Hypertension Hypertension The Silent KillerThe Silent Killer

Is ... “the level of blood Is ... “the level of blood pressure at which the pressure at which the benefits of action benefits of action

(i.e. Therapeutic (i.e. Therapeutic intervention) exceed those intervention) exceed those of Inaction.”of Inaction.”

HYPERTENSION•Is a medical term for elevated blood pressure

•Definition: SBP>or =140 mm Hg DBP > or =90 mm Hg •Can also occur in children and adults but more common among people >50 years old•Prevalence. 20% - 30 %Prevalence. 20% - 30 %•In 90- 95%, the cause is unknown•Most of the time patient is asymptomaticRemains the significant cause of morbidity Remains the significant cause of morbidity and mortality in the world.and mortality in the world.Heart Attacks (Myocardial Infarction) - Heart Attacks (Myocardial Infarction) - 3.4% 3.4% Stroke – 11.5%Stroke – 11.5%Kidney Damage – 53%Kidney Damage – 53%

EpidemiologyEpidemiology

WhoWho- over 972 millions - over 972 millions adults (1 in 3 adults) adults (1 in 3 adults)

WhatWhat- high blood - high blood pressurepressure

WhereWhere-- all over the world all over the world WhenWhen- typically over the - typically over the

age of 50age of 50 WhyWhy- family history, - family history,

being overweight, having being overweight, having high sodium intakehigh sodium intake

HYPERTENSION : Types Most common cardiovascular disease in

the World

Primary (Essential)- Primary (Essential)- No pre-existing causeNo pre-existing cause• Unknown etiology• 80-90% of all cases• Treatment mainly symptomatic Secondary- Secondary- Known etiology a. Kidney Diseasea. Kidney Disease

b. Thyroid Diseaseb. Thyroid Diseasec. Adrenal Diseasec. Adrenal Disease

• Treat to eliminate cause of the disease Office or White Coat HypertensionOffice or White Coat Hypertension – –

increased in BP associated with the stress increased in BP associated with the stress of physician office visits.of physician office visits.- may affect as 50% of hypertensive - may affect as 50% of hypertensive patients.patients.

.

Why?Why?

CausesCauses Genetics- family Genetics- family

historyhistory Weight- obesityWeight- obesity Diet- too much Diet- too much

sodium intakesodium intake DiabetesDiabetes StressStress Smoke/AlcoholSmoke/Alcohol

EffectsEffects

FACTORS CONTRIBUTING TO FACTORS CONTRIBUTING TO HIGH BLOOD PRESSUREHIGH BLOOD PRESSURE

ControllableControllable

ObesityObesity Eating too much Eating too much

saltsalt AlcoholAlcohol Lack of exerciseLack of exercise StressStress

UncontrollableUncontrollable

RaceRace HeredityHeredity AgeAge

Resistant HypertensionResistant Hypertension

Blood pressure that cannot be reduced Blood pressure that cannot be reduced below 140/90 mmHg ( below 160 below 140/90 mmHg ( below 160 mmHg for ISH) in patients who are mmHg for ISH) in patients who are complying with adequate triple drug complying with adequate triple drug regimens in appropriate dosage.regimens in appropriate dosage.

50%-75% of people being treated for 50%-75% of people being treated for hypertension, target BP is not hypertension, target BP is not achievedachieved

Causes of Resistant Causes of Resistant HypertensionHypertension

Improper blood pressure measurementImproper blood pressure measurement Volume overload and pseudotoleranceVolume overload and pseudotolerance Excessive sodium intakeExcessive sodium intake Volume retention secondary to kidney Volume retention secondary to kidney

diseasedisease Inadequate diuretic therapyInadequate diuretic therapy Drug-inducedDrug-induced Non-complianceNon-compliance Inadequate dosesInadequate doses Inappropriate drug combinationsInappropriate drug combinations ObesityObesity EthanolEthanol TobaccoTobacco

Assessing Cause and Assessing Cause and Incidence of Resistant Incidence of Resistant

Blood PressureBlood Pressure Inaccurate BP MeasurementInaccurate BP Measurement White Coat HypertensionWhite Coat Hypertension Disease ProgressionDisease Progression Suboptimal TreatmentSuboptimal Treatment Non-Compliance with prescribed Non-Compliance with prescribed

therapytherapy Antagonizing SubstancesAntagonizing Substances Coexisting ConditionsCoexisting Conditions Secondary HypertensionSecondary Hypertension

Causes of Isolated Systolic Causes of Isolated Systolic HypertensionHypertension

Aging (increased aortic Aging (increased aortic rigidity)rigidity)

Increased cardiac outputIncreased cardiac output – –

Thyrotoxicosis Thyrotoxicosis ––Anemia Anemia – Aortic insufficiency – Aortic insufficiency

Patient EvaluationPatient Evaluation Medical History, Medical History, Physical Examination, Physical Examination, Routine Laboratory Tests,Routine Laboratory Tests, Other diagnostic procedures.Other diagnostic procedures. Assess presence of acute or rapidly Assess presence of acute or rapidly

progressive target organ damageprogressive target organ damage Reveal identifiable causes of Reveal identifiable causes of

hypertensionhypertension Assess the patient’s lifestyle and Assess the patient’s lifestyle and

identify other cardiovascular risk identify other cardiovascular risk factorsfactors

HYPERTENSION HYPERTENSION PRESENTATIONPRESENTATION

Usually asymptomaticUsually asymptomatic It doesn’t refer to being tense, nervous It doesn’t refer to being tense, nervous

or hyperactiveor hyperactive The only way to find out is to have it The only way to find out is to have it

checkedchecked A single reading showing high BP A single reading showing high BP

doesn’t mean you're hypertensive, but doesn’t mean you're hypertensive, but it is a sign that you need to watch it is a sign that you need to watch carefullycarefully

Symptoms & SignsSymptoms & Signs

Often people , are unawareOften people , are unaware Mild HeadacheMild Headache Blurring of VisionBlurring of Vision Dizziness/ SweatingDizziness/ Sweating PalpitationPalpitation Chest painChest pain Difficulty of BreathingDifficulty of Breathing

Measurement of Blood PressureMeasurement of Blood Pressure

Physical ExaminationPhysical Examination Mercury sphygmomanometer – gold standard deviceMercury sphygmomanometer – gold standard device Brachial arteryBrachial artery Korotkoff techniqueKorotkoff technique

Korotkoff Phase l (clear sounds)Korotkoff Phase l (clear sounds) - -record systolic blood pressurerecord systolic blood pressure

Korotkoff Phase V (sound disappear)Korotkoff Phase V (sound disappear) - -record diastolic pressurerecord diastolic pressure

Korotkoff Phase IV (muffling)Korotkoff Phase IV (muffling) - - record diastolic pressure record diastolic pressure (children)(children)

Cuff size - small overestimate BpCuff size - small overestimate Bp - Bladder approx. 80% of the circumference of the arm - Bladder approx. 80% of the circumference of the arm Seated Bp reading after 5 min of restSeated Bp reading after 5 min of rest Caffeine – 30-60 minsCaffeine – 30-60 mins Smoking – 15 – 30 minsSmoking – 15 – 30 mins Exogenous stimulants – phenylephdrine, nasal Exogenous stimulants – phenylephdrine, nasal

decongestants eye drops – decongestants eye drops – secondarysecondary hypertension hypertension

What does high BP does to your body?What does high BP does to your body? It increases the heart’s workload, causing It increases the heart’s workload, causing

it to enlarge and weaken over timeit to enlarge and weaken over time It must pump harder and the arteries It must pump harder and the arteries

carry blood moving under greater carry blood moving under greater pressurepressure

The elasticity or stretchiness in the The elasticity or stretchiness in the arteries decreases arteries decreases

As the heart struggles to pump harder the As the heart struggles to pump harder the muscle wall can grow largermuscle wall can grow larger

A constantly elevated BP hastens the A constantly elevated BP hastens the formation of plaque or fatty deposits formation of plaque or fatty deposits within the blood vessel which causes within the blood vessel which causes atherosclerosis atherosclerosis

HypertensionHypertension Therefore there is risk of stroke, Therefore there is risk of stroke,

congestive heart failure, kidney congestive heart failure, kidney failure and heart attackfailure and heart attack

Those with uncontrolled BP are:Those with uncontrolled BP are: 1. 3x more likely to developed 1. 3x more likely to developed

coronary artery diseasecoronary artery disease 2. 6x more likely to developed CHF2. 6x more likely to developed CHF 3. 7x more likely to developed stroke3. 7x more likely to developed stroke

Hypertension Affects Target Hypertension Affects Target OrgansOrgans

HypertensionHypertension

Angina pectorisAngina pectorisUnstable anginaUnstable angina

Myocardial infarctionMyocardial infarctionSudden deathSudden deathHeart failureHeart failure

TIATIAIschemic strokeIschemic stroke

Hemorrhagic strokeHemorrhagic stroke

Renovascular Renovascular diseasedisease

Renal failureRenal failure

ClaudicationClaudicationAneurysmAneurysm

Critical limb ischemiaCritical limb ischemia

Clinical Impact of HypertensionClinical Impact of Hypertension

HypertensionHypertension

The 2nd leading cause of

new cases of end

stage renal disease

2-4 fold increase in

strokes

Contributes to visual loss in

people with diabetes

IncreasedDeath from MI and CHF

Clinical disorders resulting Clinical disorders resulting fromfrom

hypertension and hypertension and atherosclerosisatherosclerosis

Congestive heart Congestive heart failurefailure

Cerebral Cerebral hemorrhagehemorrhage

Renal failureRenal failure RetinopathyRetinopathy Dissecting aneurysmDissecting aneurysm Hypertensive crisisHypertensive crisis

Coronary artery diseaseCoronary artery disease Angina pectorisAngina pectoris Myocardial infarctionMyocardial infarction 22°° renovascular renovascular

hypertensionhypertension Peripheral vascular Peripheral vascular

insufficiencyinsufficiency Cerebral thrombosis - Cerebral thrombosis -

strokestroke

Hypertension Atherosclerosis

AgeSexRaceHyperlipoproteinemiaDiabetes mellitusCigarette smoking

ObesitySalt intakePrevious cardiovascular diseaseFamily history of cardiovascular disease

Risk factors for cardiovascular complications in hypertensive subjects

DIAGNOSTIC WORK-UP OF DIAGNOSTIC WORK-UP OF HYPERTENSIONHYPERTENSION

1)1) Assess risk factors and co-morbiditiesAssess risk factors and co-morbidities2)2) Reveal identifiable causes of hypertension (Sleep Reveal identifiable causes of hypertension (Sleep

apnea, Drug-induced related, Chronic kidney apnea, Drug-induced related, Chronic kidney disease, Primay aldosteronism, Thyroid diseases, disease, Primay aldosteronism, Thyroid diseases, Cushing.s syndome)Cushing.s syndome)

3)3) Assess presence of target organ damageAssess presence of target organ damage4)4) Conduct History and Physical ExaminationConduct History and Physical Examination5)5) Obtain Lab testObtain Lab test Complete Blood Count (CBC)Complete Blood Count (CBC) UrinalysisUrinalysis Chest X-RayChest X-Ray Lipid Profile (Total Cholesterol/ Lipid Profile (Total Cholesterol/

Triglycerides/LDL/HDL)Triglycerides/LDL/HDL) Other Blood Chemistry Other Blood Chemistry

(ALT/AST/BUN/Creatinine/Uric Acid)(ALT/AST/BUN/Creatinine/Uric Acid) Obtain ECG and other workupsObtain ECG and other workups

TREATMENT OF HYPERTENSION Goals of Goals of

TherapyTherapy Reduction of cardiovascular and renal morbidity and Reduction of cardiovascular and renal morbidity and

mortality. mortality. Treating SBP and DBP to targets that are Treating SBP and DBP to targets that are <140/90 mmHg<140/90 mmHg

is associated with a decrease in CVD complicationsis associated with a decrease in CVD complications Hypertension and Diabetes or Renal disease, the BP goal is Hypertension and Diabetes or Renal disease, the BP goal is

<130/80<130/80 To decrease:To decrease:

Cerebrovascular Accidents Cerebrovascular Accidents 35-40%35-40% Coronary eventsCoronary events 20-25%20-25% Heart failureHeart failure 50%50% Progression of renal diseaseProgression of renal disease Progression to severe hypertensionProgression to severe hypertension All cause mortalityAll cause mortality

Factors to Consider in Treating Factors to Consider in Treating HypertensionHypertension

Repeat readingsRepeat readings R/O : Secondary causesR/O : Secondary causes Estimate CV risk statusEstimate CV risk status Co-morbid conditionsCo-morbid conditions Lifestyle changesLifestyle changes DrugsDrugs

cardiac output cardiac output (ß-blockers, Ca(ß-blockers, Ca2+ 2+

channel channel blockers)blockers)

plasma volume plasma volume (diuretics)(diuretics)

peripheral peripheral vascular vascular resistance resistance (vasodilators)(vasodilators)

MAP = CO X TPR

PharmacotherapyNon-pharmacological

TREATMENT OF HYPERTENSION

Restriction of Restriction of salt intakesalt intake

Reduction of Reduction of body weightbody weight

Treatment : Non Treatment : Non PharmacologicalPharmacological

Maintain a healthy body weight- lose weight Maintain a healthy body weight- lose weight if needed, obesity causes the heart to work if needed, obesity causes the heart to work harderharder

Eat a well balanced diet including fresh fruits Eat a well balanced diet including fresh fruits and vegetables and low fat dairy product. and vegetables and low fat dairy product. Avoid eating high fat high cholesterol foods Avoid eating high fat high cholesterol foods which promote atherosclerosis. Reduce which promote atherosclerosis. Reduce sodium in your diet because it leads to water sodium in your diet because it leads to water retention and increase heart workload.retention and increase heart workload.

Exercise regularlyExercise regularly Stop smoking Stop smoking

ModificationModification RecommendationRecommendation Ave SBP Reduction Ave SBP Reduction RangeRange

Weight ReductionWeight Reduction Maintain normal Body Maintain normal Body weight (BMI= 18.5-24.9 weight (BMI= 18.5-24.9

kg/m²kg/m²

5-20 mmHg/10 kg5-20 mmHg/10 kg

Eating planEating plan Adopt a diet rich in Adopt a diet rich in fruits, vegetables, and fruits, vegetables, and low fat dairy products low fat dairy products

with reduced content of with reduced content of saturated and total fatsaturated and total fat

8-14 mm Hg8-14 mm Hg

Dietary sodium Dietary sodium reductionreduction

Reduce dietary sodium Reduce dietary sodium intake to ≤ 100 intake to ≤ 100

mmolL/day (2.4 g Na or 6 mmolL/day (2.4 g Na or 6 g NaClg NaCl

2-8 mm Hg2-8 mm Hg

Aerobic physical Aerobic physical activityactivity

Regular aerobic physical Regular aerobic physical activity (eg: brisk activity (eg: brisk

walking) at least 30 walking) at least 30 minutes/day, most days of minutes/day, most days of

the week the week

4-9 mm Hg4-9 mm Hg

Lifestyle Modification Lifestyle Modification RecommendationsRecommendations

Pharmacologic TherapyPharmacologic TherapyConsider:Consider: Severity of BPSeverity of BP End organ damage, including LVHEnd organ damage, including LVH Presence of other conditions or risk Presence of other conditions or risk

factors: DM, CHD, smoking, LDLfactors: DM, CHD, smoking, LDL

50% of patients controlled with one 50% of patients controlled with one drug; another 30% with two; drug; another 30% with two;

The vast majority of patients with The vast majority of patients with diabetes require two or more drugsdiabetes require two or more drugs

"Individualized Care""Individualized Care" Risk factors consideredRisk factors considered Non-pharmacological therapy tried firstNon-pharmacological therapy tried first MonotherapyMonotherapy is instituted is instituted Considerations for choice of initial Considerations for choice of initial

monotherapy:monotherapy: Renin statusRenin status Coexisting cardiovascular conditionsCoexisting cardiovascular conditions Other conditionsOther conditions

Treatment : Treatment : PharmacologicalPharmacological

Medication is often necessary to Medication is often necessary to control BPcontrol BP

It is imperative to follow your It is imperative to follow your physician’s instruction in taking your physician’s instruction in taking your medicationsmedications

Take your medicine daily as Take your medicine daily as prescribed and never stop it unless prescribed and never stop it unless instructedinstructed

Threshold for Initiation of Treatment and Threshold for Initiation of Treatment and Target ValuesTarget Values

ConditionCondition InitiationInitiation

SBP SBP / / DBPDBP mmHgmmHg

Diastolic Diastolic ±± systolic systolic hypertensionhypertension

140/90140/90

Isolated systolic Isolated systolic hypertensionhypertension

SBP = or SBP = or >160>160

DiabetesDiabetes 130/80130/80

Renal diseaseRenal disease (( 130/80) 130/80)

Proteinuria >1 g/dayProteinuria >1 g/day (( 125/75) 125/75)

Target

SBP / DBP mmHg

<140/90

<140

<130/80

<130/80

<125/75

Drugs for HypertensionDrugs for Hypertension DiureticsDiuretics

ThiazideThiazide Loop diureticsLoop diuretics Aldosterone antagonistsAldosterone antagonists K-sparingK-sparing

Adrenergic Adrenergic inhibitorsinhibitors Peripheral agentsPeripheral agents Central (α-agonists)Central (α-agonists) alpha -blockersalpha -blockers** beta-blockersbeta-blockers Alpha+beta-blockersAlpha+beta-blockers

Direct VasodilatorsDirect Vasodilators **

Calcium channel Calcium channel blockersblockers DihydropyridineDihydropyridine Non dihydropyridineNon dihydropyridine

ACE-inhibitorsACE-inhibitors

Angiotensin-II Angiotensin-II blockersblockers

* Usually not monotherapy

JNC VII: Management of JNC VII: Management of Hypertension by Blood Pressure Hypertension by Blood Pressure

ClassificationClassificationInitial Drug TherapyInitial Drug Therapy

BP ClassificationBP Classification LifestyleLifestyle

ModificationModificationWithout Compelling Without Compelling

IndicationIndicationWith Compelling With Compelling

IndicationIndication

NormalNormal

<120/80 mmHg<120/80 mmHgEncouragedEncouraged

Pre- HypertensionPre- Hypertension

120-139/80-89 mmHg120-139/80-89 mmHgYesYes No drug indicatedNo drug indicated Drug(s) for the Drug(s) for the

compelling compelling indicationsindications

Stage I HypertensionStage I Hypertension

140-159/90-99 mmHg140-159/90-99 mmHgYesYes Thiazide-type Thiazide-type

diuretics for most; diuretics for most; may consider ACE-I, may consider ACE-I, ARB, BB, CCB, or ARB, BB, CCB, or combinationcombination

Drug(s) for the Drug(s) for the compelling compelling indications; other indications; other anti-hypertensive anti-hypertensive drugs (diuretics, drugs (diuretics, ACE-I, ARB, BB,CCB) ACE-I, ARB, BB,CCB) as neededas needed

Stage 2 HypertensionStage 2 Hypertension

> > 160/100mmHg160/100mmHgYesYes 2- drug combination 2- drug combination

for most (usually for most (usually thiazide-type diuretic thiazide-type diuretic and Ace-I, ARB, BB, and Ace-I, ARB, BB, or CCB) or CCB)

Drug(s) for the Drug(s) for the compelling compelling indications; other indications; other anti-hypertensive anti-hypertensive drugs (diuretics, drugs (diuretics, ACE-I, ARB, BB,CCB) ACE-I, ARB, BB,CCB) as neededas needed

ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker, ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker, BB = beta blocker; CCB = calcium channel blockerBB = beta blocker; CCB = calcium channel blocker

Chobanian AV et al. JAMA. 2003; 289: 2560-2572Chobanian AV et al. JAMA. 2003; 289: 2560-2572

COMPELLING INDICATIONS COMPELLING INDICATIONS FOR INDIVIDUAL DRUG FOR INDIVIDUAL DRUG

CLASSESCLASSES

Key: THIAZ=thiazide diuretic, ACEI=angiotensin converting Key: THIAZ=thiazide diuretic, ACEI=angiotensin converting enzyme inhibitor, ARB=angiotensin receptor blocker, BB=beta enzyme inhibitor, ARB=angiotensin receptor blocker, BB=beta blocker, CCB=calcium channel blocker, ALDO ANT= blocker, CCB=calcium channel blocker, ALDO ANT= aldosterone antagonist aldosterone antagonist

Compelling IndicationsCompelling Indications Initial Therapy OptionsInitial Therapy Options

Heart FailureHeart Failure THIAZ,BB.ACE-THIAZ,BB.ACE-1,ARB,ALDO ANT1,ARB,ALDO ANT

Post-MIPost-MI BB,ACE-I,ALDO ANTBB,ACE-I,ALDO ANT

High CVD riskHigh CVD risk THIAZ,BB,ACE-I,CCBTHIAZ,BB,ACE-I,CCB

DMDM THIAZ,BB,ACE-I,ARB,CCBTHIAZ,BB,ACE-I,ARB,CCB

Chronic kidney diseaseChronic kidney disease ACE-I,ARBACE-I,ARB

Recurrent stroke Recurrent stroke preventionprevention

THIAZ,ACE-ITHIAZ,ACE-I

Dental treatment and Dental treatment and hypertensionhypertension

SBP DBP MRF Recommendation 120-139 80-89 Yes/no Routine dental care OK; discuss BP guidelines 140-159 90-99 Yes/no Routine dental care OK; consider stress reduction

protocol; refer for medical consult 160-179 100-109 No Routine dental care OK; consider stress reduction

protocol; refer for medical consult 160-179 100-109 Yes Urgent dental care OK; refer for medical consult 180-209 110-119 No No dental treatment without medical consult; refer

for prompt medical consult 180-209 110-119 Yes No dental treatment; refer for emergency medical

treatment ³210 ³120 Yes/no No dental treatment; refer for emergency medical

treatment MRF: medical risk factor (e.g., history of MI, angina, high coronary disease risk, recurrent stroke prevention, diabetes mellitus, renal disease. From Merin RL: JADA 135:1220, 2004; after Herman et al: JADA 135:576-84, 2004.

Hypertension in Hypertension in DentistryDentistry

Patients have to be treated with carePatients have to be treated with care Risks of heart failure/ heart attackRisks of heart failure/ heart attack Patients must be monitored continuouslyPatients must be monitored continuously Many patients with hypertension also have Many patients with hypertension also have

metabolic syndrome, which is likely to metabolic syndrome, which is likely to develop periodontal disease due to an develop periodontal disease due to an increase in build up of calculus around the increase in build up of calculus around the gums gums

Common health issues can disrupt not only Common health issues can disrupt not only overall dietary health, but also dental health overall dietary health, but also dental health

Hypertension in Hypertension in DentistryDentistry

The risk of providing dental treatment to The risk of providing dental treatment to patients with hypertension is lowpatients with hypertension is low

LA containing epinephrine can be used with LA containing epinephrine can be used with little risk in dental patients with hypertensionlittle risk in dental patients with hypertension

For patients taking a nonselective beta For patients taking a nonselective beta blocker, use epinephrine cautiously (max. of 2 blocker, use epinephrine cautiously (max. of 2 carpules of 1:100,000 epi)carpules of 1:100,000 epi)

Gingival hyperplasia is common in patients Gingival hyperplasia is common in patients taking a calcium channel blockertaking a calcium channel blocker

Elective dental treatment should be deferred Elective dental treatment should be deferred in patients with a blood pressure ≥180/110 in patients with a blood pressure ≥180/110 (uncontrolled blood pressure)(uncontrolled blood pressure)

Implications for DentistryImplications for Dentistry Care in use of vasoconstrictors Care in use of vasoconstrictors (e.g. (e.g.

supersensitivity to catecholamines with supersensitivity to catecholamines with guanethidine)guanethidine)

Orthostatic hypotention Orthostatic hypotention (common to all (common to all antihypertensive drugs)antihypertensive drugs)

Judicious use of CNS depressants Judicious use of CNS depressants (esp. with centrally-acting antihypertensive (esp. with centrally-acting antihypertensive drugs)drugs)

Salivary inhibition Salivary inhibition (xerostomia common (xerostomia common with centrally-acting antihypertensive drugs)with centrally-acting antihypertensive drugs)

NSAIDs NSAIDs (decrease action of captopril, (decrease action of captopril, spironolactone, furosemide)spironolactone, furosemide)

Gingival hyperplasia Gingival hyperplasia (with long-term use (with long-term use of Caof Ca2+2+channel blockers)channel blockers)

Summary PointsSummary Points Hypertension is defined as a sustained blood Hypertension is defined as a sustained blood

pressure ≥140/90pressure ≥140/90 Any level of hypertension is associated with Any level of hypertension is associated with

an increased risk of cardiovascular diseasean increased risk of cardiovascular disease Hypertension remains an asymptomatic Hypertension remains an asymptomatic

disease for long periods of timedisease for long periods of time Many patients with hypertension are Many patients with hypertension are

unaware of their diseaseunaware of their disease Many patients with hypertension are Many patients with hypertension are

noncompliant with medication and thus are noncompliant with medication and thus are not well controllednot well controlled

Elevated blood pressure cannot be cured, it Elevated blood pressure cannot be cured, it can only be controlledcan only be controlled

and its effects can be prevented or reduced- and its effects can be prevented or reduced- if it is treated and controlled early.if it is treated and controlled early.

Hypertensive CrisisHypertensive Crisis Hypertensive UrgencyHypertensive Urgency

- Increased in diastolic blood pressure - Increased in diastolic blood pressure

>120 – 130 mmHg>120 – 130 mmHg

- No End-Organ Damage- No End-Organ Damage

- Lowers down BP within 24 hours- Lowers down BP within 24 hours

Hypertensive EmergencyHypertensive Emergency- Systolic Bp exceeding 210 mmHg and diastolic BP > 130 - Systolic Bp exceeding 210 mmHg and diastolic BP > 130 mmHgmmHg

- With End-Organ Damage (e.g.: Acute M.I., ICH, Unstable - With End-Organ Damage (e.g.: Acute M.I., ICH, Unstable Angina and Hypertensive Encephalopathy) Angina and Hypertensive Encephalopathy)

- Requires immediate BP reduction within an hour (IV - Requires immediate BP reduction within an hour (IV medications)medications)

What is the primary reason What is the primary reason for hypertensive for hypertensive

emergenciesemergencies

1.1. Renovascular DiseaseRenovascular Disease

2.2. PheochromocytomaPheochromocytoma

3.3. Non-adherence to anti-Non-adherence to anti-hypertensive medicationhypertensive medication

4.4. HyperaldosteronismHyperaldosteronism

5.5. ErythropoeitinErythropoeitin

Clinical PresentationClinical Presentation

VariableVariable Mean Systolic BP 210 Mean Systolic BP 210 ++ 32 32 Mean Diastolic BP 130 Mean Diastolic BP 130 ++ 15 15

Frequency of signs and symptomsFrequency of signs and symptoms Chest PainChest Pain 27%27% DyspneaDyspnea 22%22% Neuro defectNeuro defect 21%21% Interestingly….Interestingly….

Headache was only 3% and epistaxis was Headache was only 3% and epistaxis was 0%0%

Threshold BPThreshold BP

There is no specific BP where There is no specific BP where hypertensive emergencies occurhypertensive emergencies occur

But, organ dysfunction is rare with But, organ dysfunction is rare with diastolic BPs < 130 mm Hgdiastolic BPs < 130 mm Hg Rate of increase may be more importantRate of increase may be more important Hence, encephalopathy will occur at Hence, encephalopathy will occur at

lower BPs in pregnancy and in childrenlower BPs in pregnancy and in children

Hypertensive EmergencyHypertensive Emergency

Heart - CHF, MI, angina

Kidneys - acute kidney injury, microscopic hematuria

CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy

Vasculature - aortic dissection, eclampsia

Initial EvaluationInitial Evaluation Focused historyFocused history

History of hypertension?History of hypertension? How well is hypertension controlled?How well is hypertension controlled? What antihypertensives?What antihypertensives? Adherence to antihypertensive regimen?Adherence to antihypertensive regimen? Last dose of antihypertensive?Last dose of antihypertensive?

Social HistorySocial History Recreational DrugsRecreational Drugs

AmphetaminesAmphetamines CocaineCocaine PhencyclidinePhencyclidine

Initial EvaluationInitial Evaluation Confirm BP in both armsConfirm BP in both arms Use appropriate sized BP cuffUse appropriate sized BP cuff Cuff that is too smallCuff that is too small

BP cuffs that are too small falsely elevate BP BP cuffs that are too small falsely elevate BP measurements in obese patientsmeasurements in obese patients

Assess for end-organ damageAssess for end-organ damage Vascular DiseaseVascular Disease

Assess pulses in all extremitiesAssess pulses in all extremities Auscultate over renal arteries for bruitsAuscultate over renal arteries for bruits

CardiopulmonaryCardiopulmonary Listen for rales (CHF)Listen for rales (CHF) Murmurs or gallopsMurmurs or gallops

Initial EvaluationInitial Evaluation Neurologic ExamNeurologic Exam

Hypertensive Encephalopathy - mental status Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizureschanges, nausea, vomiting, seizures

Lateralizing signs uncommon and suggest Lateralizing signs uncommon and suggest cerebrovascular accidentcerebrovascular accident

Retinal ExamRetinal Exam Lost artLost art Keith-Wagener-Barker ClassificationKeith-Wagener-Barker Classification

ECGECG LVH, look for signs of ischemia, injury, infarctLVH, look for signs of ischemia, injury, infarct

Renal Function Tests (urine included)Renal Function Tests (urine included) Elevated BUN, Creatinine, proteinuria, hematuriaElevated BUN, Creatinine, proteinuria, hematuria

CBCCBC CXR - pulmonary edema, aortic arch, cardiac CXR - pulmonary edema, aortic arch, cardiac

enlargementenlargement

Lab TestingLab Testing

Aortic Dissection?Aortic Dissection? Suspect with severe tearing chest pain, Suspect with severe tearing chest pain,

unequal pulses, widened mediastinumunequal pulses, widened mediastinum Contrast Chest CT Scan or MRIContrast Chest CT Scan or MRI

Pulmonary Edema/CHFPulmonary Edema/CHF Transthoracic Echocardiogram Transthoracic Echocardiogram Differentiate between systolic Differentiate between systolic

dysfunction, diastolic dysfunction, dysfunction, diastolic dysfunction, mitral regurgitationmitral regurgitation

ManagementManagement

Elevated BP without target organ damageElevated BP without target organ damage Hypertensive Hypertensive urgencyurgency Oral medsOral meds Goal - gradual reduction of BP over 24 - 48 Goal - gradual reduction of BP over 24 - 48

hourshours Elevated BP with Elevated BP with target organ damagetarget organ damage Hypertensive Hypertensive emergencyemergency Parenteral medsParenteral meds Goal - Reduce diastolic BP by 10-15% or to Goal - Reduce diastolic BP by 10-15% or to

110 mm Hg over a period of 30 - 60 minutes110 mm Hg over a period of 30 - 60 minutes

ManagementManagement

Where?Where? ICU with close monitoringICU with close monitoring Severe requires intra-arterial BP Severe requires intra-arterial BP

monitoringmonitoring Which Parenteral meds?Which Parenteral meds? Depends on the situationDepends on the situation

Acute Post Operative Acute Post Operative HypertensionHypertension

Frequent in post-operative state (20-75%)Frequent in post-operative state (20-75%) Hyper-responsiveness to surgical traumaHyper-responsiveness to surgical trauma

Increased stress hormones?Increased stress hormones? Activation of RAA?Activation of RAA?

Also hypothermia, hypoxia, carbon dioxide Also hypothermia, hypoxia, carbon dioxide retention, bladder distentionretention, bladder distention

PreventionPrevention Safe to give antihypertensives pre-opSafe to give antihypertensives pre-op Hold diureticsHold diuretics

Treatment - BP thresholds varyTreatment - BP thresholds vary Control pain and anxietyControl pain and anxiety While NPO use nicardipine, esmolol or labetololWhile NPO use nicardipine, esmolol or labetolol Resume oral medications when possibleResume oral medications when possible