hypertension crisis 8 CONCLUSION

1. Hypertensive crisis occurs when there is increased blood pressure suddenly, where TD diastole above 120-130 mmHg.
2. Interference in the target organs in acute or hypertension attack en route to emergency associated with hypertension, and should receive treatment as soon as possible in matter of minutes or hours to avoid complications - complications that can occur.
3. Increased high blood pressure without a disruption in the target organ is known as a hypertensive urgency (hypertensive urgency), where treatment can be done in a few hours to 48 hours but remain in close supervision.
4. handling and proper management can reduce the risk of complications there, so patients can perform activities as usual.

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hypertension crisis 7 Management AND THERAPY

Management of inpatients
Patients with hypertension  genuine emergency requiring the careful IV therapy to control both blood pressure and decrease slowly but steadily.
 strict monitoring is needed. Treated in the ICU is appropriate.
 Another issue or another broadcaster needs to be acknowledged and addressed (for example, surgery for aortic dissection)
Management on an outpatient
 Hypertension is a chronic problem. The main thing to reduce the risk of disability and death of patients is long-term treatment.
 If the patient is known with high BP examination in the emergency room but did not show any interference with the target organ, the patient does not need to get treatment as soon as possible. Patients only need difollow-ups regularly.
 JNC recommendation from high blood pressure for routine follow-up in patients without target organ disorders:
 Prehypertension (TDS 120-139, TDD 80-89)  BP should be checked again in 1 year.
 Hypertension degree I (TDS 140-159, TDD 90-99)  TD should be checked again in 2 months.
 Hypertension degrees II (TDS> 160 or TDD> 100)  need treatment at a health center within 1 month.
 If TDnya> 180/110, the patient should be examined and given within 1 week of therapy.
Referral of patients can be done with consideration of the existing condition of the broadcaster. If known there are other disorders that accompany, such as aortic dissection or subarachnoid hemorrhage, it is necessary to be referred to health centers higher.
COMPLICATIONS, PREVENSI, and Prognosis
Complications that may arise from the crisis of hypertension or side effects of treatment given:
Congestive heart failure 
Myocardial miokardial 
Renal 
 retinopathy
Injury  brain blood vessels
Disturbance due to a decrease   TD cerebral blood perfusion and heart inadekuat, so it can towards stroke or ischemic infarction.
Some things that need to be considered in patients with high BP to prevent an attack or hypertensive crisis reactivation:
Examination  good in the long run for hypertension is the best way to prevent a sudden attack of hypertension crisis.
 Educate patients and follow-up routine in patients with essential hypertension crisis as to prevent re-attack emergency hypertension.
 Use appropriate antihypertensive drugs by doctors is the main thing to avoid the development of hypertensive emergency.
Prognosis
 The death rate within 1 year more than 90% in patients with hypertension who did not handle the emergency.
 life expectancy of about 144 months for all patients with hypertensive emergency encountered in the emergency room.
Life expectancy  5 years in all patients with hypertensive crises around 74%.

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hypertension crisis 6 Management AND THERAPY

If a case of hypertensive crisis, which first had to do is do not panic. Things - things you can do before bringing the patient into the ER, among others:
 Know all signs - there are clinical signs of hypertensive crisis, such as chest pain or heart failure. Actions to lower blood pressure is not indicated before the patient was taken to hospital.
 Oxygen, a strong diuretic (furosemide), and nitrate, all of which may be given.
 In most cases, action to deal with hypertension before being taken to the hospital was not wise. In certain circumstances, reduction in blood pressure which can drastically reduce the target organ perfusion significantly.
Subsequent handling in the ER for patients with hypertension in principle is to determine the presence or absence of interference with the target organ.
 initial action (if the patient is not in a state of distress)
 Put in patients who are not depressed in a quiet room and checked again after initial examination. In one study, 27% of patients with early diastole blood pressure> 130 mmHg can decrease significantly after relaxation without special handling.
 Consider whether there are other reasons that cause increased blood pressure (such as severe pain which sometimes causes a rise in blood pressure).
Looking for the presence or absence  interference with target organ of patients  know history, physical examination, laboratory tests, other investigations.
 Patients without interference with the target organ can be moved without the provision of therapy as soon as possible, but still difollow - up in the hope that lowering blood pressure in stages. (JNC recommendations)
 misconception is that patients should not be moved from the emergency room with blood pressure is still high. So that the patients were given oral medication, such as nifedipin, with the hope to decrease blood pressure before it moved. This is not indicated and may be dangerous.
 The work done in this way may be difficult in improving blood pressure "drop". If this happens, then the target organ will experience hipoperfusi.
 Some patients may have a talent for an increase in blood pressure and takes a long time to control it but he was not familiar with the blood pressure drops rapidly, although it was the normal number.
 Patients with target organ disorders usually requires immediate action to lower blood pressure through the line quickly. Drug therapy is given depends on the organ - the organ.
 In the case of hypertensive crisis, blood pressure should not be lowered to the normal rate.
 The decrease of blood pressure can quickly lead to decrease blood flow to the brain, kidney, and / or coronary blood vessels, which allows the emergence of ischemic and infarction.
 In general, MAP should not be lowered more than 20 - 25% in the first hours of therapy. If the patient is stable, then further blood pressure can be lowered to 160/100-110 the next 2-6 hours.
 For the best results are expected, can be obtained by continuing the infusion of working quickly, can be titrated from parenteral antihypertensive medications with a continual monitoring of patients - sustained and intensive.
 blood pressure drop rapidly as indicated in the following circumstances:
 Ischemic acute myocardial
 Nitroglycerin IV
  - blockers IV
 congestive heart failure with pulmonary edema
 Nitroglycerin IV
 Lasix IV
 Nitroprusside IV
  acute aortic dissection in this situation, if possible systole blood pressure should be lowered quickly to 100 to 110 mm Hg or more lower.
 Labetalol IV
 Alternative IV with nitroprusside   - blockers (esmolol cont.)
 Injury  brain blood vessels using antihypertensive drugs are not always recommended for stroke patients with hypertension.
 Controlling blood pressure is influenced by the use of thrombolytic drugs in ischemic stroke. TD systole> 185 mmHg or diastole TD> 110 mm Hg is a contraindication to the use of tissue plasminogen activator (TPA) in the first 3 hours of ischemic stroke patients.
 latest recommendations from the American Stroke Association explains that patients with ischemic stroke and sistolenya TD> 220 mmHg or diastolenya TD> 120-140 can be lowered blood pressure approximately 10-15% (with IV nitroprusside or labetalol IV), if the patient is always monitored closely to decrease the status neurologist associated with blood pressure lower.
Intracranial hemorrhage   there is no evidence to support that hypertension trigger further bleeding in patients with intracranial hemorrhage.
Drastic reduction  systole blood pressure can reduce perfusion in the brain and increase the risk of death.
 Control to lower blood pressure by giving IV nitroprusside or labetalol IV (there are no bradikardi) is recommended when the systole TD> 200mmHg or diastole TD> 110mmHg.
 Interaction monoamine oksidade - tiramin with acute hypertension  phentolamin IV
 Pheokromositoma
 Phentolamin IV
 Labetalol IV
 Hypertension enselopati
 Nitroprusside IV
 Labetalol IV
IV Fenoldopam 
 Acute renal failure
IV Fenoldopam 
 Nicardipin IV
  - blockers IV
 Eklamsia
 Hydralazin IV
 Labetalol IV
IV Magnesium 
 blood pressure drop quickly in the ER in addition to the above conditions is controversial and should be avoided.
 In patients who initiated because of the use of drugs - illegal drugs can be given a combination of nitroprusside with α and  - adrenergic blockers.

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hypertension crisis 5 DIAGNOSIS

Knowing the previous history and clinical findings are very important to distinguish between hypertension and hypertensive emergency urgency. Information about previous history of hypertension should include that have been diagnosed, the duration, degree, and control of blood pressure taken. Also find information about the previous history should take precedence in the discovery of the organ - the target organ affected, the situation during hypertension, and findings - that there are other findings.
Some other things that can be asked related to the occurrence of hypertensive crisis:
 Drugs - drugs
- Antihypertensive therapy previously obtained.
- The use of substances - substances "over - the - counter", as an example of a drug - a drug simpatomimetik.
- The use of drugs - drugs such as cocaine.
 Date of last menstrual
 other health problems (ex: hipertens earlier, thyroid disease, Cushing's syndrome, systemic lupus, and kidney disease).
 assessment of complaints that lead to hypertension crisis clinical findings:
-  chest pain of ischemic heart muscle or myocardium
- Back pain  aortic dissection
- Difficulty in breathing  pulmonary edema or congestive heart failure
- Symptoms - anxiety symptoms  neurologist, vision problems, level of chaos that changes - change (hypertension enselopati)
Physical examination should be given priority on things - things that can explain the crisis of hypertension in the emergency situation.
 Alerts - vital signs
 blood pressure should be measured in standing and sitting position (if possible  assess whether or not the volume depletion
 blood pressure should also be measured on both arms  significant differences leading to the aortic dissection.
Funduskopi examination may include changes that are consistent from chronic hypertension. Acute changes include arterial spasm (focal or diffus), retinal edema, bleeding in the retina (surface and shape as a tongue of fire, or deep and wide), exudate in the retina (hard or like cotton wool), or papiledema.
Examination focused on the cardiovascular whether there is a sign - a sign of heart failure (such as the lungs ronkhi voice, increased jugular venous pressure, askultasi emergence of S3 in the heart, and peripheral edema) or aortic dissection. Results further possibility of compensation can occur from an artery that is usually caused by a decrease in pulse rate, and this may result in ischemic brain, muscles, or digestive tract. Additional sound new murmur or mitral insufficiency penigkatan than may sound as a result of increased left ventricular afterload.
With the heart - the heart, neurological examination can directly explain the sign - a sign that will soon happen / is happening. Symptoms often arise as a result of hypertension among other enselopati, disorientation, decreased level of consciousness, and in some cases focal neurological deficit or seizures comprehensive or specific focal only. Enselopati hypertension is a stand-alone diagnosis, where the existence of other lesions (cont: stroke, subarachnoid hemorrhage, mass lesions) could be set aside. This is possible because of cerebral edema caused by the loss of autoregulation of cerebral blood vessels that appear because of hypertension weight.
The laboratory should be done immediately upon discovery of clinical symptoms and explain the important results for the ongoing situation. Routine blood tests can determine the presence or absence of mikroangiopati hemolytic anemia. Examination of urine can also indicate a hematuri, proteinuri or sediment on the state azotermia or kidney failure. Urine examination to determine the levels metanefrin can also be done to eliminate the possibility of pheokromositoma. Increased levels of serum urea and creatinine, metabolic acidosis, and hypokalemia can be seen on the blood chemistry tests which can indicate a decrease in kidney function. Aldosterone levels and plasma rennin can also be examined to rule out the existence of primary hiperaldosteronism in patients with significant hypokalemia previously not received diuretic drugs at the time of attack .. Hypokalemia which is the description of secondary aldosteronism, is at approximately 50% of patients with hypertensive crisis. In patients with elevated blood pressure due to natriuresis, serum sodium levels are usually lower than the state of primary aldosteronism. This happens because the increase in hydrostatic pressure peritubuler kidney-related increase in arterial pressure. This Natriuresis causes a secondary decrease in sodium reabsorbsi. Laboratory tests that can be done as an alternative to support the diagnosis of hypertensive crisis, among others, toxicology tests, pregnancy testing, and endocrine examinations.
Hipertropi the left ventricle and changes associated with ischemia or infarction can be seen on electrocardiography examination. Photo roentgens thoracic show evidence of heart enlargement, pulmonary edema, or a widened mediastinum, where it all can lead to aortic dissection. In addition, to further strengthen the suspicion of aortic dissection, can be performed chest CT examination, transesofageal ekhokardiografi, or with aortic arteriogram. Ekhokardiografi two dimensions can be used to distinguish pure diastole dysfunction of the heart during systole dysfunction sign - a sign of heart failure appear. All this may help in determining the therapy given and the provision of long-term therapy.
Head CT scan can be performed on patients with symptoms of neurological disorders. Sign - a sign that may arise from this investigation, among others, brain hemorrhage, brain edema, or ischemia in the brain.
In the end, it is important to determine the cause of secondary hypertension (eg hypertension renovaskular) which may cause the crisis. Test with a single dose of captopril may be given, especially in patients who did not receive drug therapy for hypertension before. Aktvitas levels of plasma rennin known in advance and then the patients were given 25 to 50 mg of captopril, 60 minutes and then re-examined rennin levels. The sensitivity value is a good test, but for very low spesifisitasnya. For further examination, such as Doppler ultrasound, MRI renal angiography, angiography with contrast, may be done to better diagnosis.
Using Skrening captopril test for secondary causes of the crisis of hypertension:
METHOD
o Patients receive adequate intake of salt and not getting a diuretic drug.
o Stop all hypertension medications three weeks before the test, if possible.
o The patient is seated at least 30 minutes, take blood samples and determined aktvitas levels of plasma rennin.
o captopril 50 mg diluted in 10 ml of water, the patient should immediately take the solution.
o After 60 minutes, take back the blood sample and measured re-elevated levels of plasma rennin.
INTERPRETATION
Expressed a positive test if:
 There was elevated levels of plasma rennin or more 12 ng/ml/jam.
and
 absolute increase in plasma rennin levels of 10 ng / ml / hour or more.
and
 Increased levels of plasma rennin > 150 % or > 400 % if the lower threshold value of plasma rennin levels were < 3 ng / ml / days.

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hypertension crisis 4 Pathophysiology

Pathophysiology for sure about the development of hypertensive crisis is unknown. Progressive malignant hypertension may be a nonspecific process that causes increased blood pressure is extreme. Humoral factors (especially the renin-angiotensin axis) and local products produced by blood vessels (eg prostaglandins and free radicals) may also be involved in increasing blood pressure very quickly.
However, the progressive increase in blood pressure is an important first step. There are three major organ systems are affected by high blood pressure is the central nervous system, cardiovascular system, renal system.

Central Nervous System 
Cerebral autoregulation is an important ability of the cerebral blood vessels to maintain cerebral blood flow remained constant in addition to changes in blood pressure. When the average arterial pressure - mean (MAP) increased, disturbed and endhotelium cerebral brain barrier can become loose. Fibrinoid material deposited in the brain blood vessels and cause lumen narrowed. Then the blood vessels of the brain trying to vasodilatation in the lumen was narrowed. This could be the beginning of cerebral udem and mikrohemoragik. Patients with chronic hypertension may tolerate a high MAP before an interruption in autoregulasi system.
Enselopati Hypertension is one of the clinical manifestations of cerebral edema and mikrohemoragi, which occur dysfunction of cerebral autoregulation. Without immediate treatment, enselopati hypertension can lead to cerebral hemorrhage, coma and eventually died.
Cardiovascular system 
Hypertension affects the structure and function of coronary arteries and left ventricle. Hypertension also activate the renin-angiotensin system, aldosterone, which causes systemic vasokonstriktif. This resulted in increased oxygen demand of the heart muscle because of increased left ventricular wall stress that can lead to hipertropi left ventricle and compression of the coronary blood vessels. When hypertension emergency occurs, the left ventricle can not compensate for systemic vascular resistance. This will ultimately lead to left ventricular failure and pulmonary edema, or ischemic heart muscle.
 renal system
Chronic hypertension causes pathological changes in small arteries of kidney. This continued on endothelial dysfunction and a weak vasodilatation, which will affect renal autoregulation. When disturbed renal autoregulation, intraglomerular pressure is directly related to systemic arterial pressure, this makes the lack of protection of renal changes in fluctuating blood pressure. When the crisis of hypertension, such interference can cause ischemia in acute renal.

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hypertension crisis 3

CAUSES AND RISK FACTORS
Although the causes of the crisis relatively low blood pressure, but hypertension is a disorder of pervasive and highly significant effect for men. Most of hypertension is essential or primary (no other cause), and hypertensive crisis appears more frequently in patients who have a history of previous hypertension. Hypertensive crisis may also arise because the disease that causes hypertension or any other cause:
  kidney disease parenkhim chronic pyelonephritis, preimer glomerulonephritis, tubulointerstitial nephritis (approximately 80% of all secondary causes).
 systemic disorders involving the kidney erimatosus  systemic lupus, systemic sclerosis, vasculitides.
Renovascular disease   atherosklerotik disease, displasi fibromuskuler, poliartritis nodosa.
Endocrine   pheokromositoma, Cushing syndrome, primary hiperaldosteronism.
  drugs cocaine, amphetamines, cyclosporin, dismissal klonidin, phensiklidin, diet pills, oral contraceptive pill.
  drug interactions Monoamine oxidase inhibitors with Tricyclic antidepressants, antihistamines, or tyramine-containing foods.
  central nervous system CNS trauma or spinal disorders, for example Guillain-Barré syndrome.
Aortic Koarktasio 
 Preeclampsia - eklamsia
Hypertension  post-surgery.
Hypertensive crisis can occur at any time. Hypertensive crisis may occur in neonates with congenital renal artery hipoplasi, children with acute glomerulonephritis, a young pregnant woman with eklamsia, or parents with atherosclerosis and renal artery stenosis. Some individuals may not be used to increase blood pressure significantly, and the symptoms and clinical manifestations of hypertensive crises arise in blood pressure are lower than those with chronic hypertension. However, treatment must be provided.
In the United States, approximately 50 million people stricken with hypertension. Prevalence increases with age. More than half of people aged between 60-69 years and about three-quarters of people aged 70 years or older who attacked hypertension. According to Mc Cowan, 2006, the crisis of hypertension attacked about 500,000 U.S. residents, or about 1% of adults who suffer from hypertension. And approximately one billion people worldwide suffer from hypertension.
Death due to ischemic heart disease and stroke increases with increasing blood pressure. For every increase in blood pressure 20 mmHg 10 mmHg systole and diastole, the risk of death due to ischemic heart disease and stroke would double.
When compared to existing inter-racial, African-American race is a race that has the greatest risk factor for hypertension crisis stricken. Hypertensive crisis appears more frequently in patients with advanced age. And overall, the prevalence and incidence of hypertension incidence is greater in men than women. The frequency of occurrence of hypertension crisis also two times more in men than women.
From a research note that blood pressure control is less effective in terms of systole blood pressure measurement is an independent risk factor for hypertension crisis cases that appeared in the ER.
But instead of that, mobilities and mortality due to hypertensive crisis, depending on the number of infected target organs and the extent of blood pressure can be controlled.

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hypertension crisis 2

DEFINITIONS
Hypertensive crisis can be defined as an increase in blood pressure arrived - arrived and meaningful, which diastolic pressure above 120 mm Hg - 130 mm Hg. Increased blood pressure is reached - arrived this may cause damage to several organs and can trigger a stroke occurs. Where in the incident, the heart can not function as well as function.

CLASSIFICATION
Mostly the crisis of hypertension is divided into two, namely hypertensive emergency (emergency hypertension) and hypertensive urgency (urgency hypertension).
Hypertension  emergency (emergency hypertension) which occurs  increased blood pressure is very high and there are abnormalities / target organ damage is progressive, so that in these circumstances blood pressure should be taken down immediately (within minutes to hours) in order to prevent / reduce damage to the target organ occurred.
Hypertension  urgent (urgency hypertension)  where there are blood pressure is very high but it is not accompanied by abnormalities / progressive organ damage, thus lowering blood pressure can be implemented more slowly, within hours to days.
The term for the progressive hypertension (accelerated hypertension) and malignant hypertension (malignant hypertension) is used in explaining the high blood pressure associated with clinical findings in retina. Accelerated hypertension is associated with bleeding of the retina and the presence of exudate (group 3 Keith-Wagener-Barker retinopathy). And
Malignant hypertension associated with the papiledema (group 4 Keith-Wagener-Barker retinopathy). Current clinical findings are not much different in funduscopy examination. And the situation can be described as a progressive malignant hypertension (accelerated-malignant hypertension).

SYMPTOMS AND clinical manifestations
The crisis is a symptom hypertension target organ affected, including chest pain and shortness of breath on cardiac and aortic dissection; eyes blurred in the eye papilla edema; severe headaches, disturbance of consciousness and brain disorders lateralisasi; acute renal failure in renal impairment; in addition to headache and neck pain on the increase in blood pressure in general.

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hypertension crisis 1

Community lifestyle today is a luxury lifestyle and sometimes far away from health considerations. So many health problems that arise as a result of it. One of them is hypertension.
Until now hypertension still remains a problem for several reasons, among others, increasing prevalence, is still the number of hypertension patients who had received treatment or been treated, but her blood pressure has not reached the target, as well as the accompanying diseases and complications that can increase morbidity and mortality.
Epidemiological data show that with the increasing elderly population, the number of patients with hypertension will likely increase, in which both systolic hypertension or a combination of systolic and diastolic hypertension often occurs in more than half of people aged> 65 years. In addition, blood pressure control rate of the former continue to increase, in the last decade shows no progress anymore (horizontal curve pattern), and blood pressure control was achieved only 34% of all hypertensive patients. Until now, data are incomplete hypertension most come from countries - countries that have been developed.
Hypertension of unknown cause was defined as essential hypertension, or by some doctors prefer the term primary hypertension. This is to distinguish with other hypertension secondary cause - for the unknown. Essential hypertension itself is 95% of the total cases of hypertension.

According to The Seventh Report of the Jonit National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), the classification of blood pressure in adults are divided into:
Classification TDS (mmHg) TDD (mmHg)
Normal <120> 160 or> 100

Hypertension can cause organ damage, either directly or indirectly. Disturbances in the organ - a common target organ in patients with hypertension found among others:
 Heart
 left ventricular hypertrophy
 angina or myocardial infarction
 Heart failure
 Brain
 stroke or transient ischemic attack
 Dementia
 chronic kidney disease
Peripheral arterial disease 
 retinopathy
The evaluation of hypertension in patients aims to:
1. assess and identify lifestyle factors - other cardiovascular risk factors or to assess the existence of an accompanying disorder that affects the prognosis and determine treatment.
2. find the cause of an increase in blood pressure.
3. determine the presence or absence of target organ disorders and cardiovascular disease.
Of all of the above, there is a situation where an increase in blood pressure is very high with the possibility of occurrence or interference / damage to the target organ. The situation is called hypertensive crisis. In general, hypertensive crisis occurs in patients with hypertension who do not or neglects to take antihypertensive drugs. Such conditions can cause disability or even death to the person who attacked them.
Problems that often occur during the handling of this crisis of hypertension patients are not quite right. Often, patients with blood pressure high blood pressure-lowering drugs are given directly by large doses in the hope that lowering blood pressure immediately. This is tantamount to overcome a problem but it adds another problem, as it can possible happen hipoperfusi organs - organs that targets can lead to occurrence of ischemic and infarction.

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