Crisis of Hypertension

7/30/2019 Crisis of Hypertension

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HIPERTENSI : Problem kardiovaskuler : Stroke, GPDO, PJK,

Aneurisma, Hipertensi krisis

Komplikasi : - Memperpendek usia; - Harapan hidup

INSIDEN : Tahun - tahun >>

TGT : - Kesadaran masyarakat kesehatan- Check up rutin

: 10 - 20% ( USA : 15 - 20%; JEPANG : 15 - 22%

Singapura : 14%; India : 15%; Philiphina : 10,8%

Indonesia : 15%)

Perlu survei yg luas pada masyarakat

- Case finding

- Problem kesehatan masyarakat

Pengobatan yang rasional : - Komplikasi dihindari

- Umur >>- Kualitas hidup

HIPERTENSI


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H. + Komplikasi

H. + Keluhan +

Pengobatan tak baik

H. + Keluhan +

Pengobatan baik

H. Tanpa keluhan

Nomiotensi

Border line

FENOMENA GUNUNG ES


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Piekerning : Tek Darah : - Umur- Sex

- Lingkungan

Hence : Tek darah PrognosaPenatalaksanaan

Kaplan : O

< 45 th : 130/90 mm HgO > 45 th : 140/95 mm HgO- segala umur : 160/95 mm Hg

NYHA : Tek darah > 140/90 mmHg

WHO (1993) : Tek darah > 140/90 mmHg

JNC (1997) : Tek darah > 140/80 mmHg

Kriteria : Diastole

96 - 100 Std I100 - 109 Std II110 - 119 Std III> 120 Std IV

Hipertensi sistolik : Tek sitole > 160 mmHg

D E F I N I S I


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1. Umur : >> umur Tek darah >>Kriteria 160/90

Hipertensi Umur : Hipertensisistolik

2. Sex : Muda Pria > Wanita> 45 tahun Pria = Wanita

3. BB : Gemuk HipertensiHipertensi GemukHipertensi gemuk > BB ideal

Kenaikan 10 kg dari BB ideal >> tensi, 3 mmHg4. Hiriditer: OT Anak

Anak dengan OT (+) 2 Anat OT (-)5. Garam : NaCl Na air6. Stress : Stress Hipotal Catekol >> Sympatis >> Resistensi >>7. Sosio ekonomis : - Kota > didesa

- Tegang, Makanan, Olah Raga

8. Lain-Lain : Rokok, Kopi, Alkohol

FAKTORPREDISPOSISI


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- 80 -90 % Prevalensi Hipertensi

- Faktor: Usia, Sex, BB, Heriditas, Stress, Garam

- NaCl : 5 - 15 gr/hr Prevalensi > 15 - 20 %- Simpatis >> Parasimpatis >- Ginjal : Pengaturan air + garam

Renin angiotensin sistem

- Na >> Tek Darah >>- Simpatis >> Tek Darah >>

- Atas dasar renin HE1. HE Tinggi Renin : - Muda

- NOR Adrenalin >>

- COP >>

2. HE Normo Renin

3. HE Rendah Renin : - Tua

- Resistensi >>

P E N Y E B A B1. PRIMER (IDIOPATIK) = ESSENSIAL


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Renin

Angistensin I

Angistensin IIACE

AldosteronVasokonstriksi

Tek Darah

R A A S

Na

Vol

Aktivasi RAA

COP Angiotensi I Angiotensi II

Afterload Preload

Vasokonstruksi Aldosteron


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10% Prevalensi Hipertensi

A. GINJAL : Parenchym : - GHA / GNC

- PHA / PNC

- Polikistik ginjal

- Kimmel Stiel-Wilson

- Peny Kollagen

- DM

- Tumor

- BatuVaskuler : - Stenosis A. Renalis

- Nephro Sklerosis

- Fistula A - V

- Obstruksi : Tumor

B. HORMONAL : - Phaechromacytoma

- Cushing S.

C. COARCTATIO AORTA

D. KEHAMILAN : Eklampsi

E. KEL. SYARAF

2. Hipertensi Sekunder (H.S.)


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Gejala : Individual : - Pusing, mual, muntah

- Kaku Kuduk- Iritable

- Keluhan (-)

1. H LVH Gagal Jantung2. H Atherosklerosis P.J.K

LVH : Tingginya tekanan darah LVHGNA, Eklamspi, Phaechroma LVH LHF

Frohliek : Kel Jantung OK H.I. Besar DBN EKG, X FotoII. LAH, Gallop (BJ 4)

III. LVH, EKG X FotoIV. LVF

KOMPLIKASI


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Tek Darah LVHLV DELATL.V. Wall Tension

L.V. O2 Consump

Miokard Hypobia

Diastolic Compliance LVEDP

LVF


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Atherosklerosis >>

Atherom Plaque >>

Trombus

Lumen A. Coroner 50% Lumen)

P.J.K

AP MCI SD

MC Kenna : PJK - H 22%

ASPAC : 15%

Boedi D. : 16%

Sutanegara : 22%

Antono E. : 28,6%D. Sargowo : 21,6%

ATHEROSKLEROSIS


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Mortality risk in relation to sex and B.P.

8797

98127

128-137

138-147

148-157

158-177

178-197

> 198

Systolic blood pressure

mmHg Standard risk

48-68

69-83

83-88

88-93

93-98

98-108

108-118

> 118

Diastolic blood pressure

0 100 200 300 400 500 600 700 800Mortality ratio in %

woman

men

men

woman


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Klasifikasi hipertensi untuk umur 18th ( JNC VII )

Klasifikasi Sistolik

(mmHg)

Diastolik

(mmHg)

Normal

Prehipertensi

Stadium 1

Stadium 2

< 120

120 - 139

140-159

160

< 80

80 - 89

90-99

100


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SevereHypertension


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Patient assessment

Complete cell blood count

Complete metabolic panel

ECG : ischemic, infarct ? Radiography :

cardiomegaly,pulmonary edema,aortic

abnormality


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PENATALAKSANAAN (WHO)1. HIPERTENSI : 1. Non Farmakologik

- Diet

- OR

- Stress (-)

- Rokok (-)

2. FakmakologikStepped care WHO I, II, III, IV.

2. KOMPLIKASI :

LVF : Kontraksi : InotropikPreload : DiuretikAfterload : - Vasodelator- Ace inhobitor

PJK : - Suplai O2 : - VasodelatorNitrat, Acenning

- Ca antagonis

- Demand O2 : Blocker


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MANAGEMENT HIPERTENSIPADA DIABETES


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Ang II

Vasokonstriksi Direct sel otot polos

vaskuler HT, atheroschlerosis

Faktor pertumbuhan (bFGFs, PDGF,

TGF1, IL-6, PAF, Arachidonat)

kardiomiosit: LVH , sel2 mesangial:

glomeruloschlerosis, sel otot polosvaskuler: HT, atheroschlerosis

Tonus saraf simpatik sel2 otot

polos vaskuler : HT, kardiomiosit : LVH


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In patients with proteinuria > 1g

and renal insufficiency blood

pressure goal < 125/75 mmHg


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Dietary and Lifestyle Modifications

Maintain weight loss (5 10%) Exercise 3045 min at least three times per

week

Reduced sodium intake to 100 mmol (2.4 g) per

day Smoking cessation

Adequate intake of dietary potassium, calcium,and magnesium

Reduced alcohol intake to


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Lifestyle Modification to Lower

Blood Pressure

Stults B. Diabetes Spectrum 2006; 19: 25


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Pharmacologic Treatment


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Advances in the Treatment of

Hypertension

Chobanian AV. N Engl J Med

2009;361:878-87, 2009


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Pharmacologic Therapy

ACE Inhibitors(SOLVD Trial)

Angiotesin II Receptor Blockers (ARB)

(RENAAL, IRMA II, IDNT Study)

-Blockers

(UKPDS Study)

Calcium Channel Blockers (CCB)

(ABCD Trial) Diuretics

(ALLHAT Study)


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Effects of Hypertension Treatment

on Morbid Events

Comparative Drug Trials in Patients


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Comparative Drug Trials in Patients

with Hypertension

Chobanian AV. N Engl J Med 2009;361:878-87, 2009


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In patients with proteinuria > 1g

and renal insufficiency blood

pressure goal < 125/75 mmHg

Algorithm for Management of Hypertension


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Algorithm for Management of Hypertension


Blood pessure


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Management ofHypertension in

Diabetes

Recess for causes of resistant hypertension Consider consultation with specialist

Blood pressure > 130/80 mmHgafter 1 month

Substitute DHP CCB for monDHP CCB Add -blocker Add DHP CCB


Add nonDHP CCB (veraparmil or diltiazem)



Blood pressure > 130/80 mmHg

Add thiazide (or twice daily loop diuertic if creatinine > 1.8

mg/dlor estimated GFR < ml/min/1.732) add ACE inhibitor or ARB if on thiazide

ACE inhibitors or ARB therapyor thiazzide if no albuminuria or TOD

Lifestyle modification Consider two-drugs therapy if blood

pressure > 150/90 mmHg

Lifestyle modificationfor 3 months

Blood pessure130-139/80-89 mmHg

No AlbuminuriaNo other TOD

Blood pessure> 140/90 mmHgor albuminuria

or TOD

Blood pessure> 130/80 mmHg

on two visits< month apart


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Fixed-dose

CombinationsDiuretic

+

AceARB

-Blockers

Other Combinations


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The Hypertension ParadoxMore Uncontrolled Disease Despite Improved

Therapy

INADEQUATE CONTROL OF


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only 15%of those with a BP 140/90

mmHg, were started on antihypertensive

medication

2836% of diabetic hypertensive patients

have their blood pressure controlled to 180 mmHg, diastolicBP >105

mmHg, or mean arterial BP 130 mmHg on 2readings 20 minutes apart, institute intravenousmedications (level of evidence V, grade Crecommendation).

2. if systolicBP is < 180 mmHg and diastolicBP 70 mm Hg (level ofevidence V, grade C recommendation).

Recommendation in patients with history ofchronic

hypertensionin spontaneous ICH


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3. MAP > 110 mm Hg should be avoided in the immediate

postoperative period

4. If systolic BP falls below 90 mm Hg pressure should be

given

Recommendation in patients with history ofchronic

hypertensionin spontaneous ICH


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Increased risk of hemorrhagic formation when diastolic BP > 100mmHg.

1. After ICH as a rule, systolic pressure of approximately 140-160 mmHgand diastolic pressure of 90-100 mmHg suffice for adequate systemic,cerebral and coronary perfusion

Recommendation in patients without history of

chronic hypertensionin spontaneous ICH


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In general:

Treatment of BP in patients with spontaneous ICH more

aggressive than ischemic stroke

Rationally theoretical

Lowering BP decrease the risk of ongoing bleeding

Over aggressive treatment of BP CPP

brain injury >> if ICP


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Blood pressure management

in Acute Ischemic Stroke

Blood pressure management in Acute Ischemic


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No specific data defining the levels of hypertension that

should trigger treatment in these settings.

By consensus, recommended that acute treatment be

withheld in patients with SBP is >220 mm Hg or the DBP is

>120 mm Hg

Drugs that can lead to precipitous declines in blood pressuresuch as sublingual calcium channel antagonists should be

avoided

Exceptions to the recommendation to avoid treatment of acute

hypertension noted in the American Stroke Associationscientific statement include patients with hypertensive

encephalopathy, aortic dissection, acute renal failure, acute

pulmonary edema, acute myocardial infarction, or severe

hypertension Hypertension . January 12, 2004;43:137.)

Blood pressure management in Acute Ischemic

Stroke


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http://www.mail-archive.com/[email protected]/bin00005.bin


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Tragedi Sampit
http://www.mail-archive.com/[email protected]/bin00005.bin


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Telah nampak kerusakan di darat dan dilaut disebabkan perbuatan tangan

manusia, supaya Allah merasakan kepada

mereka sebahagian dari (akibat)perbuatan mereka, agar mereka kembali

(ke jalan yang benar)

QS. Ar Ruum (30) : 41


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Jikalau Allah menghukum manusia karenakezalimannya, niscaya tidak akan

ditinggalkanNya di muka bumi sesuatupun dari

makhluk yang melata, tetapi Allah

menangguhkan mereka sampai kepada waktu

yang ditentukan. Maka apabila telah tiba waktu

(yang ditentukan) bagi mereka, tidaklah mereka

dapat mengundurkannya barang sesaatpun dantidak (pula) mendahulukannya

Qs. An Nahl (16) : 61


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Dan bila dikatakan kepada mereka:

Janganlah kamu membuat kerusakandi muka bumi, mereka menjawab:

"Sesungguhnya kami orang-orang yang

mengadakan perbaikan." Ingatlah,

sesungguhnya mereka itulah orang-orangyang membuat kerusakan, tetapi mereka

tidak sadar.

(Qur'an, 2:11-12)


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CASE PRESENTATION

CASE-1:

A 39 years old pregnant female in OBGYN department presented with

seizure 1 hour before admission, initially with headache. She had a

recurrent abortus (2x). She had a history of strumectomy and

performing ablation in 1988. History of hypertension was denied. She

has been consulted to our ward to manage her high blood pressure.

during pre operation procedure. Our examination revealed BP was

180/100 mmHg, PR was 110x/m, RR was 20x/m. slow speech, brittle

hair, dry skin, mix edema, Deep tendon reflex was decreased. TFU

~1/2 proc. Xyphoid -umbilicus. Laboratory result revealed low FT4

level and High TSH level. How do you manage this patient?


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CASE PRESENTATION

Problem list:

1. GVP1100Ab200, 36-38 weeks, HSVB, BOH, >35 y.o

2. Obs. Seizure 2.1 Emergency HT superimposed preeclampsia

3. Recurrent abortion 3.1 Antiphospholipid syndrome

3.2 Sticky platelet syndrome

4. Eclampsia


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CASE PRESENTATION

CASE 2

A 40 y.o female has been consulted from Surgery department. She

presented with burn trauma on her face, both arms and legs after she

got blast from LPG when she was cooking. She will be performed

debridement, but the blood pressure was 210/120 mmHg. No

hypertension before. How do you manage the patient?


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CASE PRESENTATION

CASE 3

A How do you manage the patient?

Crisis of Hypertension

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