Isman Firdaus, dr, Sp.

JP (K), FIHA

Qualification :
Cardiovascular Intensivist- Interventional Cardiologistand

Office : 1. Critical Cardiovascular Care (CVC) and Cardiac

Emergency Unit
National Cardiovascular Center Harapan Kita
Hospital,
2ndFloor,Jakarta
2. Critical Care and Cardiology Division,
Department of Cardiology

9 CCU
2018
th
and Vascular Medicine, Faculty of Medicine,
University of Indonesia
Cirebon Cardiology
Jakarta Update
 Isman Firdaus, dr, Sp.JP (K),
FIHA

Jabatan :
1. Kepala Bidang Pelayanan Medik RSJPD Harapan Kita
2. SMF Rawat Intensif dan Kegawatan Kardiovaskular, RSJPD Harapan Kita
3. Ketua Departemen Advokasi dan Kebijakan Pengurus Pusat PERKI
4. Sekretaris Modul Kegawatan Kardiovaskular Departemen Kardiologi,
FKUI
5. Sekretaris Divisi Critical Care dan Kardiologi Klinik Departemen
Kardiologi, FKUI
6. Anggota Working Group Pokja Acute Cardiac Care, PERKI

9 CCU
2018
Email address : ismanf@yahoo.com th

Cirebon Cardiology
Update
 Isman Firdaus, dr, Sp.JP (K), FIHA

Working experience:
2001-2003 General Physician, Pusat Kesehatan Mahasiswa Universitas
Indonesia (PKM-UI), Depok, West Java.

2001-2003 Triage Physician, Emergency Room-National General Hospital

Center of Dr. Ciptomangunkusumo, Jakarta

2003 - 2007 Cardiovascular Resident, Department of Cardiology and

Vascular Medicine, Faculty of Medicine University of Indonesia, National
Cardiovascular Center Harapan Kita, Jakarta

July-Des 2004 General Internal Medicine Resident, Department of Internal

Medicine, Dr. Kariadi Hospital, Semarang, Central Java.

2007-2008 Chief of Balai Pengobatan Haji Indonesia in Saudi Arabia

2007 Interventional Cardiologist RS Mitra Keluarga Group Hospital

2012 - now Interventional Cardiologist RS Premier Jatinegara, Jakarta

9 CCU
2007-now Cardiac Intensivist and Interventional Cardiologist at National 2018
Cardiovascular Center, Harapan Kita Hospital, Jakarta th
2007 -now Staff of Critical Care Cardiology , Department of Cardiology
and Vascular Medicine, FKUI
Cirebon Cardiology
Update
 Materi
Managing Hypertensive Crisis Role of
CCB

Isman Firdaus, dr, Sp.JP (K), FIHA

9 CCU
2018
th

Cirebon Cardiology
Update
 Hypertensive Crisis
Isman Firdaus, MD
FIHA, FAPSIC, FAsCC, FESC, FSCAI

Pusat Jantung Nasional, Harapan Kita Hospital

Departement of Cardiology and Vascular Medicine
 Epidemiolog
y
Hypertensive Emergency
 Estimates are that about 1% of those
with hypertension will present with
hypertensive emergency each year
 That is >500,000 Americans per year
 Correct and quick diagnosis and

management is critical
 Mortality rate of up to 90%
Definitions:

• Hypertension:
• Stage I: 140-159/90-99
• Stage II: >160/100

• Hypertensive Urgency:
• Systolic BP >180 or Diastolic BP >120 in the
absence of end-organ damage
 Definitions Continued:
• Hypertensive Emergencies:
• SBP >180 OR DBP>120 in the presence of end-organ
damage
• Malignant Hypertension: End-organ damage--
eyes, kidneys, brain (hemorrhage/infarct)
affected
• Hypertensive encephalopathy: Cerebral edema
leading to neurological symptoms
Treatment Options

• Hypertensive Urgency:
• Goal: Reduce BP to <160/100 over several hours to
day
• Elderly at high risk of ischemia from rapid
reduction of BP, therefore slower reduction in BP
in this patient population
• Previously treated hypertension:
• Increase dose of existing med or add another
med
• Reinstitution of med in non-compliant patients
Treatment Continued

• Hypertensive Emergency:
• Goal: Lower Diastolic BP to approximately 100-105
over 2-6 hours; max initial fall not to exceed 20 -
25%
• More aggressive decrease can lead to ischemic
stroke and myocardial ischemia
• If focal neurological sx presentobtain MRI to r/o
acute stroke (rapid BP correction contraindicated)
• Parenteral antihypertensives (IV Drip)
recommended over oral agents in hypertensive
emergency
Oral Drug Choices often Based on
Comorbid Conditions

 Heart failure—TH, BB, ACEI, ARB, ALDO

 Post MI—BB, ACEI, ALDO
 High CVD risk—TH, BB, ACEI, CCB
 Diabetes—TH, BB, ACEI, ARB, CCB
 Chronic Renal Failure—ACEI, ARB
 Recurrent stroke prevention—TH, ACEI

 KEY: ACEI, angiotensin converting enzyme inhibitor; ALDO, aldosterone antagonist; ARB,
angiotensin receptor blocker; BB, b blocker; CCB, calcium channel blocker; TH, thiazide.
IV Medications
:
• IV, short acting, titratable.
Arterial Vasodilators
• Hydralazine, diltiazem,
nicardipine
• Mixed Arterial and Venous
Vasodilators
 Nitroglycerin, Sodium
nitroprusside
• Negative
Inotrope/Chronotrope
 Labetolol (also vasodilates),
Esmolol
• Alpha blockers (inc.
Treatment
Treatmentof
ofHypertensive
Hypertensive
Emergency with
Emergency with
Calcium
CalciumChannel
ChannelBlockers
Blockers
Calcium
CalciumChannel
ChannelBlockers
Blockers(CCBs
(CCBs))

Dihydropyridine ( DHP )
Nifedipine, Amlodipine, Nicardipine, etc.

Non-Dihydropyridine ( NDHP )
Diltiazem, Verapamil

OPIE, 2001
Diltiazem Multiple Effects
SYSTEM
CIRCULATION

ANTI-
ARRHYTHMIC DILTIAZEM

• Anti-arrhythmic
PSVT - • Arterial dilator ARTERIOLAR
• Negative inotropic DILATION
• Regression of LVH
ANTI- • Post-infarct protection
ANGINAL if no LVF AFTERLOAD 
ATRIAL FIB
(with digoxin)

BP 

Opie, 2001
Parenteral Drugs for Treatment of Hypertensive
Emergencies ( Vasodilators )
Drugs Onset of action Duration of action
Nicardipine * 5 min 1 hr
Sodium Nitropruside immediate 1-2 min
Fenoldopam < 5 min 30 min
Nitroglycerin * 2-5 min 2-3 min
Enalaprilat 15-30 min 6 hr
Hydralazine 10-20 min 4-6 hr
Diltiazem * 5 min 30 min
Trimetaphan 5-10 min 10 min

* Available in Indonesia
Pathophysiologic Effects Diltiazem
Pathophysiologic Effects Diltiazem

• Potent vasodilator
– Inhibits vascular smooth muscle contractility and decreases
peripheral vascular resistance
• Reduce Coronary resistance
– Dilates coronary arteries and increases coronary blood flow
• Decrease Heart rate
– Rate-Pressure Product (HR x SBP) reduce myocardial oxygen demand
– Absence of reflex tachycardia
• No adverse effects on glucose or carbohydrate metabolism
Drugs. 1990;39:757.
Cardioprotective Efficacy
• Ischemic cardiac muscle is improved by
① Increasing insufficient coronary blood volume (O 2 supply)
② Decreasing cardiac performance （ HER two-sided effect ）

Two-sided effect for myocardial ischemia

①Increasing vascular flow in ②Decreasing cardiac performance

ischemic cardiac muscle

Thick
Thickcoronary
coronaryvasodilating
vasodilatingeffect
effect BP
BPlowering
loweringeffect
effect
Collateral
Collateralvasodilating
vasodilatingeffect
effect HR
HRdecreasing
decreasingeffect
effect

Improvement of O2 supply and demand in

ischemic cardiac muscle
DILTIAZEM INTRAVENOUS
Effective in Adjunctive Therapy
• PTCA
• CABG
• Cardiac Transplantation
• Unstable Angina Pectoris

Effective in Antiarrhythmia
• PSVT
• Atrial Fibrillation
• Atrial Flutter

Effective in Lowering Blood Pressure

• Hypertensive Emergency
• Hypertensive Peri-operative
Calcium
CalciumChannel
ChannelBlockers
Blockers
Nicardipine Diltiazem
(dihydropyridine) (benzothiazepine)
Peripheral
Vasodilation1 +++++ +++
Coronary
Vasodilation2 +++++ +++
Suppression
of SA Node2 + +++
Suppression
of AV Node2 0 +++

Suppression
of Cardiac Contractility2 0 ++

1. Frishman WH, et al. Med Clin North Am. 1988;72:523-547.

2. Adapted from Goodman and Gilman’s: The Pharmacologic Basis of Therapeutics. 9th ed. 2001.
 NICARDIPINE
NICARDIPINEand
andDILTIAZEM
DILTIAZEM

NICARDIPINE DILTIAZEM

Target organ Arteriole (ca Arteriole (ca

Channel) Channel)
Clinical effect Vasodilatation : Vasodilatation :
BP decreased BP decreased
Heart Rate
 Differentiation between Diltiazem and Nicardipine on
Heart Rate

Heart Rate
(beat/minute)
< 60 60 - 80 > 80

Nicardipine I.V Diltiazem I.V

Diltiazem Injection can use for patients who have Normally

HR until High
Antihypertensive
Antihypertensivedrugs
drugsand
andHeart
HeartRate
Rate
 Diltiazem injection Drip infusion: 5~40
μg/kg/min

 Average BP reduced
224/119 mmHg to 170/95 mmHg (mean
change 27.3 +9.0 %, P<0.001)

HR controlled

Subject : 11 patients with hypertension

emergency
Design : Open study

Current Therapeutic Research.1987: 42:1223.

30
Diltiazem IV Infusion
Introduction of infusion

HERBESSER
Nitroglycerin

• Rapidly lowers high blood

pressure
• Shows fewer side effects
than nitroglycerin

Current Therapy Research. 1988: 43

Antihypertensive
Antihypertensivedrugs
drugscause
causeincrease
increase
of
ofICP
ICP
Comparison of intracranial pressure Comparison of Cerebral perfusion pressure
change by different antihypertensives. index (CPP index) by different antihypertensives.
p<0.05
（ mmHg ） p<0.05
20 2.0 1.80±0.11
17.0 1.63±0.13
Change of intracranial pressure

14.2
1.5 1.33±0.07

CPP index
10
6.7
1.0

0 0.0
Herbesser i.v. Nitroglycerin i.v. Nicardipine i.v. Herbesser i.v. Nitroglycerin i.v. Nicardipine i.v.
①CPP index=△CPP/△SBP
②CPP index coming close to 1 indicates less
increase of intracranial pressure.
35 patients who had surgical evacuation of spontaneous intracerebral haematomas after cerebral hemorrhage
Target
Herbesser i.v.: 12, Nitroglycerin i.v.: 13, Nicardipine i.v.:10
Medication
Compare the intracranial pressure when the same blood pressure reduction level is achieved in each group.
Methods
Hirayama A, Katayama Y, et al:Neurological Research 16; 97-99, 1994 32
Diltiazem
Diltiazemi.v.
i.v.reduced
reducedcardiac
cardiacevent
eventrate
rate
in
inpatients
patientswith
withunstable
unstableangina.
angina.
Nitroglycerin i.v. group (n=61) p=0.007**
Herbesser i.v. group (n=60)
40 38
p=0.02*
Incidence during i.v.(%)

30 28

20
15
10 10
10
5

0
Myocardial infarction refractory angina Myocardial infarction
+
refractory angina
Target 129 patients with unstable angina
Methods Randomized, double blind comparative trial
Diltiazem i.v. group (n=60) :25mg i.v.+5mg/h continuous i.v. (increase dose to 25mg/h)
Nitroglycerin i.v. group (n=61) : Physiologic saline i.v.+1mg/h continuous i.v. (increase dose to 5mg)
Gobel E, et al. Lancet 346:1653-1657, 1995
Diltiazem
Diltiazem (Herbesser)
(Herbesser)
Chart
Chart Injection
Injection
Dose
Dose Flow
Flow Chart
Chart
Intravenous bolus injection
Dose
0.2 mg / kgBW calculation

Intravenous drip infusion 10-20 % MBP reduction

( 5-15 µg / kgBW / minute ) from baseline

Observe every 10-20 minutes

Stable BP until 1 hr

Switch to oral HERBESSER® CD 200

34
Diltiazem
Diltiazem(Herbesser)
(Herbesser) Chart Chart
Injectio
Injectio
For
For HypertensiveCrisis
Hypertensive
Intravenous bolus injection
Crisis
10-15 mg IV (0,2-03 mg/KgBB) 1-2 min

MAP > 15% Tidak

Observe every 10 minutes

Dose
calculation
Intravenous drip infusion 50 mg/hr (20 min)
>20 % MAP reduction
from baseline

20-30 mg/hr (15 menit)

Observe every 10 minutes

10mg/hr ( 1-4 hr)

Switch to oral drugs

 Herbesser Listed in the Guideline of JNC 8
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults:
 Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2013;():. doi:10.1001/jama.2013.284427

Date of download: Copyright © 2014 American Medical

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