REFERAT

TATALAKSANA
KRISIS HIPERTENSI
Jessica Nadia Dinda
406162035
Basic Organization of
the Cardiovascular
System
Factors Influencing BP

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

JNC 7: Classification of BP

Category Systolic BP Diastolic BP

Normal <120 <80

Prehypertension 120-139 80-89

Hypertension 140-159 90-99

Stage II >160 >100

Etiology of Hypertension
 Primary hypertension
 Also called essential or idiopathic
hypertension
 Exact cause unknown but several
contributing factors

 90% to 95% of all cases

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Etiology of Hypertension
 Secondary hypertension
 Elevated BP with a specific cause
 Clinical findings relate to underlying cause

 Treatment aimed at removing or treating

cause
 Is a contributing factor to hypertensive crisis.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension
Complications
 Target organ diseases occur most
frequently in the
 Heart
 Brain

 Peripheral vascular disease

 Kidney

 Eyes

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Manifestasi Klinis
Krisis Hipertensi

 Neurologis : Sakit kepala, kejang,

penurunan kesadaran
 Mata : retinal bleeding , edema papil
 Jantung : Nyeri dada, edema paru
 Ginjal : Azotemia,proteinuria, oligouria
 Kebidanan : Preeclampsia
Left Ventricular Hypertrophy

Fig. 32-3
 Hypertensive Emergencies
Stroke
Encephalopathy Aortic
Dissection

Decompensated Acute
Heart Failure Coronary
Syndrome

Eclampsia
Acute Renal
Failure
The Eyes
 Retinopathy, retinal hemorrhages and
impaired vision.
 Vitreous hemorrhage, retinal detachment
 Neuropathy of the nerves leading to
extraoccular muscle paralysis and
dysfunction
 Retina Normal and Hypertensive
Retinopathy
A B

Normal Retina Hypertensive Retinopathy A: Hemorrhages

B: Exudates (Fatty Deposits)
C: Cotton Wool Spots (Micro
Strokes)
 Lifestyle modifications

www.nhlbi.nih.gov
Lifestyle Changes Beneficial in
Reducing Weight

 Decrease time in sedentary behaviors such

as watching television, playing video games, or
spending time online.
 Increase physical activity such as walking,
biking, aerobic dancing, tennis, soccer,
basketball, etc.
 Decrease portion sizes for meals and snacks.
 Reduce portion sizes or frequency of
consumption of calorie containing beverages.
JNC 7 Reference Card
 JNC 7 Recommendation for
Hypertensive Emergency
Drugs Dosage Onset Duration

Sodium 0.25-10 ugr/kg/min Immediate 1-2 minutes after

nitroprusside infusion stopped
Nitroglycerin 5-500 ug/min 1-3 minutes 5-10 minutes

Labetolol HCl 20-80 mg every 10-15 min or 5-10 minutes 3-6 minutes
0.5-2 mg/min
Fenoldopan 0.1-0.3 ug/kg/min <5 minutes 30=60 minutes
HCl
Nicardipine 5-15 mg/h 5-10 minutes 15-90 minutes
HCl
Esmolol HCl 250-500 ug/kg/min IV bolus, 1-2 minutes 10-30 minutes
then 50-100 ug/kg/min by
infusion; may repeat bolus after
5 minutes or increase infusion
to 300 ug/min
JNC 7, 2003
CHEST 2007 Recommendation for
Hypertensive Emergency
Acute Pulmonary edema /
Systolic dysfunction
Acute Pulmonary edema/
Diastolic dysfunction
Acute Ischemia Coroner
Hypertensive encephalopaty
Acute Aorta Dissection
Preeclampsia, eclampsia
Acute Renal failure /
microangiopathic anemia
Sympathetic crises/ cocaine
oveerdose
Acute postoperative
hypertension
Acute ischemic stroke/
intracerebral bleeding
Nicardipine, fenoldopam, or nitropruside combined with
nitrogliceryn and loop diuretic
Esmolol, metoprolol, labetalol, verapamil, combined with
low dose of nitrogliceryn and loop diuretics
Labetalol or esmolol combined with diuretics
Nicardipine, labetalol, fenoldopam
Labetalol or combined Nicardipine and esmolol or combine
nitropruside with esmolol or IV metoprolol
Labetalol or nicardipine
Nicardipine or fenoldopam
Verapamil, diltiazem, or nicardipine combined with
benzodiazepin
Esmolol, Nicardipine, Labetalol
Nicardipine, labetalol, fenoldopam
CHEST, 2007
 AHA / ASA 2007 Recommendation for
Hypertensive Emergency

Drug I.V. Bolus Dose Continous Infus Rate

Labetalol 5 – 20 mg every 15’ 2 mg/min (max 300mg/d)

Nicardipine NA 5-15 mg/h
Esmolol 250 ug/kg IVP loading dose 25-300 ug/kg/m
Enalapril 1,25-5 mg IVP every 6 h NA
Hydralazine 5 – 20 mg IVP every 30’ 1,5-5 ug/kg/m
Nipride NA 0,1-10 ug/kg/m
NTG NA 20-400 ug/m

AHA/ASA Guideline, 2007 update. Stroke. 2007;38: 2001-2023.)

 Problem Magnitude
 Hypertension( HTN) is the most common
primary diagnosis in America.
 35 million office visits are as the primary
diagnosis of HTN.
 50 million or more Americans have high BP.
 Worldwide prevalence estimates for HTN may
be as much as 1 billion.
 7.1 million deaths per year may be attributable
to hypertension.
Definition
 A systolic blood pressure ( SBP) >139
mmHg and/or
 A diastolic (DBP) >89 mmHg.
 Based on the average of two or more
properly measured, seated BP
readings.
 On each of two or more office visits.
Accurate Blood Pressure Measurement

 The equipment should be regularly inspected and

validated.
 The operator should be trained and regularly retrained.
 The patient must be properly prepared and positioned
and seated quietly for at least 5 minutes in a chair.
 The auscultatory method should be used.
 Caffeine, exercise, and smoking should be avoided
for at least 30 minutes before BP measurement.
 An appropriately sized cuff should be used.
BP Measurement
 At least two measurements should be
made and the average recorded.
 Clinicians should provide to patients
their specific BP numbers and the BP
goal of their treatment.
 Follow-up based on initial BP
measurements for adults*

www.nhlbi.nih.gov *Without acute end-organ damage

 Classification

www.nhlbi.nih.gov
Prehypertension
 SBP >120 mmHg and <139mmHg and/or

 DBP >80 mmHg and <89 mmHg.

 Prehypertension is not a disease category

rather a designation for individuals at high risk
of developing HTN.
Pre-HTN
 Individuals who are prehypertensive are not
candidates for drug therapy but
 Should be firmly and unambiguously advised to
practice lifestyle modification
 Those with pre-HTN, who also have diabetes or
kidney disease, drug therapy is indicated if a
trial of lifestyle modification fails to reduce their
BP to 130/80 mmHg or less.
Isolated Systolic Hypertension
 Not distinguished as a separate entity as
far as management is concerned.
 SBP should be primarily considered
during treatment and not just diastolic BP.
 Systolic BP is more important
cardiovascular risk factor after age 50.
 Diastolic BP is more important before age
50.
Hypertensive Crises

 Hypertensive Urgencies: No progressive

target-organ dysfunction. (Accelerated
Hypertension)

 Hypertensive Emergencies: Progressive

end-organ dysfunction. (Malignant
Hypertension)
 Hypertensive Crisis
Hypertensive Urgency Hypertensive Emergency
• Occurs over days to weeks • Develops over hours to days
• BP > 180/110 • Severely elevated BP (often
• No evidences of target organ >220/140 mmHg)
disease • Evidence of target organ
disease
• Cause target organ damage –
Heart (AMI) Brain
(encephalopathy or
stroke[SAH]), kidney (renal
failure), Aorta (dissection), Eyes
(retinopathy)

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertensive Urgencies
 Severe elevated BP in the upper range
of stage II hypertension.
 Without progressive end-organ
dysfunction.
 Examples: Highly elevated BP without
severe headache, shortness of breath or
chest pain.
 Usually due to under-controlled HTN.
 Hypertensive Emergencies
 Severely elevated BP (>180/120mmHg).
 With progressive target organ dysfunction.
 Require emergent lowering of BP.

 Examples: Severely elevated BP with:

Hypertensive encephalopathy
Acute left ventricular failure with pulmonary
edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm
Types of Hypertension
 Primary HTN:  Secondary HTN:
also known as less common cause
essential HTN. of HTN ( 5%).
accounts for 95% secondary to other
cases of HTN. potentially rectifiable
no universally causes.
established cause
known.
Causes of Secondary HTN
 Common
 Intrinsic renal disease
 Renovascular disease
 Mineralocorticoid
excess
 Sleep Breathing
disorder
 Uncommon
 Pheochromocytoma
 Glucocorticoid excess
 Coarctation of Aorta
 Hyper/hypothyroidism
Secondary HTN-Clues in Medical
History
 Onset: at age < 30 yrs ( Fibromuscular
dysplasi) or > 55 (athelosclerotic renal artery
stenosis), sudden onset (thrombus or
cholesterol embolism).
 Severity: Grade II, unresponsive to treatment.
 Episodic, headache and chest pain/palpitation
(pheochromocytoma, thyroid dysfunction).
 Morbid obesity with history of snoring and
daytime sleepiness (sleep disorders)
Secondary HTN-clues on Exam
 Pallor, edema, other signs of renal
disease.
 Abdominal bruit especially with a diastolic
component (renovascular)
 Truncal obesity, purple striae, buffalo
hump (hypercortisolism)
Secondary HTN-Clues on Routine
Labs
 Increased creatinine, abnormal urinalysis
( renovascular and renal parenchymal
disease)
 Unexplained hypokalemia
(hyperaldosteronism)
 Impaired blood glucose
( hypercortisolism)
 Impaired TFT (Hypo-/hyper- thyroidism)
 Secondary HTN-Screening
Tests

www.nhlbi.nih.gov
Renal Parenchymal Disease
 Common cause of secondary HTN (2-5%)
 HTN is both cause and consequence of
renal disease
 Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins
imbalance
 Renal disease from multiple etiologies.
Renovascular HTN
 Atherosclerosis 75-90% ( more common in
older patients)
 Fibromuscular dysplasia 10-25% (more
common in young patients, especially females)
 Other
• Aortic/renal dissection
• Takayasu’s arteritis
• Thrombotic/cholesterol emboli
• CVD
• Post transplantation stenosis
• Post radiation
Complications of Prolonged
Uncontrolled HTN
 Changes in the vessel wall leading to
vessel trauma and arteriosclerosis
throughout the vasculature
 Complications arise due to the “target
organ” dysfunction and ultimately failure.
 Damage to the blood vessels can be seen
on fundoscopy.
Target Organs
 CVS (Heart and Blood Vessels)
 The kidneys
 Nervous system
 The Eyes
Effects On CVS
 Ventricular hypertrophy, dysfunction and
failure.
 Arrhithymias
 Coronary artery disease, Acute MI
 Arterial aneurysm, dissection, and
rupture.
Effects on The Kidneys
 Glomerular sclerosis leading to impaired
kidney function and finally end stage
kidney disease.
 Ischemic kidney disease especially when
renal artery stenosis is the cause of HTN
Nervous System
 Stroke, intracerebral and subaracnoid
hemorrhage.
 Cerebral atrophy and dementia
The Eyes
 Retinopathy, retinal hemorrhages and
impaired vision.
 Vitreous hemorrhage, retinal detachment
 Neuropathy of the nerves leading to
extraoccular muscle paralysis and
dysfunction
 Retina Normal and Hypertensive
Retinopathy
A B

Normal Retina Hypertensive Retinopathy A: Hemorrhages

B: Exudates (Fatty Deposits)
C: Cotton Wool Spots (Micro
Strokes)
(3) Target Organ Damage
 Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
 Brain
Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy
History
 Angina/MI Stroke: Complications of HTN,
Angina may improve with b-blokers
 Asthma, COPD: Preclude the use of b-blockers
 Heart failure: ACE inhibitors indication
 DM: ACE preferred
 Polyuria and nocturia: Suggest renal
impairment
History-contd.
 Claudication: May be aggravated by b-
blockers, atheromatous RAS may be present
 Gout: May be aggravated by diuretics
 Use of NSAIDs: May cause or aggravate HTN
 Family history of HTN: Important risk factor
 Family history of premature death: May have
been due to HTN
History-contd.
 Family history of DM : Patient may also
be Diabetic
 Cigarette smoker: Aggravate HTN,
independently a risk factor for CAD and
stroke
 High alcohol: A cause of HTN
 High salt intake: Advice low salt intake
Examination
 Appropriate measurement of BP in both arms
 Optic fundi
 Calculation of BMI ( waist circumference also
may be useful)
 Auscultation for carotid, abdominal, and femoral
bruits
 Palpation of the thyroid gland.
Examination-contd.
 Thorough examination of the heart and
lungs
 Abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
 Lower extremities for edema and pulses
 Neurological assessment
Routine Labs
 EKG.
 Urinalysis.
 Blood glucose and hematocrit; serum
potassium, creatinine ( or estimated GFR),
and calcium.
 HDL cholesterol, LDL cholesterol, and
triglycerides.
 Optional tests
urinary albumin excretion.
albumin/creatinine ratio.
Goals of Treatment
 Treating SBP and DBP to targets that are
<140/90 mmHg
 Patients with diabetes or renal disease, the BP
goal is <130/80 mmHg
 The primary focus should be on attaining the
SBP goal.
 To reduce cardiovascular and renal morbidity
and mortality
Benefits of Treatment
 Reductions in stroke incidence,
averaging 35–40 percent
 Reductions in MI, averaging 20–25
percent
 Reductions in HF, averaging >50 percent.
 Lifestyle modifications

www.nhlbi.nih.gov
Lifestyle Changes Beneficial in Reducing Weight

 Decrease time in sedentary behaviors such

as watching television, playing video games, or
spending time online.
 Increase physical activity such as walking,
biking, aerobic dancing, tennis, soccer,
basketball, etc.
 Decrease portion sizes for meals and snacks.
 Reduce portion sizes or frequency of
consumption of calorie containing beverages.
JNC 7 Reference Card