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Prinsip Pengobatan Hipertensi Emergensi

Goal: cegah progresivitas kerusakan organHarus menggunakan obat intravenaUtamakan keuntungan pengobatan terhadap perfusi jaringan terutama otak, miokardium dan ginjalMIMS Cardiovascular Guide, 2005PENANGGULANGAN HIPERTENSI EMERGENSI :

Bila diagnosa hipertensi emergensi telah ditegakkan maka TD perlu segera diturunkan. Langkah-langkah yang perlu diambil adalah :

Rawat di ICU, pasang femoral intraarterial line dan pulmonari arterial catether (bila ada indikasi ). Untuk menentukan fungsi kordiopulmonair dan status volume intravaskuler.

Anamnese singkat dan pemeriksaan fisik. tentukan penyebab krisis hipertensi singkirkan penyakit lain yang menyerupai krisis hipertensi tentukan adanya kerusakan organ sasaran

Tentukan TD yang diinginkan didasari dari lamanya tingginya TD sebelumnya, cepatnya kenaikan dan keparahan hipertensi, masalah klinis yang menyertai dan usia pasien.Tujuan pengobatan Hipertensi emergency adalah

-memperkecil kerusakan organ target akibat tingginya tekanan darah dan menghindari pengaruh buruk akibat pengobatan.

Berdasarkan prinsip ini maka obat antihipertensi pilihan adalah yang bekerja cepat, efek penurunan tekanan darah dapat dikontrol dan dengan sedikit efek samping.

-Tujuan pengobatan menurunkan tekanan arteri rata-rata (MABP) sebanyak 25 % atau mencapai tekanan darah diastolik 100 110 mmHg dalam waktu beberapa menit sampai satu atau dua jam.Kemudian tekanan darah diturunkan menjadi 160/100 mmHg dalam 2 sampai 6 jam. Tekanan darah diukur setiap 15 sampai 30 menit. Penurunan tekanan darah yang terlalu cepat dapat menyebabkan iskemia renal, cerebral dan miokardium. Pengobatan Hipertensi EmergensiNameDosingOnset of ActionDuration of ActionPreloadAfterloadCardiac OutputRenal perfusionSodium nitroprusside

Labetolol

Fenoldopam

Nicardipine

Esmolol

Methyldopa

HydralazineIV 0.25-10 mg/kg/min

IV (20-to 80-mg bolus/10 min)

IV 0.1-0.6 mg/kg/min

IV 2-10 mg/hr

IV 80-mg bolus over 30 second, followed by 150 mg/kg/min infusion

IV (250-to 1000-mg bolus every 6 hr)

IV bolus (10-20 mg)Within seconds

5-10 min

10-15 min

5-10 min

6-10 min

3-6 hr

10 min1-2 min

2-6 hr

10-15 min

2-4 hr

20 min

up to 24 hr

2-6 hrdecreased

no effect

no effect

no effect

no effect

no effect

no effectdecreased

decreased

decreased

decreased

no effect

decreased

decreasedno effect

decreased

increased

increased

decreased

decreased

Increaseddecreased

no effect

increased

no effect

no effect

no effect

no effectPengobatan Hipertensi EmergensiNameCommentsMajor Side EffectsSodium nitroprusside

Labetolol

Nicardipine

Esmolol

Methyldopa

HydralazineNeed to measure thiocyanate levels, caution in renal insufficiencyAlpha and beta blocker, contraindicated in acute heart failureSafe in coronary bypass patientsShort-acting beta blocker, contraindicated in acute heart failureSafe in pregnancy needs renal dosing Safe in pregnancyCyanide toxicity: nausea, vomiting, altered mental status, lactic acidosis, deathBradycardia, bronchospasm, nausea

Reflex tachycardia, flushing

Bradycardia bronchospasm

Drowsiness, fever, jaundice

Reflex tachycardia, lupus-like syndromePengobatan Hipertensi EmergensiModes of comparisonHypertensive encephalopathy, cardiovascular accident, intracranial hemorrhageAcute congestive heart failure or pulmonary edemaAcute myocardial infarction or acute coronary syndromeAortic dissectionAcute cocaine or sympathomimetic intoxicationTherapeutic goal

Suggested agents

Risk of therapy

PearlsFirst do no harm, avoid hypoperfusionDo not exceed 20% reduction of BP

Nicardipine: reduces, cerebral ischemiaConsider ultra short acting agents (esmolol or nitroprusside)

Cerebral autoregulation is disrupted in the ischemic brainPatients demonstrate marked lability of BP with any agent, and hypoperfusion of the brain can occur

There is no clear evidence of benefit with intensive control of BP in the setting of strokeReduction of BP, especially by vasodilatationPromote diuresis

IV nitroglycerinMorphineIV angiotensin converting enzyme inhibitorIV diuretic

Diuretics and angiotensin converting enzyme inhibitor can exacerbate renal dysfunction

Diuretics are slow to work Angiotensin converting enzyme inhibitor has rapid onset of actionIV nitrates dilate capacitance vessels at low doses, higher doses dilate arterioles and lower BPRedution of BP Decrease myocardial oxygen demand

IV blockerIV nitroglycerin

Blocker can exacerbate left ventricular failure

Blockade also reduces mortality associated with ventricular arrhythmiaReduction of shear orces by reduction of BP and tachycardia

IV labetalolIV blockerNitroprusside

Nitroprusside is extremely potent and requires continuous intra-arterial BP monitoring

Avoid volume depletion in patients requiring IV dye or going for general anesthesiaReduction of excessive sympathomimetic drive

BenzodiazepineIV nitroglycerinIV labetalol

Unopposed blockade can cause alpha storm and increase cocaine toxicity

Measure core temperature and treat hyperthermia if presentConsider the possibility of multidrug use