Download - Hipertensi Emergensi
HYPERTENSIVE EMERGENCY
Dwi Lestari PartiningrumNephrology and Hypertension Division, Internal Medicine Department
Medical Faculty Diponegoro University/ Kariadi Hospital
Definitions Pathophysiology and Clinical Manifestation Parenteral Agents for Hypertensive Emergencies Management of Spesific Hypertensive
Emergencies
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Definition
Hypertensive Crisis Hypertensive Emergencies Hypertensive Urgencies (Accelerated) Malignant Hypertension
?
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
Hypertensive Crisis
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Definition Hypertensive crises
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
E Grossman & FH Messerli, Comprehensive Hypertension Mosby, 2007Dwi Lestari
Definition Hypertensive urgency
A situation with markedly elevated BP but without severe symptoms or progressive target organ damage, wherein the BP should be reduced within hours, often with oral agents
or
When severe elevation in BP is not associated with end-organ injury
MN.Kaplan; Clin.Hypt 9th ed.2006
E Grossman & FH Messerli, Comprh Hypert Mosby, 2007Dwi Lestari
Clinical implicationHypertensive urgency
Common and no scientific evidence showed that acute BP lowering is beneficial.
The appropriate approach is to lower BP gradually over 12 to 24 hours with oral AHAs.
Any drug that lower BP precipitously should be avoided
MN.Kaplan; Clin.Hypertension 9th ed.2006Dwi Lestari
Definition Hypertensive emergency
A situation that requires immediate reduction in blood pressure with parenteral agents because of acute or progressing target organ damage
When BP elevation confers an immediate threat to the integrity of the cardiovascular system
Relatively rare, and immediate reduction in BP is required to avoid further end-organ damage, generally by IV therapy in an IC setting to lower the MAP by 25% over the initial 2 to 4 hours with the most specific AHA
MN.Kaplan; Clin.Hypt 9th ed.2006
E Grossman & FH Messerli, Comprehensive Hypertension Mosby, 2007Dwi Lestari
(Accelerated) Malignant Hypertension
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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Pathophysiology and Clinical Manifestation
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
Critical levelor
rapid rate of rise and increased
vascular resistance
Decrease in vasodilators,nitric oxide, prostacyclin
Severe bloodpressure elevation
Tissue ischemia
End-organ dysfunction
Essential hypertension
Renal disorders
Spontaneous natriuresis
Intravascular volumedepletion
Increase is vasoconstrictors(renin-angiotensin,
catecholamines)
Further increase inblood pressure
Endocrine disorders
Pregnancy
Drugs
Endothelial damage
Endothelial permeability
Platelet and fibrindeposition
Fibrinoid necrosis andintimal proliferation
Kitiyakara, JASN 1998Dwi Lestari
Critical degree of hypertension
Endothelial damageIncrease in vasoconstrictors(renin-angiotensin, vasopressin, catecholamines)
Further blood pressure increase
Pressure natriuresis
hypovolemia
Further release of vasoconstrictors
Platelet and fibrin deposition
Intravascular hemolysis
Fibrinoid necrosis and intimal proliferation
Increase in blood pressure and
ischemia
Mechanisms of malignant hypertensionDwi Lestari
Drugs that can increase BP 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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Prevalence of Hypertensive CrisisPrevalence of Hypertensive Crisis
Mainly due to more effective treatment ?
Hypertensive crisis
( % of all pts )
1950’s 1990’s
1
2
4
3
Zampaglione, et al. AHA ; 27 (1) : 144Dwi Lestari
Retinal findings in hypertensive encephalopathy
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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
Clinical Manifestation of Hypertensive Emergency
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
Dwi Lestari Haas, Seminars in Dialysis 2006
Evaluation
Initial evaluation for patients with HTN emergencyHistory• Prior diagnosis & treatment of HTN• Intake of pressor agents; street drugs, sympathomimetics• Symptoms of cerebral, cardiac, pulmonal, and visual
dysfunctionPhysical 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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SIMPLE APPROACH TO HYPERTENSIVE CRISIS
BP > 220/120 mmHg
Neurological sign(encephalopathy or stroke)
Retinopathy grade 3-4Severe chest pain
(Ischemia or dissecting aneurism)
Pulmonary edemaEclampsia
Cathecolamine excessAcute renal failure
HeadacheNo neurological signs
No target organ damage
EMERGENCY
URGENCY
Intravenous therapy
Identify the causeIn panic attacks or anxiety use
analgesic, anxiolyticsOtherwise use oral
antihypertensive agentsrecheck in 6-24 hours
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Principles of Therapy for Hypertensive Emergencies
Patients must be hospitalized for monitoring Direct consequences of lowering BP too quickly Treated with parenteral Lower MAP {1/3(SBP-DBP)+DBP} by no more than 25%
within minute to 2 hours or diastolic 110 mmHg, then 160/100 mmHg within 2-6 hours (JNC VII). Exception for ischemic stroke
IV infusion is prefer than bolus
Hypertension.,Brian C. Poole and Anitha Vijayan in Nephrology and Subspeciality Consult,2004Dwi Lestari
Parenteral Agents for Hypertensive Emergencies
Pheripheral Vasodilatation Sodium Nitroprusside Nitroglycerin * Nicardipine * Diltiazem * Diazoxide Fenoldopam mesylate Enaprilat
Parenteral Adrenergic Inhibitor Labetalol Esmolol Phentolamine
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Centrally acting : Clonidin
Tatalaksana Hipertensi Emergensi
Harus dilakukan di rumah sakit Pengobatan secara parenteral baik bolus atau
infus. Tekanan darah diturunkan dalam hitungan menit
– jam.
Konsensus InaSHDwi Lestari
Tatalaksana Hipertensi emergensi
Langkah penurunan tekanan darah :
− 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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Obat parenteral pd Hipertensi emergensi
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 0.15–0.3 mg over a period of 5 minutes . Reduced
MAP in 25% within minutes to 1 hour
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Clonidin (Catapres) IV (150 mcg/ampul) Clonidin 900 mcg (6ampul) dalam glucosa 5 % dengan
tetesan mikro disesuaikan dengan kebutuhan. Dosis awal 12 tetes / menit dan setiap 15 menit dapat dinaikkan 4 tetes.
Bila sasaran tekanan darah tercapai dilakukan observasi 4 jam dan diteruskan dengan tablet oral sesuai kebutuhan.
Clonidin tidak boleh dihentikan mendadak. Dosis diturunkan - perlahan-lahan oleh karena bahaya “rebound phenomen “ dimana tekanan darah naik kembali secara cepat bila obat dihentikan.
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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 µg/min, max dose 100 µg/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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Diltiazem IV (10 dan 50mg/ ampul). Diltiazem 10 mg IV bolus diberikan dalam 1-3 menit
diteruskan dengan infus 50 mg /jam selama 20 menit Bila penurunan tekanan darah mencapai 20-25 %
dosis diberikan 30 mg/jam sampai sasaran tekanan darah tercapai.
Berikutnya diberikan dosis pemeliharaan 5-10 mg/ jam, selama 4 jam, kemudian diganti tablet sesuai kebutuhan.
Perlu perhatian khusus pada gangguan konduksi dan gagal jantung.
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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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Nicardipin (Perdipin) IV (2 dan 10 mg / ampul)
Nicardipin 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
0.5 – 6Hypertensive emergencies
10 – 302 - 10Acute hypertensive crises during surgery
Bolus(g/kg)
DIV(g/kg/min)
(g/kg/min)0.5 1 2 6 10
Hypertensive emergencies
Acute hypertensive crises during surgery
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Conditions Preferred Antihypertensive Agents
Acute pulmonary edema/systolic dysfunction
Nicardipine, fedoldopam, or nitroprusside in combination with nitroglycerin and a loop diuretic
Acute pulmonary edema/diastolic dysfunction
Esmolol, metoprolol, labetalol, diltiazem, verapamil in combintaion with low-dose nitroglycerin and a loop diuretic
Acute myocardial ischemia Labetalol or esmolol in combination with nitroglycerin
Hypertensive encephalopathy Nicardipine, Diltiazem, labelatol, or fenoldopam
Acute aortic dissection Labetalol or combination of nicardipine and esmolol or combination of nitroprusside with either esmolol or IV metoprolol
Pre-eclampsia, eclampsia Labetalol or nicardipine
Acute renal failure/microangiopathic anemia
Nicardipine or fenoldopam
Sympathetic crisis/cocaine overdose
Verapamil, diltiazem, or nicardipine in combination with a benzodiazepine
APH Esmolol, nicardipine, or labetalol
Acute ischemic stroke/intracerebral bleed
Nicardipine, Diltiazem, labetalol, or fenoldopam
Recommended Antihypertensive Agents for Hypertensive Crises
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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
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