HYPERTENSION CRISIS

Andry Syahreza

RSUD Kab. Kep. Mentawai

INTRODUCTION &
TERMINOLOGY
Definition of Crisis Hypertension

Hypertensive crisis refers to elevated blood pressure

coupled with progressive or impending organ damage
due to high blood pressure.

Usually characterized by a rise in DBP to greater than

120 to 130 mmHg.
Crisis Hypertension
Urgency VS Emergency

The clinical differentiation between hypertensive

emergency and hypertensive urgency depends on
the presence of TARGET ORGAN DAMAGE
rather than the level of blood pressure
Accelerated Hypertension

Blood pressure is elevated progressively, at a

fast pace, with retinal hemorrhage and exudates
(grade II Keith-Wagner-barker retinopathy)
Malignant Hypertension

 Severe elevation BP accompanied with

papilledema which may be accompanied by
encephalopathy or nephropathy.

 In addition to Grade IV keith-Wagner-Barker

retinopathy
Epidemiology

 30 % of adult Indonesian population suffer

from hypertension. The vast majority of these
patients have essential hypertension

 < 1 % of these patients will develop one or

multiple episodes of hypertensive crises.
PERNEFRI, 2011
Causes and Precipitating Factors of
Hypertensive Crises
 Unidentified cause (most common)
– Abrupt increase in BP in patients with chronic
Hypertension without demonstrable precipitating
factors

 Drug Withdrawal
– Ussually Centrally acting drugs (clonidine). However,
it can occur with most antihypertensive drugs
Causes and Precipitating Factors of
Hypertensive Crises
 Renal dysfunction or abnormalities
– Acute GN, Parenchymal renal disease, Renovascular
Hypertension, renin secreting tumors.

 Central Nevous System abnormalities

– Head injuries, intracranial mass, intracerebral or
subarachenoid hemorrhage. Autonomic hyperactivity
in various spinal cord syndorme.
Causes and Precipitating Factors of
Hypertensive Crises
 Causes related to increases catecholamine
production:
– Pheochromocytoma, cocaine, MAO inhibitors and
tyramine ingestion, other drug-induced causes
(NSAID, Steroid, Tricyclic antidepresants,
sympathomimetics: Amphetamines, ephedrine)
Causes and Precipitating Factors of
Hypertensive Crises
 Miscellaneous causes
– Eclampsia, peri-operative hypertensive (especially
open heart surgery), severe body burns,
disseminated vasculitis, progressive systemic
sclerosis, SLE
PATOHOGENESIS
 AUTOREGULATION

X PERIPHERAL RESISTANCE
BLOOD PRESURE = CARDIAC OUTPUT and/or
Hypertension = Increased CO Increased PR

Function Structural
 Preload  Contractillity constriction hypertrophy

 Fluid Volume Venous

Contriction
Sympathetic Renin Cell Hyper
nervous over anglotensin membrane Insullinemia
activity excess alteration
Renal Decreased
Sodium filtration Endothelum
retention surface derived
factors
Excess Genetic Obesity
Sodium Stress
Genetic alteration
infake
alteration
Diagnostic

Certain tests will be given to monitor blood

pressure and assess organ damage, including:
– Regular monitoring of Blood Pressure
– Eye Exam (funduscopic)  Hemorrhages,
Exudates, and/or papilledema
– Blood and urine testing
– ECG
Diagnostic

The diagnosis is based on altered end-organ

function and the rate of the rise in BP, NOT the
level of BP
HYPERTENSIVE URGENCY
Hypertensive Urgency
(a.k.a Severe Asymptomatic Hypertension)

Severe hypertension in adults (often defined as

systolic blood pressure ≥180 mmHg and/or
diastolic blood pressure ≥120 mmHg)
Hypertensive Urgencies

 Papilledema

 Headache

 Shortness of breath

 Pedal edema
How quickly should the blood pressure be
reduced? (Hypertensive Urgencies )
 The blood pressure should be reduced over a
period of hours to days

 Slower reductions may be needed in older

adult patients at high risk for cerebral or
myocardial ischemia resulting from
excessively rapid reduction of blood pressure.
What is the blood pressure target during
period of time? (Hypertensive Urgencies )
 Lowered to < 160 / <100

 MAP should not be lowered by more than 25 –

30 %

 Above 160/100 in patients with very high

pressures
How should this goal be achived?
(Hypertensive Urgencies )

 Moving patients to a quiet room  Systolic

reduce 10 – 20 mmHg.

 If BP needs to be lowered over a period of

hours: Furosemide, Clonidine, Captopril

 If BP needs to be lowered over a period of

days: treat with antihypertensive therapy.
Kaiser Permanente Colorado, 2012
HYPERTENSIVE EMERGENCY
Hypertensive Emergency

Defined as a sudden increase in systolic and/or

diastolik BP associated with end organ damage
of the CNS, the heart, or the kidney
Hypertensive Emergencies
Hypertensive Emergencies
Hypertensive Emergencies
How to manage?

 It is generally unwise to lower the blood

pressure too quickly or too much

 as ischemic damage can occur in vascular beds

that have grown accustomed to the higher level
of blood pressure (ie, autoregulation).
How to manage?

For most hypertensive emergencies, mean

arterial pressure should be reduced gradually by:

 10 to 20 % in the first hour

 5 to 15 % over the next 23 hours

Recognition of Hypertensive Emergency
USE OF CAPTOPRIL SUB LINGUAL FOR
HYPERTENSION CRISIS
THANK YOU