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Hypertensive Crisis
Hypertension
Blood pressure
=
=
Preload
Contractility
Heart rate
Fluid volume
Sympathetic
nervous
system
Renal sodium
retention
Excess
sodium
intake
Reninangiotensinaldosterone
system
Genetic
factors
Kaplan (1994)
Hypertension
Systemic Vascular
Resistance
Cardiac
Output
Hypervolemia
- Renal artery stenosis
- Renal disease
- Hyperaldosteronism
- Aortic coarctation
Stress
- Sympathetic activation
Pheochromocytoma
- Increased
cathecholamines
Stress
- Sympathetic activation
Atherosclerosis
Renal artery disease
- Increased Ang II
Pheochromocytoma
- Increased cathecholamine
Thyroid dysfunction
Diabetes
Cerebral ischemia
Hypertension Guidelines
BP Classification
WHO-ISH 2003
ESH-ESC 2003
BP-JNC 7
Optimal
<120 / <80
<120/<80
Normal
Normal
<130 / <85
120-129 /80-84
Prehypertension
130-139 / 85-89
130-139 / 85-89
140-159 / 90-99
(140-149 / 90-94)
140-159 / 90-99
Stage 1 Hypertension
160-179/100-109
Stage 2 Hypertension
High normal
Grade 1 Hypertension
(mild)
Grade 2 Hypertension
(moderate)
160-179 /100-109
Grade 3 Hypertension
(severe)
Isolated Systolic
Hypertension
>140 / < 90
Isolated Systolic
Hypertension
Essential (Primary)
Hypertension
Certain
Risk factors
Secondary Hypertension
Secondary Hypertension
1. Identifiable underlying cause:
kidney disease
renal artery stenosis
hyperaldosteronism
pheochromocytoma
2. Represents approximately 10% of all hypertension
3. Has specific therapy, and is potentially curable
4. Often distinguishable from essential hypertension on
clinical grounds
Endocrine hypertension
Secondary hypertension
6-8%
Renal
4-5%
Miscellaneous
~2%
Endocrine
1-2%
Primary hyperaldosteronism 0.3%
Cushings syndrome
<0.1%
Pheochromocytoma
<0.1%
COMPLICATIONS
Cerebrovascular
disease: Thromboembolic,
16
14
Cumulative 12
10
incidence of 8
CV events
6
(%)
4
2
0
12
Cumulative 10
incidence of 8
CV events 6
4
(%)
2
0
High-normal BP
Men
Normal BP
Optimal BP
Women
High-normal BP
Normal BP
6
Years
10
12
Optimal BP
DIAGNOSIS
Diagnosis
Based
or isolated office HT
Approximately 20 to 25 % of pts
persistent office HT but repeatedly normal
when measured at home, at work, or by
ABPM
more common in the elderly, but is infrequent
(< 5%) in pts with office DP 105 mmHg.
Taken by a nurse or technician, rather than
the physician
Masked hypertension
Elevated
white coat HT
Suspected episodic HT (eg, pheochromocytoma)
HT resistant to increasing medication
Hypotensive symptoms while taking
antihypertensive medications
Autonomic dysfunction
EVALUATION
Aim
To determine
damage.
To assess the patient's overall
cardiovascular risk status.
To rule out identifiable and often curable
causes of hypertension
If HT diagnosed
Evaluate
Evaluate
Think
Physical examination
Goal
Testing
Hematocrit,
Severe or refractory HT
An acute rise in BP over a previously stable baseline
Proven age of onset before puberty or above age 50.
An acute Cr that is either unexplained or occurs after the
institution of therapy with an ACE-i or AIIRB
Moderate to severe HT in a patient with diffuse atherosclerosis
or an incidentally discovered asymmetry in renal disease.
A systolic-diastolic abdominal bruit that lateralizes to one side.
Negative family history for HT.
Moderate to severe HT in patients with recurrent episodes of
acute pulmonary edema or otherwise unexplained CHF.
TREATMENT
WHOISH targets
<130/85 mmHg in young, middle-aged and diabetic
patients
<140/90 mmHg in elderly patients
JAMA. 2003; 289:2560-2572
J Hypertens 1999;17:151183
Lifestyle Modification
Modification
Weight reduction
814 mmHg
Dietary sodium
reduction
28 mmHg
Physical activity
49 mmHg
Moderation of
alcohol consumption
24 mmHg
Drug treatment
cardiac output
-adrenergic
blockers
Ca2+ Channel blockers
Dilate
resistance vessels
Ca2+
Channel blockers
Renin-angiotensin system blockers
1 adrenoceptor blockers
Nitrates
Reduce
vascular volume
Diuretics
Direct
vasodilators
Renin inhibitors
Renin
BLOCKERS
Cardiac
Output
Thiazids
ACE-i
ARBs
Calsium Antagonist+
BLOCKERS
HYDRALAZINE
PERIPHERAL
VASCULAR
RESISTENCE
Preferred drugs
Drugs to be
avoided
Asthma
CCBs
-blockers/ARB/Diuretics/
ACE-i
-blockers
Diabetes
mellitus
-blockers/ACE-i/
ARB
CCBs
Diuretics/
-blockers
High
cholesterol
levels
-blockers
ACE-i/ARB/ CCB
-blockers/
Diuretics
Elderly
patients
CCBs
-blockers/ACE-i/
BPH
- blockers
ARB/- blockers
-blockers/ ACE-i/ ARB/
Diuretics/ CCBs
Stage 1 Hypertension
(SBP 140159 or DBP
9099 mmHg)
Thiazide-type diuretics
for most. May consider
ACEI, ARB, BB, CCB,
or combination
Stage 2 Hypertension
(SBP >160 or DBP >100
mmHg)
2-drug combination for
most (usually thiazidetype diuretic and ACEI
or ARB or BB or CCB)
Not at Goal BP
Optimize dosages or add additional drugs
until goal BP is achieved.
Consider consultation with hypertension
specialist.
Main side-effects
Contraindications/
Special Precautions
Electrolyte
Hypersensitivity, Anuria
imbalance,
level of total and
C-LDL,, glucose
levels, UC, CHDL
Impotence,
-blockers
(e.g. atenolol) Bradycardia,
fatique
Hypersensitivity, Bradycardia,
Conduction disturbances,
Diabetes, Asthma, Severe
cardiac failure
Main side-effects
Pedal edema,
Headache
Contraindications/
Special Precautions
Non-DHP CCBs (e.g diltiazem)
Hypersensitivity, Bradycardia,
Conduction disturbances, CHF, LV
dysfunction.
DHP CCBsHypersensitivity
Headache, Dizziness
Hypersensitivity, Pregnancy,
Bilateral renal artery stenosis
Hypertensive Crises
Definitions:
Acute
life-threatening increase in BP
Hypertensive
urgency: severe
hypertension (usually SBP > 180 and DBP
> 120 mmHg) without acute target organ
damage (TOD)
Hypertensive
TOD
Pathogenesis
Untreated
Sudden
essential hypertension
withdrawal / non-adherence to
Renovascular
Clinical Manifestations
Encephalopathy
AMI/USA
Nephropathy
Aortic
dissection
LV failure/cardiac decompensation
Eclampsia
Patient evaluation
Medical
history
Physical examination
Laboratory evaluation
serum
urine
Medication profile
Drug use
Fundoscopy
EKG, CXR, head CT, echo
Laboratory evaluation
Urinalysis:
Therapeutic approach
Time
selection
Route
neurologic deficits
Retinal ischemia: blindness
Acute myocardial infarction
Deteriorating renal function
Drug treatment of
hypertensive emergencies
Nitroprusside
Potent
steal
cyanide toxicity
Hepatic
conversion to thiocyanate
Less toxic
Cleared renally
Na thiosulfate antidote
ototoxicity,
encephalopathy, seizures
Increase mortality post MI
May
Nicardipine
Water
Nifedipine
Given
SL, absorbed PO
onset 5min, peak 30-60, duration 6h
direct arterial dilation, decrease PVR
unpredictable BP lowering
cerebral, renal, cardiac ischemia- fatal!
Elderly most prone to ADR
Do not use!
Oral agents
Treatment of specific
hypertensive emergencies
Pregnancy
Usually
Nah gambar di atas ada dua,Tata Surya dan Pulau Jawa. Takaran Alam ini
kira2 kalau dihitung pakai matematika hasilnya:
Tata Surya dibanding Galaksi Bima Sakti = 1 cm dibanding 1000 km
Jadi = sebuah neker dibanding sebuah pulau Jawa sebagai radiusnya.
Kalau Tatasurya sebesar kelereng, maka Galaksi Bima Sakti adalah sebesar
Bola dengan Radius sepanjang pulau Jawa pokoknya bayangin sendiri
ajakarena saat itu kita ndak jelas seberapa ukuran kita..???
Padahal Galaksi tidak sekedar satu namun Milyaran