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HYPERTENSION

Emergencies & Urgencies

Stephen S. Levin, D.O.

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Definitions

EmergenciesSymptomaticAcute End-Organ Damage

Diastolic B.P. usually >130 mmHg

Urgencies

AsymptomaticNO Acute End-Organ DamageDiastolic B.P. usually >110 mmHg;

Systolic B.P. usually >180 mmHg

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Begin Treatment!This is a Hypertensive Emergency

Begin to look for other causes of symptoms

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Principles of Therapy

Lower B.P. over hours

Initial goal B.P. 160s/90s

Too rapid lowering may cause direconsequences (CVA, MI)

May take several days to get to

reasonable levelsAvoid medications that cannot be

controlled (sublingual nifedipine)

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Hypertensive Emergencies: Treatment

For most patients the greatest risk of

treating a hypertensive emergency isthe risk of accompanying hypotension.

Treat with short acting, easilytitratable, I.V. drug.

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Parenteral Drugs for Treatmentof Hypertensive Emergencies

Drug Dosage Onset Duration Adverse

Effects

Indic.(I)

Contrain.(C)

VasodilatorsNitroprus-side

0.3-10mcg/kg/minIV infusion

1-2 min. 1-2 min. N/V,mus.twitch.,cyanide,thiocyan.tox.

intracran.pressure

I: CHF,aorticdissect.,

catechol.

C: hepatic,renal

insuff.Nitrogly-cerin (IV)

5-100mcg/kg/min

2-5 min. 3-5 min. HA,dizziness,vomit.,methemglo.tolerance

I: coronarydis., CHFC: CVAintracran.

pressure

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Parenteral Drugs for Treatmentof Hypertensive Emergencies

Diazoxide(HyperstatIV)

1-3 mg/kg(up to 150mg) IVbolus, q5-

15 min;repeat q4-24 hr asneeded

2-4 min 3-12 hr Nausea,hypotension,flushing,tachycardia,

hypergly-cemia,aggravationof angina,fluidretention

C:Syndromes ofcoronaryinsufficiency,

(unless usedwith beta-blockingagent),cerebrovascular accident,hypersensi-

tivity tosulfonamides

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Parenteral Drugs for Treatmentof Hypertensive Emergencies

Fenoldopammesylate(Corlopam)

0.1-1.7micrograms/kg/minIV infusion

5-15min 1-4 hr Headache,dizziness,flushing,increasedintraocularpressure,hypokalemia,dose-relatedtachycardia

I: Severehyperten-sion withrenal insuffi-ciencyC: Glaucoma

HydralazineHCl(Apresoline)

10-20 mg IV or IMbolus, repeat q4-6 hras needed (maximumdose, 40 mg)

10-20min

3-8 hr Tachycardia,flushing,headache,vomiting,

aggravationof angina

I: CHFC: Coronaryinsufficiency,aortic

dissection,cerebrovas-cular accident(may increaseintracranialpressure)

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Parenteral Drugs for Treatmentof Hypertensive Emergencies

Enalaprilat(Vasotec I.V.)

1.25-5 mg q6hr IV

15min

6 hr Precipitous drop inblood pressure inhigh-renin states,

variable response

I: CHFC: Use withcaution in

patients withsevere renalinsufficiency(not receivingdialysis)

NicardipineHCl(Cardene)

5-15 mg/hr

IV infusion

5-20

min

1-2

hr

Tachycardia,

headache, flushing,local phlebitis

C: Greater

than first-degree heartblock, CHF

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Parenteral Drugs for Treatmentof Hypertensive Emergencies

Adrenergic InhibitorsPhentol-amine(Regitine)

-blocker

5-20 mg IV,repeat asnecessary

1-2min

10-30min

Tachycardia,nausea,flushing,

abdominalpain,aggravationof angina

I:Catecholamineexcess

C: Syndromesof coronaryinsufficiency

EsmololHCl

(Brevibloc)

200-500micrograms/kg/

min over 1-4min, then 50-300micrograms/kg/min IV infusion

1-2min

10-20min

Hypotension,nausea,

bradycardiaor heartblock,dizziness

I: Syndromes ofcoronary

insufficiencyC: Greater thanfirst-degreeheart block,CHF

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Parenteral Drugs for Treatmentof Hypertensive Emergencies

LabetalolHCl(Normo-dyne,

Trandate)-

blocker

20-80 mgIV bolus,repeat asneeded

(maximum dose,300 mg);or 2mg/minIV

infusion

2-10 min 2-4 hr Hypoten-sion,nausea,itching,

scalptingling,dizziness

I:Synd-romes ofcoronaryinsuffi-

ciency,catechol-amineexcessC:> first-degree

heartblock,CHF,bronchialasthma

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Fenoldopam: Indications

In-hospital, short-term (up to 48 hours)management of severe hypertensionwhen rapid, but quickly reversible,emergency reduction of blood pressure

is clinically indicated, includingmalignant hypertension withdeteriorating end organ function.

Transition to oral therapy with anotheragent can begin at any time after bloodpressure is stable during fenoldopaminfusion.

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Fenoldopam:

Adverse EventsHeadache

FlushingNausea

Hypotension

Hypokalemia

EKG Abnormalities

Tachycardia

Vomiting

Dizziness

ExtrasystolesDyspnea

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Nicardipine: Characteristics

Dihydropyridine

Reflex tachycardia

Useful when-Blockerscontraindicated

Water soluble andlight stable(allows for IV infusion)

Slow onset andoffset

Arterial catheter notmandatory

May accumulate

Variable duration of

hypertensive effectGood in patients

with renal disease

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Therapy Hypertensive Urgencies

Oral meds. Preferred

Close monitoring

Fast follow-up

Start with short acting forms(not Ca+2channel blockers)

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Drugs for Urgencies

Clonidine

-Blockers, -Blockers

Captopril, Enalapril

Minoxidil (if already on -blocker& diuretic)

Hydralazine

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Drug Related

Malignant Hypertension

MAO Inhibitors

Cold Preparations

Withdrawal Antihypertensive Meds

Clonidine,

-BlockersStreet Drugs

Cocaine, PCP