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    Hypertensive Emergency: Beny Ghufron Dept. of Internal Medicine June 2011

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    Dendian Berlia Jelita
    Hypertensive emergencies are acute, severe elevations in blood pressure that can cause end organ damage if not treated quickly. They are rare, accounting for about 1% of hypertensive cases annually. It can be difficult to diagnose an emergency versus a non-emergency based on blood pressure alone. Treatment of an emergency requires rapid blood pressure reduction, usually with intravenous medications, to prevent further damage. The goals and medications differ depending on the underlying cause and end organ involvement. Proper recognition and management of hypertensive emergencies is critical for preventing mortality, which can be as high as 90% without treatment.

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    Hypertensive Emergency: Beny Ghufron Dept. of Internal Medicine June 2011

    Uploaded by

    Dendian Berlia Jelita
    40 views31 pages
    Hypertensive emergencies are acute, severe elevations in blood pressure that can cause end organ damage if not treated quickly. They are rare, accounting for about 1% of hypertensive cases annually. It can be difficult to diagnose an emergency versus a non-emergency based on blood pressure alone. Treatment of an emergency requires rapid blood pressure reduction, usually with intravenous medications, to prevent further damage. The goals and medications differ depending on the underlying cause and end organ involvement. Proper recognition and management of hypertensive emergencies is critical for preventing mortality, which can be as high as 90% without treatment.

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    Hypertensive emergencies are acute, severe elevations in blood pressure that can cause end organ damage if not treated quickly. They are rare, accounting for about 1% of hypertensive cases annually. It can be difficult to diagnose an emergency versus a non-emergency based on blood pressure alone. Treatment of an emergency requires rapid blood pressure reduction, usually with intravenous medications, to prevent further damage. The goals and medications differ depending on the underlying cause and end organ involvement. Proper recognition and management of hypertensive emergencies is critical for preventing mortality, which can be as high as 90% without treatment.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    40 views31 pages

    Hypertensive Emergency: Beny Ghufron Dept. of Internal Medicine June 2011

    Uploaded by

    Dendian Berlia Jelita
    Hypertensive emergencies are acute, severe elevations in blood pressure that can cause end organ damage if not treated quickly. They are rare, accounting for about 1% of hypertensive cases annually. It can be difficult to diagnose an emergency versus a non-emergency based on blood pressure alone. Treatment of an emergency requires rapid blood pressure reduction, usually with intravenous medications, to prevent further damage. The goals and medications differ depending on the underlying cause and end organ involvement. Proper recognition and management of hypertensive emergencies is critical for preventing mortality, which can be as high as 90% without treatment.

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    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 31

    Hypertensive Emergency

    Beny Ghufron
    Dept. of Internal Medicine
    June 2011
    Why this is a difficult topic

    Hypertension is common (up to


    25%) but emergencies are rare
    Failing to treat an emergency AND
    treating a non-emergency can have
    serious consequences for the
    patient
    Blood pressure alone is a poor
    indicator of an emergency
    Why this is a difficult topic

    The physical exam is often not helpful


    Different emergencies have vastly
    different goals in BP reduction
    The first line agent for one emergency
    may be contraindicated for another
    emergency
    Lack of consensus regarding definitions,
    therapeutic goals, and 1st line
    medications
    Outline

    Epidemiology

    Definitions

    Pathophysiology

    Diagnosis and Recognition


    Treatment

    Special Circumstances
    Epidemiology

    Why should we care about hypertension?


    One of the most common chronic medical
    concerns in the US
    Affects >30% of the population > age 20
    Risk factor for
    Cardiovascular disease and mortality
    Cerebrovascular disease and mortality

    End stage renal disease

    Other end organ damage


    Epidemiology
    Why should we care about hypertension?
    30% of the population is unaware they have
    hypertension
    Control rates for known cases is about 50%
    (we dont do a great job at controlling BP)
    Risk Factors
    If >50, systolic BP > 140 is a more concerning
    risk factor for cardiovascular disease than
    diastolic BP.
    The risk of cardiovascular disease doubles for
    every increase in BP of 20/10 over 115/75.
    Epidemiology

    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 (according to JNC VII)


    Normal BP <120/<80
    Prehypertension 121-139/80-89
    Stage I HTN 140-159/90-99
    Stage II HTN >160/>100
    (Severe HTN >180/>110)
    Severe HTN is not a JNC VII defined
    entity
    Definitions
    Hypertensive Emergency
    Acute, rapidly evolving end-organ damage associated
    with HTN (usu. DBP > 120)
    BP should be controlled within hours and requires
    admission to a critical care setting
    Hypertensive Urgency
    DBP > 120 that requires control in BP over 24 to 48
    hours
    No end organ damage

    Acute hypertensive Episode : SBP>180 or DBP>110


    and no organ damage
    Malignant Hypertension is no longer used
    Transient hypertension : hypertension associated with pain,
    withdrawl syndrom, anxiety, toxic substances, cessation
    medication
    Definitions
    End-Organ Damage (% of cases)
    Cerebral infarction 24%
    Hypertensive encephalopathy16%
    Intracranial hemorrhage4.5%
    Acute aortic dissection2%
    Acute coronary syndrome/myocardial infarction12%
    Pulmonary edema with respiratory failure22%
    Severe eclampsia/HELLP syndrome2%
    Acute congestive heart failure14%
    Acute renal failure9%
    Categories of Hypertensive
    Emergencies

    Cardiovascular
    Acute LV failure (Flash pulmonary
    edema)
    Acute coronary syndrome
    Aortic dissection
    Pregnancy related hypertension
    Pre-eclampsia
    Eclampsia
    HELLP syndrome
    Categories of Hypertensive
    Emergencies

    Hypertensive encephalopathy

    Stroke syndromes
    Embolic
    Hemorrhagic
    Subarachnoid hemorrhage
    Categories
    Catecholamine excess
    Pheochromocytoma
    MAOI + tyramine
    Cocaine/amphetamines/OTCs
    Clonidine withdrawal
    Other
    Renal failure
    Epistaxis
    Childhood hypertension
    Diagnosis and Recognition
    Presentation
    Always present with a new onset
    symptom
    Take a good history
    History of HTN and previous control
    Medications with dosage and compliance
    Illicit drug use, OTC drugs
    Diagnosis and Recognition
    What precipitates an emergency?

    1. Non-compliance with medications


    in a chronic hypertensive patient
    2. Those with secondary
    hypertension (e.g.
    pheochromocytoma, reno-vascular
    hypertension, Cushings)
    3. Hypertension during pregnancy is
    a major risk factor for women
    Diagnosis and Recognition
    Physical
    Confirm BP in more than one extremity
    Ensure appropriate cuff size
    Pulses in all extremities
    Lung examlook for pulmonary edema
    Cardiacmurmurs or gallops, angina, EKG
    Renalrenal artery bruit, hematuria
    Neurologicfocal deficits, HA, altered MS
    Fundoscopic examretinopathy, hemorrhage
    Diagnosis and Recognition
    Laboratory/Radiologic evaluations
    Basic Metabolic Panel (BUN, Cr)
    CBC with smear (hemolytic anemia)
    Urinalysis (proteinuria, hematuria)
    EKG to look for ischemia
    CXR to look for pulmonary edema if dyspnea
    Head CT for hemorrhage if HA or altered MS
    MRI chest if unequal pulses and wide
    mediastinum to look for aortic dissection
    Treatment
    Hypertensive Urgency
    No end-organ damageNOT emergent
    Look for reactive HTN and treat this first
    Drugs, pain, anxiety, cocaine, withdrawal

    Use oral medications to lower BP gradually


    over 24-48 hours, likely 2 agents needed
    May be chronic, decrease BP slowly to avoid
    hypoperfusion of organs
    Avoid sublingual and IM administration due to
    unpredictable absorption
    Treatment

    Hypertensive Urgency
    Appropriate follow up for asymptomatic
    patients with no end-organ damage
    BP range Action Plan
    140-159/90-99 Observe, confirm BP 2mos
    160-179/100-109 Confirm, treat within 1mo
    180-209/110-119 Confirm, treat within 1wk
    210+/120+ Confirm, treat now, close f/u
    Medications

    Oral drug choices often based on


    comorbid conditions
    Heart failureTH, BB, ACEI, ARB, ALDO
    Post MIBB, ACEI, ALDO
    High CVD riskTH, BB, ACEI, CCB
    DiabetesTH, BB, ACEI, ARB, CCB
    Chronic Renal FailureACEI, ARB
    Recurrent stroke preventionTH, ACEI
    KEY: ACEI, angiotensin converting enzyme inhibitor; ALDO, aldosterone antagonist; ARB,
    angiotensin receptor blocker; BB, b blocker; CCB, calcium channel blocker; TH, thiazide.
    Treatment
    Hypertensive Emergency
    Act Quickly
    Start IV goal directed pharmacologic therapy
    Continuous infusion: short acting titratable meds

    Initiate critical care monitoring


    Intraortic BP monitoring may be necessary

    Start SLOW: Limit initial lowering of BP to 20% below


    pretreatment level
    Due to increased threshold of hypoperfusion of
    the organs from abnormal autoregulation
    Goal: Lower DBP by 10-15% in 30-60 min
    Initiate oral therapy and titrate IV medications down
    Medications
    IV, short acting, titratable.
    Arterial Vasodilators
    Hydralazine, fenoldepam, nicardipine, enalapril
    Venous Vasodilators
    Nitroglycerine
    Mixed Arterial and Venous Vasodilators
    Sodium nitroprusside
    Negative Inotrope/Chronotrope
    Labetolol (also vasodilates), Esmolol
    Alpha blockers (incl. sympathetic activity)
    Phentolamine
    Medication
    Esmolol
    Cardiloselective beta blocker with short duration of
    action that is useful for aortic dissection patients &
    perioperative patients
    Fenoldopam
    Dopamine (DA) 1 agonist that can be used in most
    hypertensive emergencies
    Increases renal blood flow & Na excretion
    Gliseril trinitrat
    Useful if patient suffers from coronary ischemia
    GTN not considered an effective vasodilator, it is a
    potent venodilator & only at high doses affects arterial
    tone
    Hydralazine
    Preferred agent in eclampsia
    Should be avoided in other hypertensive emergencies
    because it can cause a progressive (often extreme) fall in BP
    that ca last up to 12 hr
    Labetalol
    Combined blocker of alpha & beta adrenergic receptors that
    is useful in most hypersetensive emergencies except acute
    HF
    Nicardipine
    Dihydropyridine Ca antagonist that is useful inmost
    hypertensive emergencies except acute HF & should be used
    with caution in coronary ischemia
    Phentolamine
    Alpha adrenergic blocking agent that is useful when
    there iscatecholamine excess (eg pheochromocytoma)

    Na Nitroprusside
    Very potent arterial & venous vasodilator useful inmost
    hypertensive emergencies but use with caution in
    patiens with hight intracranial pressure or azotemia
    There is potential for severe toxicity therefore other
    agents may be preferred if they are available.
    Medications
    Preferred agents by end organ damage
    Pulmonary Edema (systolic)nitropruside,
    fenoldopam, GTN, Diuretic, Nicardipine
    Pulmonary Edema (diastolic)Esmolol
    Acute MILabetolol, Esmolol, GTN, additional :
    nicardipin, fenoldopam
    Hypertensive EncephalopathyLabetolol,
    fenoldopam, nicardipin
    Acute Aortic DissectionLabetolol, nitropruside,
    esmolol
    EclampsiaLabetolol or Nicardipine
    Acute Renal Failure/MAHAFenoldopam, nicardipin
    Sympathetic Crisis/CocaineFenoldopam,
    nicardipin, Verapamil or Diltiazem. Avoid beta
    blocker
    Special Circumstances
    Acute Aortic Dissection
    Start IV meds STAT to lower pulsitile load and
    aortic stress to lessen the dissection
    Vasodilators alone may reflex tachycardia
    Use beta blocker AND vasodilator
    Esmolol and Nitroprusside

    Surgical evaluation
    Type A all go to surgery

    Type B only if rupture/leak. Treat with


    aggressive BP control
    Special Circumstances
    Stroke
    Number one cause of permanent disability
    HTN is a protective physiologic effect to maintain
    blood flow to brain (Cushing Effect)
    One study showed better outcome if hypertensive
    upon presentation of stroke
    Treat HTN rarely and cautiously
    Lower BP 10-15% in first 24 hours (not >20%)

    Hemorrhagic stroke
    Treat if >200/>110, but still with modest lowering
    of BP because still worse outcome with low BP
    Special Circumstances
    Eclampsia
    Vasoconstricted and hemoconcentrated
    Volume expand, magnesium sulfate, and
    aggressive BP control.
    Delivery is only definitive treatment
    Labetolol or Nicardipine are drugs of choice.
    Hydralazine was first line but slow onset and
    unpredictable so may lead to hypotension
    Special Circumstances
    Sympathetic Crisis
    Cocaine use, rarely pheochromocytoma
    AVOID beta blockersleads to uninhibited
    alpha stimulation and increased BP
    Labetolol has alpha and beta blockade, but
    experimental studies show poor outcomes
    Nicardipine, fenoldopam or verapamil (with a
    benzodiazepine) are drugs of choice
    References
    Haas, A. and Marik, P. Current Diagnosis
    and Management of Hypertensive
    Emergency. Seminars in Dialysis. Vol
    19, No 6. (2006) pp. 502-512.
    Flanigan, J. and Vitberg, D.
    Hypertensive Emergency and Severe
    Hypertension: What to Treat, Who to
    Treat, and How to Treat. The Medical
    Clinics of North America. Vol 90 (2006)
    pp. 439-451.

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