Definisi

HIPERTENSI KRISIS suatu kedaruratan medik

yang ditandai dengan peningkatan TD secara
mendadak dan dengan atau tanpa kerusakan
organ.
1 % dari populasi hipertensi dewasa
Hipertensi Emergensi
- > 50% penderita di ICU
- karena terapi tak adekuat

Klasifikasi berdasarkan prioritas pengobatan

1.
2.

Hipertensi emergensi (darurat )

Hipertensi urgensi ( mendesak )

Table 2 : Algorithm for Triage Evaluation

Parameter

Severe Hypertension (Urgency)

Hypertensive Emergency

Asymptomatic

Symptomatic

Blood pressure
(mmHg)

> 180/110

> 180/110

Usually > 220/140

Symptoms

Headache, anxiety;
often asymtomatic

Severe headache,
shortness of breath

Shortness of breath, chest pain,

nocturia, dysarthria, weakness,
altered consciousness

Examination

No target organ
damage, no clinical
cardiovascular
disease

Target organ
damage; clinical
cardiovascular
disease present,
stable

Encephalopathy,pulmonary
edema, renal insufficiency,
cerebrovascular accident,
cardiac ischemia

Therapy

Observe 1-3 hr;

initiate, resume
medication; increase
dosage of inadequte
agent

Observe 3-6 hr;

lower BP with
shortacting oral
agent; adjust
current therapy

Baseline laboratory tests;

intravenous line; monitor BP, may
initiate parenteral therapy in
emergency room

Plan

Arrange follow-up
within 3-7 days; if no
prior evaluation,
schedule appointment

Arrange follow-up
evaluation in less
than 72 hr

Immediate admission to ICU;

treat to initial goal BP, additional
diagnostic studies

BP, Blood pressure; ICU, Intensive care unit

Sumber : Hebert e.j Prim Care 2008. 35 (3)

DIAGNOSIS
ANAMNESIS
- Lama menderita
hipertensi
- Obat-obat yang
dikonsumsi
- Penyakit penyerta

PEMERIKSAAN FISIS
- Pengukuran tekanan
darah
- Perabaan a. radialis,
a. karotis
PEMERIKSAAN KHUSUS
- Funduskopi
- Tes Urin
- dll

Table : Manifestasi klinis hipertensi emergensi

Blood
Pressure
(mmHg)

Fundusco
pic
Findings

Neurologic
Status

Cardiac
Findings

Renal
Symptoms

Gastrointesti
nal
Symptoms

Usually
>220/140

Hemorrha
ges,
exudates
papilede
ma

Headache,
confusion,
somnolence,
stupor,
visual loss,
seizures,
focal
neurologic
deficits,
coma

Prominent

Azotemia,
proteinuria
, oliguria

Nausea.
vomiting

apical

pulsation,
cardiac
eniargement
, congestive
heart failure

Sumber : Hebert e.j Prim Care 2008. 35 (3)

PENGOBATAN
Hipertensi Emergensi
- Dirawat di ICU
- Obat anti hipertensi parenteral
- Target : - Penurunan tekanan darah pd jam
pertama 20-25 % MAP
- Minimalisir hipoperfusi organ vital
(eg: otak)
- Penurunan tekanan darah selanjutnya dl 24 jam

Table : Treatment of Hypertensive Emergencies

Agent

Dosage

Onset/Duration of
Action (after
discontinuation)

Precautions

Sodium
Nitroprusside

0.25-10 g/kg/min as
IV infusion

Immediate/2-3 min
after infusion

Nausea, vomiting; prolonged use

may cause thiocyanate
intoxication,
methemoglobinemia, acidosis,
cyanide poisoning; bags, bottles,
delivery sets must be light
resistant

Nitroglycerin

5-100 g as IV
infusion

2-5 min/5-10 min

Headache, tachycardia,
vomiting; flushing.
Methemoglobinemia; requires
special delivery system because
of drug binding to PVC tubing

Nicardipine

5-15 mg/hr as IV
infusion

1-5 min/15-30 min,

but may exceed 12
hr after prolonged
infusion

Tachycardia, nausea, vomiting,

headache, increased intracranial
pressure; hypotension may be
protracted after prolonged
infusions

Fenoldopam
Mesylate

0.1-0.3 g/kg/min as IV
infusinon

<5 min/30 min

Headache, tachycardia, flushing,

local phlebitis, dizziness

Hydralazine

5-20 mg as IV bolus or
10-40 mg IM; repeat
every 4-6 hr

10 min IV/> 1 hr (IV);

20-30 min IM/4-6 hr
(IM

Tachycardia, headache,
vomiting, aggravation of angina
pectoris, sodium and water
retension, increased intracranial
pressure

Parenteral
Vasodilators

Sumber : Hebert e.j Prim Care 2008. 35 (3)

Tabel : Medikamentosa untuk keadaan2 khusus hipertensi

emergensi
Emergenci dengan
keadaan khusus

Pengobatan

Target TD

Aortic dissection

Nitroprusside + esmolol

110-120 SBP as soon as possible

AMI, ischemia

Nitroglycerin, nitroprusside, nicardipine

Secondary to ischemia relief

Pulmonary edema

Nitroprusside, nitroglycerin, labetalol

Improve symptoms 10%-15% in 1-2

hr

Renal emergencies

Fenoldopam, nitroprusside, labetalol

Catecholamine excess

Phentolamine, labetalol

Hypertensive encphalopathy

Nitroprusside

Control paroxysms, 10 %-15% in 1-2

hr

Subarachnoid hemorrhage

Nitroprusside, nimodipine, nicardipine

20%-25% in 2-3 hr

Ischemic stroke

Nitroprusside (controversial), nicardipine

20%-25% in 2-3 hr

Target BP 20%-25% in 2-3 hr

0%-20% in 6-12 hr

Sumber : Hebert e.j Prim Care 2008. 35 (3)

PENGOBATAN
Hipertensi Urgensi
- Medikamentosa Oral anti hipertensi yg
bekerja cepat
- Jika Target tidak tercapai, tingkatkan
dosis
- Target tercapai dalam 3-7 hari

Table : Management of Hypertensive Urgencies

AGENT

DOSE

ONSET/DURATION OF
ACTION
(AFTER
DISCONTINUATION)

Captopril

25 mg p.o., repeat as
needed SL, 25 mg

15-30 min/6-8 h SL,

15-30 min/2-6 h

Hypotension, renal
failure in bilateral
renal artery
stenosis

Clonidine

0.1-0.2 mg p.o., repeat

hourly as required to
total dose of 0.6 mg

30-60 min/8-16 h

Hypotension,
drowsiness, dry
mouth

Labetalol

200-400 mg p.o repeat

every 2-3 h

30 min-2 h/2-12 h

Bronchoconstrictio
n, heart block,
orthostatic
hypotension

Amblodipin

2,5-5 mg

1-2 hr/12-18 hr

Tachycardia,
hypotension

Nifedipin

5 mg sl

5-20 min/2-6 hr

Tachycardio,
hypotension

PRECAUTIONS

Adapted with permission from Vidt DG. Hypertensive crises: emergencies and urgencies. J Clin Hypertens
(Greenwich
Sumber :). 2004;6:520-525

-Hebert C.J Hypertensive Crises Prim Care 2008. 35 (3)

PROGNOSIS
Angka kematian tinggi
Tanpa terapi : 1 year survival rate 1020%
Terapi adekuat : 5 year survival rate
50-60%

Kaplan, clinical hypertension