crisis of hypertension
TRANSCRIPT
-
7/30/2019 Crisis of Hypertension
1/91
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
-
7/30/2019 Crisis of Hypertension
2/91
H. + Komplikasi
H. + Keluhan +
Pengobatan tak baik
H. + Keluhan +
Pengobatan baik
H. Tanpa keluhan
Nomiotensi
Border line
FENOMENA GUNUNG ES
-
7/30/2019 Crisis of Hypertension
3/91
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
-
7/30/2019 Crisis of Hypertension
4/91
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
-
7/30/2019 Crisis of Hypertension
5/91
- 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
-
7/30/2019 Crisis of Hypertension
6/91
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
-
7/30/2019 Crisis of Hypertension
7/91
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.)
-
7/30/2019 Crisis of Hypertension
8/91
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
-
7/30/2019 Crisis of Hypertension
9/91
Tek Darah LVHLV DELATL.V. Wall Tension
L.V. O2 Consump
Miokard Hypobia
Diastolic Compliance LVEDP
LVF
-
7/30/2019 Crisis of Hypertension
10/91
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
-
7/30/2019 Crisis of Hypertension
11/91
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
-
7/30/2019 Crisis of Hypertension
12/91
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
-
7/30/2019 Crisis of Hypertension
13/91
SevereHypertension
-
7/30/2019 Crisis of Hypertension
14/91
-
7/30/2019 Crisis of Hypertension
15/91
-
7/30/2019 Crisis of Hypertension
16/91
-
7/30/2019 Crisis of Hypertension
17/91
-
7/30/2019 Crisis of Hypertension
18/91
-
7/30/2019 Crisis of Hypertension
19/91
-
7/30/2019 Crisis of Hypertension
20/91
-
7/30/2019 Crisis of Hypertension
21/91
-
7/30/2019 Crisis of Hypertension
22/91
-
7/30/2019 Crisis of Hypertension
23/91
-
7/30/2019 Crisis of Hypertension
24/91
-
7/30/2019 Crisis of Hypertension
25/91
-
7/30/2019 Crisis of Hypertension
26/91
-
7/30/2019 Crisis of Hypertension
27/91
-
7/30/2019 Crisis of Hypertension
28/91
Patient assessment
Complete cell blood count
Complete metabolic panel
ECG : ischemic, infarct ? Radiography :
cardiomegaly,pulmonary edema,aortic
abnormality
-
7/30/2019 Crisis of Hypertension
29/91
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
-
7/30/2019 Crisis of Hypertension
30/91
MANAGEMENT HIPERTENSIPADA DIABETES
-
7/30/2019 Crisis of Hypertension
31/91
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
-
7/30/2019 Crisis of Hypertension
32/91
In patients with proteinuria > 1g
and renal insufficiency blood
pressure goal < 125/75 mmHg
-
7/30/2019 Crisis of Hypertension
33/91
-
7/30/2019 Crisis of Hypertension
34/91
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
-
7/30/2019 Crisis of Hypertension
35/91
Lifestyle Modification to Lower
Blood Pressure
Stults B. Diabetes Spectrum 2006; 19: 25
-
7/30/2019 Crisis of Hypertension
36/91
Pharmacologic Treatment
-
7/30/2019 Crisis of Hypertension
37/91
Advances in the Treatment of
Hypertension
Chobanian AV. N Engl J Med
2009;361:878-87, 2009
-
7/30/2019 Crisis of Hypertension
38/91
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)
-
7/30/2019 Crisis of Hypertension
39/91
Effects of Hypertension Treatment
on Morbid Events
Comparative Drug Trials in Patients
-
7/30/2019 Crisis of Hypertension
40/91
Comparative Drug Trials in Patients
with Hypertension
Chobanian AV. N Engl J Med 2009;361:878-87, 2009
-
7/30/2019 Crisis of Hypertension
41/91
In patients with proteinuria > 1g
and renal insufficiency blood
pressure goal < 125/75 mmHg
Algorithm for Management of Hypertension
-
7/30/2019 Crisis of Hypertension
42/91
Algorithm for Management of Hypertension
Chobanian AV. N Engl J Med 2009;361:878-87, 2009
Blood pessure
-
7/30/2019 Crisis of Hypertension
43/91
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
Blood pressure > 130/80 mmHgafter 1 month
Add nonDHP CCB (veraparmil or diltiazem)
Blood pressure > 130/80 mmHgafter 1 month
Blood pressure > 130/80 mmHgafter 1 month
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
-
7/30/2019 Crisis of Hypertension
44/91
Fixed-dose
CombinationsDiuretic
+
AceARB
-Blockers
Other Combinations
-
7/30/2019 Crisis of Hypertension
45/91
Chobanian AV. N Engl J Med 2009;361:878-87, 2009
-
7/30/2019 Crisis of Hypertension
46/91
The Hypertension ParadoxMore Uncontrolled Disease Despite Improved
Therapy
INADEQUATE CONTROL OF
-
7/30/2019 Crisis of Hypertension
47/91
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
-
7/30/2019 Crisis of Hypertension
70/91
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
-
7/30/2019 Crisis of Hypertension
71/91
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
-
7/30/2019 Crisis of Hypertension
72/91
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
-
7/30/2019 Crisis of Hypertension
73/91
Blood pressure management
in Acute Ischemic Stroke
Blood pressure management in Acute Ischemic
-
7/30/2019 Crisis of Hypertension
74/91
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
-
7/30/2019 Crisis of Hypertension
75/91
-
7/30/2019 Crisis of Hypertension
76/91
-
7/30/2019 Crisis of Hypertension
77/91
-
7/30/2019 Crisis of Hypertension
78/91
-
7/30/2019 Crisis of Hypertension
79/91
-
7/30/2019 Crisis of Hypertension
80/91
-
7/30/2019 Crisis of Hypertension
81/91
-
7/30/2019 Crisis of Hypertension
82/91
http://www.mail-archive.com/[email protected]/bin00005.bin -
7/30/2019 Crisis of Hypertension
83/91
Tragedi Sampit
http://www.mail-archive.com/[email protected]/bin00005.bin -
7/30/2019 Crisis of Hypertension
84/91
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
-
7/30/2019 Crisis of Hypertension
85/91
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
-
7/30/2019 Crisis of Hypertension
86/91
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)
-
7/30/2019 Crisis of Hypertension
87/91
-
7/30/2019 Crisis of Hypertension
88/91
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?
-
7/30/2019 Crisis of Hypertension
89/91
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
-
7/30/2019 Crisis of Hypertension
90/91
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?
-
7/30/2019 Crisis of Hypertension
91/91
CASE PRESENTATION
CASE 3
A How do you manage the patient?