Hipertensi

dr M. arman Nasution SpPD

WHAT IS HYPERTENSION?
I. SYSTOLIC AND DIASTOLIC
PRESSURES
The top and bottom numbers of blood pressure
reading are called systolic and diastolic pressures
respectively.
When your heart contracts, it forces blood through
the arteries, which in turn creates a pressure and
that pressure is called systolic pressure. A
normal systolic pressure is below 120mmHg.
The bottom number or the diastolic pressure is
the pressure in the arteries when the heart is in
the phase of relaxation. This number should ideally
be below 90.
II. WHAT IS
HYPERTENSION?
A sustained elevation of the systemic
arterial pressure is termed as
hypertension and is also called arterial
hypertension.
A systolic blood pressure (SBP) of 140
mmHg or a diastolic blood pressure
(DBP) of > 90 mmHg indicates the
presence of hypertension.
In presence of diabetes a blood
pressure > 130/80 mmHg is defined as
III. CLASSIFICATION OF
HYPERTENSION
1. Hypertension in Adults
- A person is said to be pre-hypertensive if their systolic pressure
is in the range of 120-139mmHg and diastolic pressure falls in
the range of 80-90mmHg.
- The following table clearly shows how the new classification is
different from the older version.
2. Hypertension in Children and Adolescents
- Blood pressure readings normal for an adult are above the normal
range for a child.
- Children who are overweight or obese with abnormal eating habits
should specifically get their blood pressures checked during medical
checkups.
IV. CAUSES OF
HYPERTENSION
1. Essential Hypertension
- A systolic blood pressure of 140mmHg or a
diastolic blood pressure of >90mmHg on
multiple readings, in the absence of a
specific, identifiable underlying cause is
known as essential hypertension.
- The most common presentation of essential
hypertension is an asymptomatic patient, in
whom an elevated blood pressure is found
during a routine examination.
- When a patient presents with symptoms
then they are more likely associated with:
Hypertensive emergency.

Long-term complications of end-organ

damage.
Symptoms of diseases underlying
secondary causes of hypertension.
2. Secondary hypertension
Presentation in this case depends on the underlying cause and the
organ
that is affected.
The following table shows the types of hypertension and the
percentage of
the population affected
Most common secondary causes of
hypertension are:
a. Sleep apnea: around 50 percent of people

with sleep apnea have hypertension.

a. Renal hypertension: renal diseases that

cause vascular damage, reduce the ability
of the kidneys to excrete the salt and
water, which in turn causes fluid retention
and leads to hypertension.
c. Endocrine hypertension
Three major conditions that cause over the
functioning of the adrenal gland and result in
hypertension are:
- Primary aldosteronism
- Cushings disease
- Pheochromocytoma

d. Monogenic hypertension: mutations in a

number of single genes are known to cause
hypertension. This type of hypertension is
known as monogenic hypertension.
e. Coarctation of aorta: coarctation of the
aorta is congenital narrowing of the aorta
which causes hypertension, mostly in
teenagers.

f. Thyroid hormone imbalance

Other secondary causes of hypertension

include,
stress, anxiety and depression, anabolic
steroids,
non-steroidal anti-inflammatory drugs, and
V. RISK FACTORS FOR
HYPERTENSION
Family history
Co-morbid diseases like diabetes or renal disease
African-American heritage
Obesity
Smoking
Alcohol consumption (more than two drinks/day)
Oral contraceptive pills
Physical inactivity
Stress
VI. HYPERTENSION
SYMPTOMS
- The most common presentation of essential hypertension is
an asymptomatic patient. Such patients are unaware of their
elevated blood pressures and get to know about this at a
routine check up
- Hypertensive emergency symptoms
Signs and symptoms of cardiac, neurological, renal and retinal
involvement
There is evidence of stroke, subarachnoid hemorrhage,
myocardial ischemia and other abnormalities on fundoscopy
Most commonly and acutely this condition results in headaches,
dizziness, chest pain, dyspnea, blurred vision, and palpitations.
- In secondary hypertension the symptoms are associated
with the underlying disease that has resulted in elevated blood
pressure symptoms.
VII. CONDITION RESULTING
FROM VASCULAR INJURY
1. Cardiac complications
Myocardial infarction, heart failure, left
ventricular hypertrophy, aortic aneurysm and
dissection are few of those complications that
could be a result of persistent elevation of blood
pressure.

2. Cerebrovascular complications
One-third of the population affected by
hypertension is not aware of their condition,
until they have an attack of stroke.
3. Renal proteinuria and failure
An elevated blood pressure is one of the
leading causes of kidney damage that
eventually requires a transplant.
4. Retinopathy
Hemorrhages, exudates and arteriolar
narrowing can occur. They result in
blurred vision and sometimes blindness as
well
VIII. MANAGEMENT OF
HYPERTENSION
1. Lifestyle modification
Weight reduction
Dietary sodium restriction
Aerobic exercise
Avoiding excessive alcohol intake
DASH diet- increase fruits, vegetables, low-fat dairy and low-fat
diet

2. Drug treatment
There are around 50 medications approved for initial treatment
of hypertension. Candidates ideal for drug therapy are those
whose diastolic blood pressure remains above 90mmHg despite
a 3-6 month trial of non-pharmacological therapy.
 Treatment of Hypertension
Based on the Seventh Report of the
Joint National Committee on
Prevention, Detection ,Evaluation and Treatment
of High Blood Pressure (JNC-7)
Objectives
Define hypertension
Principles of treatment
Special groups
Blood Pressure Classification
BP
SBP DBP
CLASSIFICATION
Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 HTN 140-159 or 90-99

Stage 2 HTN >160 >100

 Why Treat Hypertension ?
To decrease:
Cerebrovascular Accidents 35-40%
Coronary events 20-25%
Heart failure 50%
Progression of renal disease
Progression to severe hypertension
All cause mortality
Awareness, Treatment and Control of
Blood Pressure 1976-2000 (NHANES)

80
70
60
50
Awareness
40
Treatment
30 Control
20
10
0
1976-1980 1988-1991 1991-1994 1999-2000
Factors to Consider in Treating
Hypertension

Repeat readings
r/o secondary causes
Estimate CV risk status
Co-morbid conditions
Lifestyle changes
Drugs
Secondary Hypertension
Difficult to control
Sudden onset of HTN
Well controlled-> difficult to
control
Severe hypertension
History/physical/labs
Initial Workup of
Secondary HTN
Renal parenchymal disease
UA, spot urine protein/creatinine, serum creatinine, USG.
Renovascular
Captopril scan
Coarctation
Lower Extremity BP
Primary aldosteronism
Serum and urinary K
Plasma renin and aldosterone ratio
Pheochromocytoma
Spot urine for metanephrine/creatinine
Laboratory Tests in
Uncomplicated HTN
ECG
Urine analysis
Blood glucose, hematocrit
Basic metabolic panel
Lipid profile after 9-12 hour fast
Urine microalbumin
 Estimate Risk Status
Hypertension
Smoking
Obesity (BMI > 30kg/m2)
Dyslipidemia
Diabetes
Microalbuminuria or GFR <60ml/min
Age > 55 (men), 65 (women)
Family history of CVD
(Men< 55, Women <65)

Metabolic Syndrome
Target Organ Damage
Heart Disease
CAD (Angina, myocardial infarction, coronary
revascularization
Left Ventricular Hypertrophy
Heart Failure

Stroke/TIA
Chronic kidney disease
Peripheral arterial disease
Retinopathy
 Goals of Therapy
BP <140/90 mmHg

BP <130/80 mmHg in patients

with diabetes or chronic kidney disease.

Achieve SBP goal especially in persons

>50 years of age.
 Lifestyle Modification
Modification Approximate SBP reduction
(range)
Weight reduction 520 mmHg/10 kg weight loss

Adopt DASH eating plan 814 mmHg

Dietary sodium reduction 28 mmHg

Physical activity 49 mmHg

Moderation of alcohol 24 mmHg

consumption
 Drugs for Hypertension
Diuretics Direct Vasodilators *
Thiazide
Loop diuretics
Aldosterone antagonists Calcium channel
K-sparing blockers
Dihydropyridine
Adrenergic inhibitors Non dihydropyridine
Peripheral agents

Central (-agonists)
ACE-inhibitors
alpha -blockers*
beta-blockers
Alpha+beta-blockers Angiotensin-II blockers
* Usually not monotherapy
 Algorithm for Treatment of Hypertension
Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140159 or DBP 9099 mmHg) (SBP >160 or DBP >100 mmHg) indications
Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs
May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB)
or combination. ACEI, or ARB, or BB, or CCB) as needed.

Not at Goal
Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
 Classification and Management
of BP for adults
Initial drug therapy
BP Class SBP DBP Lifestyle Without compelling Compelling
indication indications
Normal <120 <80 Encourage None None
Pre- 120 or 80 Yes No antihypertensive drug Drug(s)
hypertension 139 89 indicated.
Stage 1 140 or 90 Yes Thiazide-type diuretics
Hypertension 159 99 for most. May consider
ACEI, ARB, BB, CCB, or Other
combination. antihypertensive
drugs (diuretics,
Stage 2 >160 or Yes Two-drug combination ACEI, ARB, BB,
Hypertension >100 (usually thiazide and CCB) as needed.
ACEI or ARB or BB or
*Treatment determined by highest BP category. CCB).
Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
Special Considerations

Compelling Indications
Special populations
HTN with COPD and MI
A 55 year old patient with COPD and HTN (controlled
with nifedipine) is admitted with severe chest pain
x24 hrs.
BP is 170/100 and she has a soft S3 gallop.

ECG shows an anterior wall MI.

She is not a candidate for thrombolysis. ECHO shows an

ejection fraction of 35%.

How will you manage her hypertension?

Compelling Indications for
Certain Drug Classes
HTN with CAD
Beta blockers: cardioprotective
(reinfarction, arrhythmias and sudden
death)
ACE inhibitors: MI with systolic
dysfunction- heart failure and mortality
improved
Renal Insufficiency
A 30 year old patient with IDDM is referred
with difficult-to-control HTN on diltiazem and
clonidine.

Exam reveals BP=190/100 and 3+ edema.

Labs: Creatinine = 2.2 mg/dL

Serum K = 5.1 meq/L
24 hour protein =5g
Hypertension with Renal Insufficiency
Goal BP <130/80
ACE-inhibitors/angiotensin receptor blockers
should be used if no contraindications
Most patients have volume overload:
Diuretics should be included in the regimen.
Thiazides ineffective if S Creat>2.5
A 40 year old previously healthy male is brought to the E.R. with 3
days of progressive shortness of breath and has experienced
blurred vision in both eyes.
Physical exam:
Blood pressure 230/140. Lethargic.
Eye exam: Papilledema
Chest: Bibasilar crackles
Cardiac: S1S2S4
Neuro: Bilateral upgoing plantars:
Extr: 2+ edema
Labs: K=3.4, BUN=35, Creatinine: 2.2
CXR: Pulmonary edema
Urine: 10-15 red cells, 2+ albumin.
Hypertensive Urgencies and
Emergencies
HYPERTENSIVE EMERGENCIES
Require immediate blood pressure reduction (not necessarily
to normal range) to prevent or limit target organ damage.

HYPERTENSIVE URGENCIES
Require reduction of blood pressure within a few hours
 KRISIS
HIPERTENSI
LATAR BELAKANG
Hipertensi Masalah kesehatan masyarakat
dunia
Beberapa penulis 1% dari penderita
hipertensi akan mengalami krisis hipertensi
Majalah the Lancet dan WHO Kejadian
krisis hipertensi akan m dari 0,26% th 2000
0,29% th 2025 pd penduduk dewasa di
dunia
Untuk mencegah kerusakan organ akibat
krisis hipertensi di Indonesia perlu dilakukan
upaya pengenalan dini dan penatalaksanaan
krisis hipertensi yang disepakati bersama.
DEFINISI
Krisis hipertensi
Suatu keadaan peningkatan tekanan
darah yang mendadak (sistole 180
mmHg dan/atau diastole 120 mmHg),
pd penderita hipertensi, yg
membutuhkan penanggulangan segera.
KLASIFIKASI KRISIS HIPERTENSI
1. Hipertensi emergensi
Kenaikan TD mendadak yg disertai
kerusakan organ target yang
progresif. Di perlukan tindakan
penurunan TD yg segera dalam kurun
waktu menit/jam.
2. Hipertensi urgensi
Kenaikan TD mendadak yg tidak
disertai kerusakan organ target.
Penurunan TD harus dilaksanakan
dalam kurun waktu 24-48 jam.
MANIFESTASI KLINIS KRISIS HIPERTENSI

1. Bidang neurologi:
Sakit kepala, hilang/ kabur
penglihatan, kejang, defisit neurologis
fokal, gangguan kesadaran
(somnolen, sopor, coma).
2. Bidang mata:
Funduskopi berupa perdarahan
retina, eksudat retina, edema papil.
3. Bidang kardiovaskular
Nyeri dada, edema paru.
4. Bidang ginjal:
Azotemia, proteinuria, oligouria.

5. Bidang obstetri
Preklampsia dg gejala berupa gangguan
penglihatan, sakit kepala hebat, kejang,
nyeri abdomen kuadran atas, gagal
jantung kongestif dan oliguri, serta
gangguan kesadaran/ gangguan
serebrovaskuler.
FAKTOR RISIKO
Penderita hipertensi yg tidak meminum obat
atau minum obat anti hipertensi
Kehamilan
Penggunaan NAPZA
Penderita dg rangsangan simpatis yg tinggi
seperti luka bakar berat, phaechromocytoma,
penyakit kolagen, penyakit vaskuler, trauma
kepala.
Penderita hipertensi dengan penyakit
parenkim ginjal
PENDEKATAN AWAL PD KRISIS HIPERTENSI

Anamnesis
R/ hipertensi (awal hipertensi, jenis
obat anti
hipertensi, keteraturan konsumsi
obat).
Ganguan organ (kardiovaskuler,
serebrovaskular, serebrovaskular,
renovaskular, dan organ lain).
 Pemeriksaan fisik
Sesuai dengan organ target yang terkena
Pengukuran TD di kedua lengan
Palpasi denyut nadi di keempat
ekstremitas
Auskultasi untuk mendengar ada/ tidak
bruit
pembuluh darah besar, bising jantung
dan ronki
paru.
Pemeriksaan neurologis umum
Pemeriksaan laboratorium awal dan penunjang

Pemeriksaan laboratorium awal:

a. Urinalisis
b. Hb, Ht, ureum, kreatinin, gula darah
dan
elektrolit.
Pemeriksaan penunjang: ekg, foto
toraks
Pemeriksaan penunjang lain bila
memungkinkan:
PENETAPAN DIAGNOSTIK
Walau biasanya pd krisis hipertensi
ditemukan TD 180/120 mmHg perlu
diperhatikan kecepatan kenaikan TD
tersebut dan derajat gangguan organ
target yang terjadi.
TATALAKSANA KRISIS HIPERTENSI

Penatalaksanaan krisis hipertensi

sebaiknya dilakukan di rumah sakit,
namun dapat dilaksanakan di tempat
pelayanan primer sebagai pelayanan
pendahuluan dengan pemberian obat
anti hipertensi oral.
TATALAKSANA HIPERTENSI EMERGENSI

Harus dilakukan di RS dg fasiltas

pemantauan yg memadai
Pengobatan parenteral diberikan secara
bolus atau infus sesegera mungkin
TD harus diturunkan dalam hitungan menit
sampai jam dengan langkah sbb:
a. 5 menit s/d 120 menit pertama TD rata-
rata
(mean arterial blood pressure) diturunkan
20-
25%.
b. 2 s/d 6 jam kemudian TD diturunkan
sampai 160/100 mmHg.

c. 6-24 jam berikutnya diturunkan sampai

<140/90 mmHg bila tidak ada gejala
iskemia organ.
OBAT-OBATAN YANG DIGUNAKAN PADA
HIPERTENSI EMERGENSI
Clonidin (catapres) IV (150 mcg/ampul)

a. Ckonidin 900 mcg dimasukkan dalam

cairan
infus glucosa 5% 500cc dan diberikan
dengan mikrodrip 12 tetes/ menit, setiap
15
menit dapat dinaikkan 4 tetes sampai TD
yg
diharapkan tercapai.
b. Bila TD target tercapai pasien diobservasi
selama 4 jam kemudian diganti dg tablet
clonidin oral sesuai kebutuhan.
c. Clonidin tidak boleh dihentikan
mendadak, tetapi diturunkan perlahan-
lahan oleh karena bahaya rebound
phenomen, dimana TD naik secara
cepat bila obat dihentikan.
 Diltiazem (Herbesser) IV (10 mg dan 50
mg/ampul)
a. Diltiazem 10 mg IV diberikan dalam 1-3
menit
kemudian diteruskan dg infus 50 mg/jam
selama 20 menit.
b. Bila TD telah turun >20% dari awal,
dosis
diberikan 30 mg/jam sampai target
tercapai.
c. Diteruskan dg dosis maintenance 5-10
mg/jam
 Nicardipin (Perdipin) IV (12 mg dan 10
mg/ampul)
a. Nicardipin diberikan 10-30 mcg/kgBB bolus.
b. Bila TD tetap stabil diteruskan dengan 0,5-6
mcg/kgBB/menit sampai target TD tercapai.
Labetalol (Normodyne) IV
Diberikan 20-80 mg IV bolus setiap 10 menit
atau dapat diberikan dalam cairan infus dg dosis
2 mg menit.
Nitroprusside (Nitropress, Nipride) IV
Diberikan dlm cairan infus dg dosis 0,25-10.00
mcg/kg/menit.
 KRISIS HIPERTENSI PD KEADAAN
KHUSUS

Krisis hipertensi pd gangguan otak

1. Stroke
A. Infark: aterotrombotik, kardioembolik,
lakunar.
TD sistolik >220 mmHg dan diastolik
>120 mmHg. Pengukuran dilakukan dua
kali dalam jangka waktu 30 menit
Tidak ada tanda-tanda yg meningkatkan TD
seperti nyeri kepala/artikular, kandung kemih
penuh.
 Obat anti hipertensi parenteral diberikan
sesuai
prosedur dengan batas penurunan
maksimal
TD 20-25% dari mean arterial blood
pressure.

Jika TD sistolik 180-220 mmHg dan TD

diastolik 105-120 mmHg, dilakukan
penatalaksanaan seperti terapi pd
hipertensi
b. Perdarahan: perdarahan intraserebral,
perdarahan subarachnoid, pecahnya Arteriovenous
Malformation (AVM).
TD sistolik >220 mmHg dan diastolik >120 mmHg.

Pengukuran dilakukan dua kali dalam jangka waktu

30 menit.
Tidak ada tanda-tanda lain yg meningkatkan
TD seperti nyeri kepala/ artikular, kandung
kemih penuh.
 Obat anti hipertensi parenteral diberikan
sesuai
prosedur tatalaksana krisis hipertensi dg
batas penurunan TD 20-25% dari mean
arterial blood pressure.

Target TD adalah sistolik 160 mmHg dan

diastolik 90 mmHg.
 Tabel No. 1. Obat-obat parenteral untuk terapi emergensi
hipertensi pada stroke akut

Obat Dosis Mulai kerja Lama Efek samping Keterangan

kerja

Labetolol 20-80 mg iv 5-10 menit 3-6 jam Nausea, vomtus Terutama

bolus setiap ,hipotensi, blok untuk
10 menit at atau gagal kegawatdaru
2 mg/menit, jantung,kerusak ratan
infus an hati, hipertensi,
kontinyu bronkospasme kecuali pd
gagal
jantung
Nikardipin 5-15 mg/jam 5-15 menit Sepanjan Takikardi Larut dalam
Infus g infus air, tidak
kontinyu berjalan sensitif
terhadap
cahaya
Diltiazem 5-40 5-10 menit 4 jam Blok nodus A-V, Krisis
g/kg/menit denyut prematur hipertensi
infus atrium, terutama
kontinyu usia lanjut
2. Ensefalopati hipertensi
TD sistolik >220 mmHg dan diastolik >120

mmHg. Pengukuran dua kali dalam jangka

waktu 30 menit.
Terdapat gangguan kesadaran, retinopati dg
papiledema, peningkatan tekanan intrakranial
sampai kejang.
Tidak ada tanda-tanda lain yg meningkatkan TD

Obat antihipertensi parenteral diberikan sesuai

prosedur tatalaksana hipertensi krisis dg batas
penurunan TD 20-25% dari MAP.
3. Cedera kepala dan Tumor intrakranial

Terdapat gejala tekanan intrakranial yg

meningkat seperti: sakit kepala hebat, muntah
proyektil/ tanpa penyebab gastrointestinal,
papiledema (sembab papil), kesadaran
menurun.
TD sistolik >220 mmHg dan diastolik >120
mmHg . Pengukuran 2x dlm jangka waktu 30
menit.
Tidak ada tanda-tanda lain yg meningkatkan TD
 Obat anti hipertensi parenteral diberikan sesuai
prosedur tatalaksana hipertensi krisis dg batas
penurunan TD 20-25% dari MAP.

Khusus untuk tumor intrakranial hipofisis perlu

dilakukan pemeriksaan hormonal dan
penatalaksanaan sesuai dg hipertensi krisis
dengan gangguan endokrin.
KRISIS HIPERTENSI PADA PENYAKIT JANTUNG

Krisis Hipertensi dan Diseksi aorta

Definisi
Suatu kondisi akibat robekan pada dinding
aorta
sehingga lapisan dinding aorta terpisah dan
darah dapat masuk ke sela-sela lapisan
dinding
pembuluh darah aorta.
MANIFESTASI KLINIS
Keluhan dapat bervariasi
1. Nyeri khas Aorta: onset mendadak, nyeri
teriris sudah maksimal dirasakan saat awal,
lokasi nyeri sesuai lokasi dimana robekan
aorta tadi.
2. Rasa nyeri dada seperti nyeri dada khas
infark miokard, bila proses diseksi menjalar
ke ostium arteri koronaria.
3. Rasa nyeri leher disertai pandangan kabur,
bila proses diseksi ekstensi ke arteri karotis.
4. Sinkope merupakan petanda komplikasi yg
DIAGNOSIS
Kecurigaan diagnosa Diseksi Aorta
berdasarkan anamnesa dan pemeriksaan
fisik cukup unruk menatalaksana sebagai
diseksi aorta.

Diagnosa pasti dengan pencitraan:

1. Ekokardiografi transesofageal (TEE)
2. CT scan dengan kontras.
3. Magnetic Resonance Imaging (MRI)
 Prinsip tatalaksana/ sasaran tekanan darah
Atasi rasa nyeri dg morfin iv. Menurunkan TD

diastolik segera (dalam 10-20 menit) dg target

TD sistolik 110-120 mmHg dan frekwensi nadi
60 x/mnt.
-blocker merupakan obat pilihan utama untuk

mengurangi shear stress dan mengontrol TD

Terapi medikamentosa dapat dilakukan pd
diseksi aorta desenden tanpa komplikasi ke
organ lain (hipoperfusi ginjal, ekstremitas dan
mesenterika)
Setelah pasien stabil, idealnya 24-48 jam, obat

IV diganti dengan oral.

 Tabel No.1 Obat-obat intravena Diseksi Aorta
yg ada di Indonesia
OBAT DOSIS Bolus DOSIS
PEMELIHARAAN
Penyekat Beta
Propanolol 1 mg IV setiap 3-5 menit 2-6 mg IV
(max 6.15 mg/kgBB) Setiap 4-6 jam

Kalsium Antagonis 0,25 mg/kg IV dalam 2 5 mg/jam dapat dititrasi 2,5-

Diltiazem menit setelah 15 menit 0,35 5 mg/jam, max 15 mg/jam
mg/kg IV

Verapamil 0,075-0,1 s/d 2,5-5 mg/kg 5-15 mg/jam IV drip

Selama 2 menit
Krisis Hipertensi dengan edema paru
Definisi

Suatu keadaan timbulnya tanda dan

gejala gagal jantung yang disertai
dengan peningkatan tekanan darah dan
gambaran rontgen toraks sesuai
dengan edema paru.
Manifestasi Klinis

Keluhan/ gejala:
1. Sesak Nafas
2. Orthopnea
3. Dyspnea deffort
Pemeriksaan fisik
1. TD sesuai definisi krisis hipertensi
2. Frekwensi pernafasan meningkat
3. Pada pemeriksaan jantung ditemukan
S3 dan/ atau S4 gallop.
4. Pada pemeriksaan paru suara nafas
ekspirasi memanjang disertai ronchi
basah halus seluruh lapangan paru.
5. Peningkatan tekanan vena jugularis.
DIAGNOSIS
1. Peningkatan tekanan darah sesuai
krisis hipertensi
2. Gejala dan tanda gagal jantung
3. Edema paru pada foto thorax
Prinsip Tatalaksana dan Sasaran
Tekanan Darah
1. O2 dengan target saturasi 02 perifer > 95%,
bila perlu dapat digunakan CPAP atau
ventilasi mekanik non-invasif bahkan
ventilasi mekanik invasif.
2. Pemberian Nitroglycerin sublingual, bila
perlu dilanjutkan dg pemberian drip.
3. Pemberian diuretik loop IV (Furosemid)
4. Pemberian obat anti hipertensi IV at
sublingual
5. Bila tidak ada kontra indikasi morfin IV dapat
dipertimbangkan.
 Target penurunan TD sistolik atau
diastolik sebesar 30 mmHg dalam
beberapa menit.
Sasaran akhir TD sistolik < 130 mmHg
dan TD diastolik < 80 mmHg.
Sebaiknya dicapai dalam 3 jam
 Tabel No 2 Obat-obat parenteral untuk penanganan hipertensi emergensi pd
edema paru dan sindroma koroner akut
Obat Golongan Dosis Onset Masa Efek samping
kerja kerja

Sodium Vasodilator 0,25-10 Segera stlh 1-2 Mual, hipotensi,keracunan

nitroprusid Arteri & Mg/kg/mnt distop mnt tiosianat,
vena methemoglobinemia dan
sianida.
Nitrogliserin Vasodilator: 5-300 1-5 mnt 3-5 Sakit kepala, mual,
Arteri & mcg/mnt mnt takikardia, muntah toleransi
vena
Isosorbid Vasodilator: 1- 10 1-5 mnt 3-5 Sakit kepala,mual, takikardia,
dinitrat Arteri & mg/jam mnt muntah, toleransi
vena
Nikardipin Kalsium 5-15 5-15 30-40 Hipotensi,takikardi,mual
antagonis mg/jam menit menit muntah, muka merah
Furosemide Diuretik 20-40 mg 10-20 mnt 4-6 Hipokalemi
loop jam Hipovolemia
Krisis Hipertensi pd Sindroma Koroner Akut

Definisi
Krisis hipertensi yang terjadi pada
pasien dengan sindroma koroner akut.
Sindroma koroner akut tdd :
1. angina pektoris tidak stabil,
2. Infark miokard non ST elevasi
3. Infark miokard dengan ST elevasi
Manifestasi Klinis
Keluhan
Nyeri dada dg penjalaran ke leher atau
lengan kiri dengan durasi lebih dari 20 menit
dan dapat disertai dg gejala sistemik berupa
keringat dingin, mual dan muntah dan
pemeriksaan fisik tidak ditemukan tanda-
tanda gagal jantung.
Temuan Klinis
Pemeriksaan fisik dapat normal atau tanda-
tanda gagal jantung
Diagnosis
1. Anamnesis
2. EKG
3. Enzim petanda kerusakan otot jantung
(CKmb, Troponin T)
 Prinsip tatalaksana dan Sasaran Tekanan Darah
1. Penyekat Beta dan nitrogliserin merupakan anjuran
utama.
2. Bila tidak terkontrol dapat diberikan gol kalsium
antagonis parenteral, nicardipin dan diltiazem bila tidak
ada kontraindikasi.
3. Sasaran TD sistolik adalah <130 mmHg dan TD
diastolik < 80 mmHg.
4. Penurunan TD harus dilakukan secara bertahap.
5. Penurunan TD perlu pemantauan ketat agar TD
diastolik tidak lebih rendah dari 60 mmHg, karena
dapat mengakibatkan iskemia miokard bertambah
berat.
 KRISIS HIPERTENSI PADA PENYAKIT
GINJAL
Stenosis arteri renalis dicurigai biladitemukan:
1. Ditemukan hipertensi sebelum usia 30 th
khususnya jika tidak ada riwayat hipertensi di
keluarga.
2. Ditemukan hipertensi berat (hipertensi stadium II
dengan TD > 160/100 mmHg) setelah usia > 50.
3. Ditemukan hipertensi yg refrakter dan sulit
dikendalikan dengan obat kombinasi lebih dari 3
macam ( termasuk diuretik)
4. Terjadinya peningkatan TD tiba-tiba pd
keadaan pasien hipertensi yg terkontrol
baik sebelumnya.

5. Hipertensi maligna ( hipertensi dg

keterlibatan gangguan organ lain seperti
gagal ginjal akut, perdarahan retina, gagal
jantung, dan kelainan neorologis.

6. Peningkatan plasma kreatinin dalam

waktu singkat setelah pemberian golongan
obat ACEI/ARB
Pemeriksaan penunjang diagnostik

1. Arteriografi ginjal (pemeriksaan baku

emas)
2. Magnetic resonance angiography.
3. Computed tomography angiography.
4. Duplex doppler ultrasonography.
KRISIS HIPERTENSI PD GANGGUAN
ENDOKRIN
Krisis Feokromositoma
Keganasan pd kelenjar adreno-medulari
menyebabkan terjadi krisis hipertensi, karena
kelebihan produksi epinefrin dan non
epinefrin dilepaskan ke dalam peredaran
darah. Juga karena stimulasi beta reseptor
ginjal oleh kadar katekolamin yg tinggi
menyebabkan dilepaskannya renin yg pd
akhirnya meningkatkan tekanan arteri
 Diagnosis feokromositoma ditegakkan
dengan pemeriksaan katekolamin plasma,
katekolamin urine dan atau metabolitnya
dalam urine 24 jam
( seperti metanefrin dan VMA= Vanil
mandelic acid).

Feokromositoma jarang ditemukan, tetapi

merupakan penyebab yang penting pada
krisis hipertensi.
KRISIS HIPERTENSI PADA KEHAMILAN
Keadaan yg menyertai krisis hipertensi
adalah preeklampsi.
Dapat ditemukan gangguan penglihatan,
sakit kepala hebat, nyeri abdomen kuadran
atas, gagal jantung kongestif dan oliguri
sampai gangguan serebrovsaskuler.
Bila terjadi kejang penderita masuk stadium
eklampsia.
 Krisis hipertensi hanya dapat diakhiri
dengan proses persalinan dan
penanggulangan dilakukan sesuai
penanggulangan krisis hipertensi dg
perhatian khusus pd kehamilan.
Keputusan untuk melakukan terminasi
kehamilan/ proses persalinan dilakukan
oleh ahli medis di bidang kebidanan.
(Obstruksi ginekolog)
HIPERTENSI KRISIS PD PENGGUNA NAPZA

Sejumlah obat/ senyawa yg termasuk

NAPZA dapat menimbulkan krisis
hipertensi, terutama pada pasien yg
sudah hipertensi.

Senyawa tersebut adalah, kokain,

amfetamin, metamfetamin,
phencyclidine.
Emergencies
& Urgencies
HYPERTENSIVE
EMERGENCIES
Require immediate
blood pressure
reduction (not
necessarily to normal
range) to prevent or
limit target organ
damage.

HYPERTENSIVE
URGENCIES
Require reduction of
blood pressure within a
few hours
 Parenteral Drugs For Treatment of
Hypertensive Emergencies

VASODILATORS ADRENERGIC
Nitroprusside INHIBITORS
Fenoldopam Labetalol

Nitroglycerine Esmolol

Enalaprilat Phentolamine

Nicardipine

Hydralazine
Pregnancy and Hypertension
A 24 year old primiparous woman is seen in the
obstetric clinic at 30 weeks gestation.

BP: 160/100, 2 + pedal edema

Otherwise unremarkable physical exam.
Urine shows 1000 mg of protein. Other labs: N

After 2 days of bed rest BP remains 160-170/100

 Drug Therapy of the Hypertensive
Pregnant Patient

Methyldopa: Drug of choice.

Beta blockers (not early pregnancy).
Hydralazine is the parenteral drug of
choice.

Most agents if used prior to pregnancy

may be continued
(except ACE-I OR A-II BLOCKERS)
 Resistant Hypertension
Improper BP measurement
Excess sodium intake
Inadequate diuretic therapy
Medication
Inadequate doses
Drug actions and interactions (e.g., nonsteroidal anti-inflammatory
drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
Over-the-counter (OTC) drugs and herbal supplements
Excess alcohol intake
Identifiable causes of HTN
 Conclusions
The initial approach to hypertension should start with ruling out
secondary causes, detecting and treating other cardiovascular risk
factors, and looking for target organ damage.
Treatment should always include lifestyle changes.
Medication use should be guided by the severity of HTN and the
presence of compelling indications.
Thiazide-type diuretics should be initial drug therapy for most, either
alone or combined with other drug classes.
Most patients will require two or more antihypertensive drugs
Conclusions
HTN is a risk factor for mortality and
cardiovascular and renal disease
HTN is common but not controlled.
Target BP 140/90 (130/80 in DM, CKD)
Remember Compelling Indications
Terima kasih
ASS WR WB