and coronary ischemia, tachycardia, increase myocardial oxigen demand, headache, nausea and vomiting Cannot use in severe coronary ischemia
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bolus diberikan 10-50mcg/Kg BB Diteruskan dengan 0.5-6mcg/kg BB/menit sampai mencapai sasaran tekanan darah. Kemudian diganti dengan antihipertensi oral.
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DOSIS
PERDIPINE
DIV (g/kg/min) Bolus (g/kg) 10 30
2 - 10 0.5 6
Hypertensive emergencies
(g/kg/min)
0.5
10
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Dwi Lestari
Preferred Antihypertensive Agents Nicardipine, fedoldopam, or nitroprusside in combination with nitroglycerin and a loop diuretic Esmolol, metoprolol, labetalol, diltiazem, verapamil in combintaion with low-dose nitroglycerin and a loop diuretic Labetalol or esmolol in combination with nitroglycerin Nicardipine, Diltiazem, labelatol, or fenoldopam Labetalol or combination of nicardipine and esmolol or combination of nitroprusside with either esmolol or IV metoprolol Labetalol or nicardipine Nicardipine or fenoldopam
Verapamil, diltiazem, or nicardipine in combination with a benzodiazepine Esmolol, nicardipine, or labetalol Nicardipine, Diltiazem, labetalol, or fenoldopam
Summary
Hypertension Crisis included Hypertensive Emergency and Hypertensive Urgency HE required immediate reduction in BP to avoid further end-organ damage, by IV therapy to lower the MAP by 25 Parenteral agents for hypertensive emergency : Clonidin, Nitroglycerin, Diltiazem, Nicardipine
Dwi Lestari
Dwi Lestari