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First described by Volhard and Fahr (1914), who saw patients with severe hypertension accompanied by signs of vascular injury to the heart, brain, retina, and kidney. Prior to the introduction of antihypertensive medications, 7% of hypertensive pts had HE.
Currently, 1 to 2% of pts with hypertension will have a HE at some time in their life.
Marik Paul E, Varon Joseph, CHEST 2007;131:1949-62
InaSH-2009 2
Definitions
Hypertensive Crisis BP > 180/120
Hypertensive Urgency Hypertensive Emergency
Markedly elevated BP without severe symptoms or progressive target organ damage. BP should be reduced within hours. Oral agents.
Markedly elevated BP with acute or progressing target organ damage. BP should be reduced immediate. Parenteral agents.
Kaplan NM ,Hypertensive Crises in : Clinical hypertension 9th Ed, Lippincott Williams & Wilkins 2006:609-630
Definitions
markedly elevated BP with papiledema (grade 4 Keith-Wagener retinopathy) and/or hemorrhages and exudates (grade 3 Keith-Wagener retinopathy). The Clinical features and prognosis are similar with grade 3 or 4 retinopathy (Ahmed et al., 1986) Hypertensive encephalopaty is a sudden, marked elevation of BP with severe headache and altered mental status, reversible reduction of BP.
Kaplan NM ,Hypertensive Crises in : Clinical hypertension 9th Ed, Lippincott Williams & Wilkins 2006:609-630
InaSH-2009 4
Clinical Presentation
30% 25% 20% 16% 15% 10% 5% 0%
Cerebral Infarction ICH or SAH Hypertensive encephalopathy Acute Acute CHF AMI or UAP Aortic pulmonary dissection edema Zampaglione B, Pascale C et al. Hypertension
1996;27:144-7
25% 23%
14% 12%
5% 2%
Renal failure
Hypertensive Emergency
Cardiovascular disease
PATHOPHYSIOLOGY
Hypertensive emergency occur in association with target organ complications Caucasians : 20 30 % African-Americans : 80 %
cardeneiv.com
TRIGGERS
NORMAL
HIPERTENSIVE EMERGENCY
TRIGGERS
NO
ENDOTHELIAL DYSFUNCTION
MECHANICAL STRETCH
INFLAMATION
History :
Physical exam.
Prior diagnosis and treatment of HT Intake of pressor agents : street drugs, sympathomimetics Symptoms of cerebral, cardiac, and visual dysfunction BP Funduscopy Neurologic status Cardiopulmonary status Body fluid volume assessment InaSH-2009 Peripheral pulses
12
Patients should be admitted to an Intensive Care Unit for continuous monitoring of BP and parenteral administration of an appropriate agent The initial goal therapy is to reduce mean arterial BP by no more than 25% (within minutes to 1 hour). Then if stable, to 160/100 to 110 mmHg within the next 2 to 6 hours. Excessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia should be avoided.
If this level of BP is well tolerated and the patients is clinically stable , further gradual reductions toward a normal BP can be implemented in the next 24 to 48 hours. Exceptions :
1. 2. 3.
Patients with ischemic stroke Aortic dissection SBP should < 100 mmHg Patients whom BP is lowered to enable the use of thrombolytic
Chobanian AV et al, The JNC 7 report, JAMA 2003;389: 2560-70
Dose
0.25-10 ugr/kg/min 5-500 ug/min 20-80 mg every 10-15 min or 0.5-2 mg/min 0.1-0.3 ug/kg/min
Onset
Immediate 1-3 minutes 5-10 minutes <5 minutes
Duration of Action
1-2 minutes after infusion stopped 5-10 minutes 3-6 minutes 30-60 minutes
Nicardipine HCl
Esmolol HCl
5-15 mg/h
250-500 ug/kg/min IV bolus, then 50-100 ug/kg/min by infusion; may repeat bolus after 5 minutes or increase infusion to 300 ug/min
5-10 minutes
1-2 minutes
15-90 minutes
10-30 minutes
This parenteral drugs are approved for hypertensive emergency in acute ischemic stroke and intracerebral AHA/ASA Guideline, 2007 update. Stroke. 2007;38: 2001-20 hemmorhage
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
Marik Paul E, Varon Joseph, CHEST 2007;131:1949-62
Nitroglycerin
Nitroglycerin is a potent venodilator and only at high doses affect arterial tone. It reduces BP by reducing cardiac ouput and preload which are undesirable effects in patient with compromised cerebral and renal perfusion
Nifedipine
Nifedipine has been widely used via oral or sublingual administration in the management of hypertensive emergencies. This mode of administration has not been approved by FDA and since JNC VI because it may cause sudden uncontrolled and severe reductions in blood pressure may precipitate cerebral, renal, and myocardial ischemia that have been associated with fatal outcomes
USE OF NICARDIPINE
Nicardipine : . Dihydropiridine class of CCB Reduce peripheral resistance --- blood
pressure
water soluble, light insensitive, -- can be parenteraly used (deference with nifedipine / sodium nitroprusid)
DOSIS
PERDIPINE
DIV (g/kg/min) Bolus (g/kg) 10 30
2 - 10 0.5 6
Hypertensive emergencies
(g/kg/min)
0.5
10
PERDIPINE
The 1st line treatment of Hypertensive Emergency
Could be used :
Sodium Chloride / NaCl ( OTSU-NS : 100/250/500 ml ) Dextrose 5% ( OTSU-D5 : 100 / 250 / 500 ml ) Glucose 5% Potacol R
Couldnt be used :
Sodium bicarbonat Ringer Laktat
Ringer Asetat
KN 1A / 1B / 4A
Kasus
Seorang laki-laki 31 tahun datang diantar keluarga dalam keadaan tidak sadar sejak 3 jam yll. Pasien saat mau ke kamar mandi mendadak mengeluh sakit kepala hebat, kemudian diikuti kejang-kejang dan selanjutnya tidak sadar. Dari pemeriksaan kesadaran sopor, TD 210/110; HR 104x/menit, febris (-). Kaku kuduk (-), gerakan tangan dan kaki kanan kurang aktif dibandingkan kiri. BB 75 kg Stroke?
26
Kasus
Seorang laki-laki, 70 th, pagi hari saat ke kamar mandi mengeluh tungkai kiri terasa lemah. Ia masih dapat berjalan, beberapa saat kemudian kaki bertambah lemah disertai dengan kelemahan pada tangan kiri dan bicara pelo. Dari pemeriksaan kesadaran composmentis, TD 200/110; HR 104x/menit, febris (-). Kaku kuduk (-), ekstremitas kanan lebih lemah dibandingkan kiri. BB 61 kg Sebulan yang lalu pasien mengalami hal yang sama tapi pulih kembali dalam beberapa menit.
SUMMARY
Antihypertensive agent that preffered in this condition should be fast action, parenteral, and titratable Nicardipine is the only Calcium Antagonist recommended by JNC 7, AHA, 2007, CHEST 2007 to manage hypertensive emergency Nicardipine has favorable antiischemic profile because of an increase myocardial , brain, and kidney oxygen supply
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