CRISIS HYPERTENSION

Dr. Santoso C.

 The syndrome of hypertensive emergency was first described by Volhard & Fahr in 1914 and was characterized by severe accelerated hypertension (also called malignant-accelerated hypertension), accompanied by evidence of renal disease and by signs of vascular injury to the heart, brain, retina and kidney, and by a rapidly fatal course ending in heart attack, renal failure or stroke .

DEFINITION
The 2003 Joint National Committee (JNC) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) defi nes hypertensive crisis as a systolic BP (SBP) >179 mmHg or a diastolic BP (DBP) >109 mmHg with or without acute target organ involvement.

HYPERTENSIVE EMERGENCIES : DEFINITION

Acute, life-threatening, and increases in BP > 180/120 mmHg There are two major clinical syndromes :
Malignant hypertension, is marked hypertension with retinal hemorrhages, exudates, or papilledema. Hypertensive encephalopathy, sign of cerebral edema.

HYPERTENSIVE EMERGENCIES
Diagnosis : Papiledema must be present

Papiledema. Note the swelling of the optic disc, with blurred margins

HYPERTENSIVE EMERGENCIES
Develop in up to 1% of patients with essential hypertension Elevated blood pressure results in target organ damage The systems primarily involved include :
CNS CVS Renal system

 Hypertensive urgency :
Severely elevated BP (systolic >180 mmHg; or diastolic >110 mm Hg) No evidence of ongoing or imminent target organ dysfunction related to the current episode of hypertension

Cerebral autoregulation in hypertension

Schematic representation of autoregulation of cerebral blood flow in normotensive and hypertensive subjects. In both groups, initial increases or decreases in mean arterial pressure are associated with maintenance of cerebral blood flow due to appropriate changes in arteriolar resistance. More marked changes in pressure are eventually associated with loss of autoregulation, leading to a reduction (with hypotension) or an elevation (with marked hypertension) in cerebral blood flow. These changes occur at higher pressures in patients with hypertension, presumably due to arteriolar thickening. Thus, aggressive antihypertensive therapy will produce cerebral ischemia at a higher mean arterial pressure in patients with underlying hypertension. Redrawn from Kaplan, NM, Lancet 1994; 344:1335.

PATHOPHYSIOLOGY
The reason is poorly understood Mechanical and humoral factors Mechanical stress and endothelial injury leading to :
Increased permeability Activation of the coagulation cascade and platelets Deposition of fibrin.

Endothelial injury and fibrinoid necrosis Release of additional vasoactive mediators Activate RAA system result in further vasoconstriction and production of proinflammatory cytokines Volume depletion due to pressure natriurresis further stimulates the release of vasoconstrictor These collective mechanisms can culminate in end organ hypoperfusion, ischemia and dysfunction

 Dilatation of cerebral arteries following a breakthrough of the normal autoregulation of cerebral blood flow. This results in hyperperfusion and cerebral edema, which causes the clinical manifestations of hypertensive encephalopathy

OTHER CAUSES :
Complications of pregnancy Use of cocaine, MAOIs, oral contraceptives Withdrawal of alcohol, beta-blockers, or alpha stimulants Renal artery stenosis Pheochromocytoma Aortic coarctation Hyperaldosteronism Hyper and hypothyroidism

CLINICAL MANIFESTATIONS
Most often occurs in patients with long -standing uncontrolled hypertension. Marked elevation in BP, usually above 180/120 mmHg. Retinal hemorrhages, exudates and papilledema. Malignant nephrosclerosis, leading to acute kidney injury, hematuria and proteinuria. Neurologic symptoms due to intracerebral or subarachnoid bleeding, lacunar infarcts, or hypertensive encephalopathy.

EVALUATION
Duration and previous level of high BP Quantification of smoking and physical activity, weight gain and dietary intake Screening for symptoms of malignant hypertension, focusing on the cardiac, renal, and CNS Underlying medical disorders The patients medications and other drugs should be thoroughly reviewed The most common presentations : chest pain, dyspnea and neurologic deficit

PHYSICAL EXAM
Palpation of kidneys Auscultation of abdominal murmurs ( renovascular hypertension); Auscultation of heart sound and murmurs (aortic coarctation or aortic stenosis) Murmurs over neck arteries Motor or sensory neurological defects Abnormal cardiac rhythms, ventricular gallop Pulmonary rales Fundoscopic abnormalities in the retina Intravascular volume status Absence, reduction or asymmetry of pulses in lower extremities and ischemic skin lesions Body weight, waist circumference and body mass index.

CARDIOVASCULAR SYSTEM
Presenting symptoms :
Angina Myocardial infarction Congestive heart failure Pulmonary edema

Blood pressure must be checked in both arms to screen for aortic dissection or coarctation Volume status must be assessed

CENTRAL NERVOUS SYSTEM

Neurologic presentations :
Occipital headache Cerebral infarction or hemorrhage Visual disturbance

Encephalopathy (severe hypertension, headache, vomiting, visual disturbance, mental status changes, seizure, and retinopathy (papil edema) Focal signs mandate screening for cerebral hemorrhage, infarct or the presence of a mass

RENAL, GASTROINTESTINAL AND OPHTHALMOLOGIC SYSTEMS

Renal symptoms : oliguria, any of the typical features of renal failure Gastrointestinal symptoms : nausea, vomiting Ophthalmologic systems : blurred vision, flame-shaped retinal hemorrhages, soft exudates or papiledema Others : microangiopathic hemolytic anemia

THE FOLLOWING CONDITIONS SHOULD ALSO BE CONSIDERED : Stroke Intracranial mass Head injury Epilepsy or postictal state Connective-tissue disease (especially lupus with cerebral vasculitis) Drug overdose or withdrawal Cocaine or amphetamine ingestion Acute anxiety Thrombotic thrombocytopenic purpura

WORKUP
Initial lab studies : CBC and electrolytes (including calcium), BUN, creatinine, glucose, coagulation profile, and urinalysis Others are as indicated : cardiac enzymes, urinary catecholamines, and TSHs, and 24hour urine collection for VMA and catecholamines.

1. RADIOLOGIC STUDIES
Chest radiograph Others are as indicated :
Head CT scanning Transesophageal Echocardiogram Renal angiography

2. Electrocardiography

Tabel 1. Manifestasi Klinis dari Hipertensi Emergensi

Hipertensi ensefalopati Stroke iskemik akut dan perdarahan Diseksi aorta akut Infark miokard akut Sindroma koronaria akut Edema paru dengan gagal nafas Pre-eklampsia berat, sindroma HELLP, Eklampsia Gagal ginjal akut Trauma kepala Krisis adrenal : withdrawal penyekat beta atau klonidin, penggunaan kokain, fensiklidin HCl, krisis feokromositoma Perdarahan : paska operasi, epistaksis berat

Tabel 2. Triase pasien dengan hipertensi sangat tinggi

Hipertensi berat
Tekanan darah
Gambaran klinis : gejala Gambaran klinis : tanda

Hipertensi urgensi
> 180/110 mmHg

Hipertensi emergensi

> 180/110 mmHg

Target jangka pendek

Tempat pengobatan Obat-obatan

Evaluasi

Sering kali > 220/140 mmHg Dapat tidak Sakit kepala hebat, sesak Nyeri dada, sesak berat, bergejala; sakit nafas, edema gangguan status mental, kepala defisit neurologik fokal Tidak ada kerusakan Biasanya tidak ada Kerusakan organ akut organ akut kerusakan organ akut, yang mengancam jiwa tetapi mungkin terdapat (contoh : infark miokard peningkatan kreatinin akut, stroke, ensefalopati, serum gagal ginjal akut dan gagal jantung) Turunkan tekanan Turunkan tekanan darah Turunkan tekanan darah darah dalam hitungan dalam 24 hingga 72 jam segera; turunkan 15 hari hingga 25% dalam 2 jam Rawat jalan Biasanya dapat dilakukan Rawat inap, di unit rawat jalan perawatan intensif Oral, kerja panjang Oral, dengan onset Intravena cepat; kadang-kadang diperlukan intravena Dalam 3 hingga 7 Dalam 24 hingga 72 jam Intensif hari

Tabel 3. Obat-obatan yang dipakai untuk hipertensi urgensi

Obat
Labetalol Klonidin

Dosis
200 400 mg po 0,1 0,2 mg po; dapat diulang tiap jam hingga max 0,6 mg 12,5 25 mg po

Onset kerja Keterangan

20 120 mnt 30 60 mnt Spasme bronkus, bradikardi, memperburuk gagal jantung Rebound jika dihentikan mendadak

Kaptopril

15 60 mnt

Dapat mempresipitasi gagal ginjal akut pada stenosis arteri renalis bilateral Hindari nifedipin sub lingual atau kerja pendek karena risiko stroke, infark miokard akut dan hipotensi berat Sakit kepala, takikardia, flushing, edema perifer Sinkope (dosis pertama), takikardi, hipotensi postural

Nifedipin lepas lambat

30 mg po

20 mnt

Amlodipin Prazosin

5 10 mg po 1 2 mg po

30 50 mnt 2 4 jam

Obat
Sodium nitroprusid

Dosis
0,25-2,0 g/kg/mnt iv

Onset/lama kerja Keterangan (setelah distop)

Segera/2-3 mnt Mual, muntah, twitching otot; penggunaan jangka lama dapat menyebabkan intoksikasi thiosianat, asidosis methemoglobinemia, intoksikasi sianida; botol atau iv set harus terlindung dari cahaya Sakit kepala, pening, takifilaksis

Nitrogliserin

Nikardipin

5 g/mnt, titrasi 5 g/mnt tiap 5 hingga 10 mnt ingga maksimum 60 g/mnt 5 mg/jam, dinaikkan 2,5 mg/jam tiap 5 mnt hingga maksimum 15 mg/jam

2-5 mnt/ 5-10 mnt

Fenoldopam

Labetalol

Klonidin

0,1 g/kg/mnt sbg dosis inisial, dinaikkan 0,05 hingga 0,1 g/kg/mnt hingga maksimum 1,6 g/kg/mnt Bolus inisial 20 mg, bolus iv dapat 2-5 mnt/2-4 jam diulang 20 80 mg atau infus 2 mg/mnt dengan dosis max 300 mg/24 jam 0,15-0,3 mg iv tiap 40 mnt

1-5 mnt/15-30 mnt, tapi mungkin lebih dari 12 jam setelah pemberian lama < 5 mnt/30 mnt

Sakit kepala, pening, flushing, mual, edema, takifilaksis, meningkatkan tekanan intrakranial

Mual, sakit kepala, flushing, phlebitis lokal

Spasme bronkus, hipotensi, pening, mual/muntah, hipotensi orthostatik, blokade irama jantung

Diltiazem

Verapamil Enalapril

Dosis inisial 0,25 mg/kg diberikan 3-30 mnt dalam 2 mnt, diikuti infus 5-15 g/kg/mnt atau 15-45 mg/jam (BB 50 kg) 5-10 mg iv; dapat diikuti dengan 1-5 mnt/30-60 mnt infus 3-25 mg/jam 0,625-1,250 mg iv tiap 6 jam 15-60 mnt/12-24 jam

Efek paradoksal berupa kenaikan tekanan darah dapat dijumpai pada sebagian pasien setelah dosis inisial, kondisi ini dapat dicegah dengan pemberian fentolamin iv Sedasi, mulut kering, konstipasi, rebound hipertensi Hipotensi, flushing

Hambatan irama jantung Gagal ginjal pada pasien stenosis arteri renalis bilateral, hipotensi

Tabel 5. Rekomendasi obat antihipertensi untuk hipertensi emergensi

Kondisi Edema paru akut Iskemik miokard akut Hipertensi ensefalopati Diseksi aorta akut Eklampsia Gagal ginjal akut Krisis adrenal Obat antihipertensi yang di rekomendasi Fenoldopam atau nitropruside kombinasi dengan nitrogliserin dan diuretik kuat Labetalol kombinasi dengan nitrogliserin Labetalol, nikardipine, atau fenoldopam Labetalol atau kombinasi dengan nikardipin atau fenoldopam Labetalol atau nikardipin, hydralazin Fenoldopam atau nikardipin Verapamil, diltiazem, atau nikardipin dengan benzodiazepin

kombinasi

TERIMA KASIH