Hypertensive Crisis: - Alexter John C. Fajardo M.D

Hypertensive Crisis
• Alexter John C. Fajardo M.D.

• 1st year Internal Medicine Resident
• AUFMC
• Sources:
– JNC 7: Hypertensive Crisis
– Braunwald’s Heart Disease, Hypertensive Crisis
• M.S.
• 35 year old, Male
• Single
• Catholic, Filipino
• Residing at Angeles City
Chief Complaint
Headache
HISTORY OF PRESENT ILLNESS
• 10 hours PTA
– sudden onset of throbbing headache localized to
frontal and temporal areas of the head. Pain scale
of 5/10
– No vomiting, no blurring of vision, no slurring of
speech, no lateralizing symptoms.
– Opted consult at the ER
Past Medical History
• Hypertensive – diagnosed 2 years ago, stopped
medications 6 months PTA, highest Bp of 210/100,
usual Bp of 160/80-90
• Diabetic – diagnosed 2 years ago, stopped
medications
• Non asthmatic
• No history of PTB
• No known renal, or thyroid condition
• No previous surgery
Family Medical History
• (+) DM – maternal side
• (+) HPN – both maternal and paternal side
• No family history of cardiovascular deaths less
than <55 among males, <65 among females
Personal & Social History
• Patient
– Works as Call Center agent, mostly on graveyard
shift
– Non alcoholic
– Non smoker
Physical Examination
• General Survey: conscious, coherent, not in
respiratory distress
• Vital Signs:
– BP: 210/130
– HR: 87 bpm
– RR: 21 cpm
– T: 36.7 OC
– Weight 70kg, Height 170cm, BMI 24.2
• Skin: No jaundice, no rashes, no pallor, warm to
touch
• HEENT: pink palpebral conjunctiva, anicteric sclera ,

no nasoaural congestion, moist buccal mucosa, no
oral sores, no ear lesions, no neck vein distention,
no carotid bruit, no tonsillopharyngeal congestion
or mass, no cervical lymphadenopathy, no anterior
neck mass
• Chest and Lungs: symmetrical chest
expansion, (-) supraclavicular and intercostals
retractions, equal tactile and vocal fremiti,
clear breath sounds on both lung fields
• Heart: Adynamic precordium, regular rate
regular rhythm, no murmur, no heaves.
• Abdomen: Flabby, No visible skin lesion,
normoactive bowel sounds,, soft, nontender,
Traube’s space not obliterated, no palpable
mass.
• Extremities: No gross deformities, (-) swelling,
(-) edema, pink nail beds, no calf tenderness,
full and equal peripheral pulses, good range of
motion on both upper and lower extremities
• Neurologic exam:
• Cerebral: conscious, coherent, oriented to 3 spheres
• Cranial nerves
– CN I – not assessed
– CN II- pupils 2-3 mm reactive to light
– CN II, IV, VI – intact
– CN V- (+) corneal reflex,
– CN VII – no facial asymmetry; good facial expressions
– CN VIII – can hear
– CN IX-X (+) Gag reflex, can swallow
– CN XI- good shoulder shrug; able to turn head sideways
– CN XII – tongue midline
• Motor: 5/5 on all extremities
– Cerebellum: (-) dysmetria, (-) dysdiadochokinesia
– Reflexes: Normoreflexive on all extremities, (-) Babinski’s sign
– Sensory: 100% on all extremities
– Meningeal signs: (-) nuchal rigidity
Salient Features of the Case
• 35 years old, male • BP of 210/130
• Headache
• No neurologic deficit
• History of Hypertension
and Diabetes
• Family History of
Hypertension
• History of Non
compliance to medication
Hypertensive Crisis
Severe elevations
in BP (180/120
mm Hg)
complicated by
evidence of
No Yes
impending or
progressive
target organ
dysfunction
Hypertensive
Urgency require Hypertensive
immediate BP
Emergency
reduction (not
Hypertensive emergencies
• Severe elevations in BP (180/120 mm Hg)
complicated by evidence of impending or
progressive target organ dysfunction
• require immediate BP reduction (not
necessarily to normal) to prevent or limit
target organ damage
Hypertensive Crises: Emergencies and Urgencies, JNC 7

Hypertensive emergencies
Examples
• hypertensive encephalopathy
• intracerebral hemorrhage
• acute myocardial infarction
• acute left ventricular failure with pulmonary edema
• unstable angina pectoris
• dissecting aortic aneurysm
• eclampsia

Hypertensive urgencies
• associated with severe elevations in BP
without progressive target organ dysfunction

Hypertensive urgencies
• Upper levels of stage II hypertension
associated with severe headache, shortness of
breath, epistaxis, or severe anxiety

At the Emergency Room
• The patient was initially given Clonidine 75mg
1 tab sublingual
• BP decreased to 180/100
• He was then advised to be admitted
Hypertensive Crisis
Hypertensive Hypertensive
Urgency Emergency
short-acting agent ICU Admission

such as
captopril, labetalol,
or clonidine followed
by several hours of
Observation
no evidence to reduce mean arterial
suggest that failure to BP by no more than
aggressively lower BP 25% (within
in the emergency minutes to 1 hour)
room is associated
with any increased
short-term risk if stable, to 160/100
to 110 mm Hg within
the next 2 to 6 hours
Early Triage
• Early triage to establish the appropriate
therapeutic strategies for these patients is
critical to limiting morbidity and mortality
Hypertensive Crisis
Urgency Emergency
short-acting agent such ICU Admission

as
captopril, labetalol, or
clonidine followed by
several hours of
Observation
no evidence to suggest reduce mean arterial
that failure to BP by no more than
aggressively lower BP in 25% (within
the emergency room is minutes to 1 hour)
associated with any
increased short-term
risk
if stable, to 160/100 to
110 mm Hg within the
next 2 to 6 hours
On Admission
• Laboratory Work-Up:
– Creatinine, serum K, Na
– HGT stat then q6hours
– HgbA1C
– Lipid profile
– ECG-12
– Chest Xray, Pa
– CBC
Laboratory Results
CBC 2/5 HGT 413/198
Hct 0.52 Na 131.6
Hgb 187
WBC 11.98 K 3.88
Neutro 0.66 Creatinine 91.49
Lympho 0.28
Mono 0.05 Hba1C 27.6%
Eosino 0.01 Cholesterol 201
Platelet 210 HDL 85
s
LDL 136
On Admission
• Therapeutics
– Amlodipine 5mg 1 tab OD
– Losartan 50mg 1 tab OD
– Linagliptin 5mg 1 tab OD
JNC 8 Recommendation
• Recommendation 6
In the general nonblack population, including
those with diabetes, initial antihypertensive
treatment should include a thiazide-type
diuretic, calcium channel blocker (CCB),
angiotensin-converting enzyme inhibitor
(ACEI), or angiotensin receptor blocker (ARB).
• Moderate Recommendation – Grade B
What if this patient has…
• Severe elevations in BP (180/120 mm Hg)
complicated by headache, irritability,
alterations in consciousness
• Accelerated-malignant hypertension - retinal
hemorrhages, exudates, or papilledema
• Hypertensive encephalopathy - headache,
irritability, alterations in consciousness, and
other manifestations of central nervous
dysfunction with sudden and marked
elevations in BP
Hypertensive Crisis
Urgency Emergency
short-acting agent such ICU Admission

as
captopril, labetalol, or
clonidine followed by
several hours of
Observation
no evidence to suggest reduce mean arterial
that failure to BP by no more than
aggressively lower BP in 25% (within
the emergency room is minutes to 1 hour)
associated with any
increased short-term
risk
if stable, to 160/100 to
110 mm Hg within the
next 2 to 6 hours
Permissive Hypertension
Allow “permissive hypertension” during the first
week to ensure adequate CPP but ascertain
cardiac and renal protection
Treat if SBP>220 or DBP>120 or MAP>130
Appendix III, Guidelines for the Prevention, Treatment and Rehabilitation of Brain Attack
Permissive Hypertension
Defer emergency BP therapy if MAP is within 110-
130 or SBP=185-220 mmHg or DBP=105-120
mmHg, unless in the presence of:
Acute MI
Congestive heart failure
– Aortic dissection
– Acute pulmonary edema
Acute renal failure
– Hypertensive encephalopathy
Parenteral Drugs for Hypertensive Crisis
Treatment: Hypertensive Emergency
• If diastolic pressure exceeds 140 mm Hg and
the patient has any complications, such as an
aortic dissection, a constant infusion of
nitroprusside is most effective and almost
always lowers the pressure to the desired
level.
• The potency and rapidity of action of
nitroprusside have made it the treatment of
choice for life-threatening hypertension.
Hypertensive Crisis, Braunwald’s Heart Disease, Text Book of Cardiovascular Disease 9 th edition page 952
Hypertensive Emergency
• Intravenous furosemide is often needed to
lower BP further and prevent retention of
sodium and water.
• Less immediate danger - oral therapy
• Oral doses of short-acting formulations include
furosemide, propranolol, captopril, or
felodipine.
• Clonidine is a poor choice because of the
difficulty of maintaining it for long-term
therapy.
Another Slide
• Some patients may suffer vascular damage
from lower levels of pressure, whereas others
are able to withstand even higher levels
without apparent harm.
• The rapidity of the rise may be more
important than the absolute level in producing
acute vascular damage
• The degree of target organ damage, rather
than the level of blood pressure alone,
determines the rapidity with which blood
pressure should be lowered.
• A persistent diastolic pressure exceeding 130
mm Hg is often associated with acute vascular
damage
• All patients with diastolic BP above 130 mm Hg
should be treated, some more rapidly with
parenteral drugs and others more slowly with
oral agents
• If diastolic pressure exceeds 140 mm Hg and
the patient has any complications, such as an
aortic dissection, a constant infusion of
nitroprusside is most effective and almost
always lowers the pressure to the desired
level.
• The potency and rapidity of action of
nitroprusside have made it the treatment of
choice for life-threatening hypertension.
• Intravenous furosemide is often needed to
lower BP further and prevent retention of
sodium and water.
• Less immediate danger - oral therapy
• Oral doses of short-acting formulations include
furosemide, propranolol, captopril, or
felodipine.
• Clonidine is a poor choice because of the
difficulty of maintaining it for long-term
therapy.

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Hypertensive Crisis

• Alexter John C. Fajardo M.D.

• HEENT: pink palpebral conjunctiva, anicteric sclera ,

Hypertensive Crises: Emergencies and Urgencies, JNC 7

Hypertensive Crises: Emergencies and Urgencies, JNC 7

Hypertensive Crises: Emergencies and Urgencies, JNC 7

Hypertensive Crises: Emergencies and Urgencies, JNC 7

short-acting agent ICU Admission

short-acting agent such ICU Admission

short-acting agent such ICU Admission

Treat if SBP>220 or DBP>120 or MAP>130

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