Hypertensive Urgency/Emergency

Dr. Sudhir DeoHouse OfficerGPEM, BPKIHS

JNC 7 Classification Of HTN

Evaluation Of Patient’s with HTN

Evaluation of hypertensive patients has three objectives:

(1) to assess lifestyle and identify other

cardiovascular risk factors or associated disorders that may affect prognosis and guide treatment

(2) to reveal identifiable causes of high BP (3) to assess the presence or absence of target

organ damage.

Cardiovascular risk factors

Major Risk Factors

Hypertension*Age (older than 55 years for men, 65 years for women)†Diabetes mellitus*Elevated LDL (or total) cholesterol, or low HDL cholesterol*Estimated GFR <60 mL/minFamily history of premature CVD (men <55 years of age orwomen <65 years of age)MicroalbuminuriaObesity* (BMI >30 kg/m2)Physical inactivityTobacco usage, particularly cigarettes

Identifiable causes of hypertension

Chronic kidney diseaseCushing’s syndrome and other glucocorticoid excess statesincluding chronic steroid therapyDrug induced or drug related (see table 18)Obstructive uropathyPheochromocytomaPrimary aldosteronism and other mineralocorticoid excess statesRenovascular hypertensionSleep apneaThyroid or parathyroid disease

Target Organ Damage

HeartLVHAngina/prior MIPrior coronary revascularizationHeart failure

BrainStroke or transient ischemic attackDementia

CKDPeripheral arterial diseaseRetinopathyPlacenta

Eclampsia

Approach to All Patients With HTN

Look for:• LOC and orientation• Respiratory status• For neurological deficits

Hemiparesis, slurred speech• Baseline

Temperature, HR, RR, BP• Maintain continuous monitoring of BP and HR• ***BP should not only be measured in both the supine

position and the standing position (assess volume depletion), but it should also be measured in both arms (a significant difference may suggest aortic dissection).

• Assess for changes in cardiac rhythm if patient is on a monitor• Monitor I&O

SaO2 via pulse oximetry if available

For associated symptoms Visual disturbance, chest pain, peripheral edema, hematuria

Drug use in Hypertension

Combination drugs

REF: JNC -7 (THE 7TH REPORT OF JOINT NATIONAL COMMITTEE ON PREVENTION, DETECTION, EVALUATION AND TREATMENT OF HIGH BLOOD PRESSURE) PAGE 27, 28,29

HTN URGENCY

Severe elevations in BP (DBP≥120-130mmhg) without evidence progressive target organ dysfunction.

Examples: Severe uncomplicated essential hypertensionSevere uncomplicated secondary hypertensionPostoperative hypertensionDrug-induced hypertensionRebound hypertension (i.e., sudden withdrawal of clonidine)Cessation of prior antihypertensive therapySevere hypertensive crises related to anxiety, panic attacks or pain

Agents that reliably cause an immediate fall in BP include captopril(25-50 mg), central sympatholytics(clonidine0.1–0.2 mg), labetalol(200–400 mg), and amlodipine(2.5–5 mg)• Initiation of therapy with two oral agents is appropriate to lower BP

to an intermediate target over 24 to 72 hours • Appropriate follow-upwithin 3 days.

TREATMENT OF HTN URGENCY:Goals: Lower mean arterial pressure to goal or near goal within several hours. Oral medications can be used.MAP=(2xDP)+SP/3Lower mean arterial pressure by 20- 25% or diastolic pressure to <100 to 110 mmHg within 30–60 minutes. excessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia.

HTN EMERGENCY

Hypertensive EmergenciesSevere elevations in BP (>180/120 mmHg) 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.

Exampleshypertensive encephalopathyIntracerebral hemorrhage,acute MIacute left ventricular failure with pulmonary edemaunstable anginadissecting aortic aneurysm,eclampsia

Initial Evaluation of Patients with a Hypertensive

Emergency

History• Prior diagnosis and treatment of hypertension• Intake of pressor agents: street drugs,

sympathomimetics• Symptoms suggesting an acute end-organ

involvement• chest pain –myocardial infarction, thoracic aortic

dissection• back pain –thoracic aortic dissection• dyspnea–acute pulmonary edema• neurological symptoms-hypertensive

encephalopathy

Physical examination

• Blood pressure –both upper limbs• Fundoscopy• Cardiopulmonary status

AR, MR , signs of CHF• Neurologic status

level of consciousness, focal sigh of ischemia

• Body fluid volume assessment• Peripheral pulses

Laboratory evaluation

Hematocrit and blood smear (microangiopathic hemolysis)Urine analysisAutomated chemistry: creatinine, glucose, electrolytesElectrocardiogramChest radiograph (if heart failure or aortic dissection is

suspected)CT brain in patients with neurological symptomsCT chest or MRI in patients with unequal pulses/ an enlarged

mediasternum

Clinical Characteristics HTN Emergency

Blood pressure: usually >140 mm Hg diastolic

Fundoscopic findings : accelerated HT -grade 3 retinopathy ( haemorrhages, exudates) malignant HT -grade 4 retinopathy (papillodema)

Neurologic status: headache, confusion, somnolence, stupor, vision loss, focal deficits, seizures, coma

Renal status: oliguria, azotemia(high levels of nitrogen- containing compounds)

Gastrointestinal status: nausea, vomiting

HTN EMERGENCY TREATMENT

GOALS:

Almost all hypertensive emergencies are caused or exacerbated by intense systemic vasoconstriction, often with profound blood volume reduction

goal of therapy is to reduce vasoconstriction while maintaining adequate perfusion of target organs

Treatment: All HTN Emergencies should be admitted and

treated in ICU/CCU The initial goal of therapy in hypertensive

emergencies is to reduce mean arterial BP by no more than 25 percent (within minutes to 1 hour)

If clinical is stable, reduce BP to 160/100–110 mmHg within the next 2–6 hours

Further gradual reductions toward a normal BP can be implemented in the next 24–48 hours.

Exceptions• acute stroke in evolution (for which no BP

lowering is generally recommended)

• The American Heart Association recommends:

• Treatment with intravenous labetalol or nicardipine

Started when BP values are above 220/120mmHgThe target BP should be a 10–15% lowering of BP

DRUGS FOR HTN EMERGENCY• Nitroprusside — a rapidly acting arteriolar and venous dilator,

given as an intravenous infusion. Initial dose: 0.25 to 0.5 mcg/kg per min; maximum dose: 8 to 10 mcg/kg per min which should be continued for no more than 10 minutes.

• Nitroglycerin — a rapidly acting venous and, to a lesser degree, arteriolar dilator, given as an intravenous infusion. Initial dose: 5 mcg/min; maximum dose: 100 mcg/min.

• Labetalol — an alpha- and ß-adrenergic blocker, given as an intravenous bolus or infusion. Bolus: 20 mg initially, followed by 20 to 80 mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg/min.

• Nicardipine — a calcium channel blocker, given as an intravenous infusion. Initial dose: 5 mg/h; maximum dose: 15 mg/h.

• Clevidipine — a calcium channel blocker. Initial dose: 1

mg/hour; maximum dose: 16 mg/hour.

DRUGS FOR HTN EMERGENCY• Fenoldopam — a peripheral dopamine-1 receptor agonist, given

as an intravenous infusion. Initial dose: 0.1 mcg/kg per min; the dose is titrated at 15 min intervals, depending upon the blood pressure response.

• Hydralazine — an arteriolar dilator, given as an intravenous bolus. Initial dose: 10 mg given every 20 to 30 minutes; maximum dose: 20 mg.

• Propranolol — a ß-adrenergic blocker, given as an intravenous infusion and then followed by oral therapy. Dose: 1 to 10 mg load, followed by 3 mg/h.

• Phentolamine — an alpha-adrenergic blocker, given as an intravenous bolus. Dose: 5 to 10 mg every 5 to 15 minutes.

• Enalaprilat — an angiotensin converting enzyme inhibitor, given as an intravenous bolus. Dose: 1.25 mg every six hours.

Drugs In HTN Emergency

Drugs of choice and relative contraindications for hypertensive emergencies

References• JNC VII Seventh report of

Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

• Manual of Hypertension of the European Society of Hypertension 2008

Thank You!