The Diagnosis and Management of Hypertensive Crisesntent

8/13/2019 The Diagnosis and Management of Hypertensive Crisesntent

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The Diagnosis and Management of

Hypertensive Crises*

*+ ,o)ep$ Va"on- MD- FCCP an#

.+ Pa(/ E+ Ma"ik- MD- FCCP

0A(t$o" A11i/iation)

0A(t$o" A11i/iation)

1. *From the Department of Medicine (Dr. Varon), Baylor College of Medicine, Houton

!"# and the Department of $nternal Medicine, %ection of Critical Care (Dr. Mari&),

'ahington Hopital Center, 'ahington, DC.

Ne2t Section

Abstract
http://www.chestjournal.org/http://www.chestjournal.org/content/currenthttp://www.chestjournal.org/contenthttp://www.chestjournal.org/feedbackhttp://www.chestjournal.org/site/subscriptions/http://www.chestjournal.org/cgi/alertshttp://www.chestjournal.org/helphttp://www.chestjournal.org/searchhttp://www.chestjournal.org/search?author1=Joseph+Varon&sortspec=date&submit=Submithttp://www.chestjournal.org/search?author1=Paul+E.+Marik&sortspec=date&submit=Submithttp://ahs2.adhostingsolutions.com/oasisc.php?s=858&w=220&h=40&t=_blankhttp://ahs2.adhostingsolutions.com/oasisc.php?s=858&c=1023&cb=1820063548http://ahs2.adhostingsolutions.com/oasisc.php?s=858&c=1023&cb=1892480853http://www.chestjournal.org/http://www.chestjournal.org/http://www.chestjournal.org/content/currenthttp://www.chestjournal.org/contenthttp://www.chestjournal.org/feedbackhttp://www.chestjournal.org/site/subscriptions/http://www.chestjournal.org/cgi/alertshttp://www.chestjournal.org/helphttp://www.chestjournal.org/searchhttp://www.chestjournal.org/search?author1=Joseph+Varon&sortspec=date&submit=Submithttp://www.chestjournal.org/search?author1=Paul+E.+Marik&sortspec=date&submit=Submit


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Se%e"e $pe"ten)ion i) a common c/inica/ p"o3/em in t$e Unite# State)- enco(nte"e# in

%a"io() c/inica/ )etting)+ A/t$o(g$ %a"io() te"m) $a%e 3een app/ie# to )e%e"e $pe"ten)ion-

)(c$ a) $pe"ten)i%e c"i)e)- eme"gencie)- o" ("gencie)- t$e a"e a// c$a"acte"i4e# 3 ac(te

e/e%ation) in BP t$at ma 3e a))ociate# !it$ en#5o"gan #amage 6$pe"ten)i%e c"i)i)7+ T$e

imme#iate "e#(ction o1 BP i) on/ "e8(i"e# in patient) !it$ ac(te en#5o"gan #amage+

Hpe"ten)ion a))ociate# !it$ ce"e3"a/ in1a"ction o" int"ace"e3"a/ $emo""$age on/ "a"e/"e8(i"e) t"eatment+ 9$i/e nit"op"())i#e i) common/ ()e# to t"eat )e%e"e $pe"ten)ion- it i)

an e2t"eme/ to2ic #"(g t$at )$o(/# on/ 3e ()e# in "a"e ci"c(m)tance)+ F("t$e"mo"e- t$e

)$o"t5acting ca/ci(m c$anne/ 3/ocke" ni1e#ipine i) a))ociate# !it$ )igni1icant mo"3i#it an#

)$o(/# 3e a%oi#e#+ To#a- a !i#e "ange o1 p$a"maco/ogic a/te"nati%e) a"e a%ai/a3/e to t$e

p"actitione" to cont"o/ )e%e"e $pe"ten)ion+ T$i) a"tic/e "e%ie!) )ome o1 t$e c(""ent concept)

an# common mi)conception) in t$e management o1 patient) !it$ ac(te/ e/e%ate# BP+

ao"tic #i))ection

:53/ocke")

ca/ci(m c$anne/ 3/ocke")

1eno/#opam

$pe"ten)ion

$pe"ten)i%e c"i)e)

$pe"ten)i%e encep$a/opat$

/a3eta/o/

nica"#ipine

nit"op"())i#e

p"egnanc

Hpe"ten)ion i) a common c/inica/ p"o3/em in t$e Unite# State)- an# p$)ician) o1 a// tpe)

a"e /ike/ to enco(nte" patient) !it$ $pe"ten)i%e ("gencie) an# eme"gencie)+ A/t$o(g$

%a"io() te"m) $a%e 3een app/ie# to t$e)e con#ition)- t$e a"e a// c$a"acte"i4e# 3 ac(te

e/e%ation) in BP+*.;?@P"ompt 3(t ca"e1(// con)i#e"e# t$e"ap i) nece))a" to /imit

mo"3i#it an# mo"ta/it+*Un1o"t(nate/- acce/e"ate# $pe"ten)ion i) among t$e mo)t

mi)(n#e")too# an# mi)manage# o1 ac(te me#ica/ p"o3/em) )een in c/inica/ p"actice+ Man

p$)ician) $a%e an ("gent nee# to "api#/ /o!e" an e/e%ate# BP !it$o(t con)i#e"ing t$e

pat$op$)io/ogic p"incip/e) in%o/%e#+

P"e%io() SectionNe2t Section

Definitions

T$e ,oint Nationa/ Committee on P"e%ention- Detection- E%a/(ation- an# T"eatment o1 Hig$

B/oo# P"e))("e $a) c/a))i1ie# $pe"ten)ion acco"#ing to t$e #eg"ee o1 BP e/e%ation+ *Stage *

patient) $a%e a ))to/ic BP o1 *


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mm Hg+ Stage ; $pe"ten)ion $a) a/)o 3een ca//e# )e%e"e $pe"ten)ion o" acce/e"ate#

$pe"ten)ion+ T$e 1eat("e) an# c/a))i1ication an# o1 p"egnanc5in#(ce# $pe"ten)ion a"e

inc/(#e# in Ta3/e *+**

A n(m3e" o1 #i11e"ent te"m) $a%e 3een app/ie# to )e%e"e ac(te e/e%ation) o1 BP+ Ho!e%e"-

mo)t a(t$o") $a%e #e1ine# $pe"ten)i%e c"i)e) o" eme"gencie) a) a )(##en inc"ea)e in ))to/ican# #ia)to/ic BP a))ociate# !it$ en#5o"gan #amage o1 t$e CNS- t$e $ea"t- o" t$e ki#ne) t$e

te"m hypertenie urgencie$a) 3een ()e# 1o" patient) !it$ )e%e"e/ e/e%ate# BP !it$o(t

ac(te en#5o"gan #amage+.;...;Like ot$e" 1o"m) o1 acce/e"ate# $pe"ten)ion- a $i)to" o1$pe"ten)ion i) common+

P"eec/amp)ia 6p"egnanc5"e/ate# $pe"ten)ion7 i) a 1o"m o1 $pe"ten)ion t$at #e)e"%e)

mention+ T$e inci#ence o1 p"eec/amp)ia %a"ie) acco"#ing to t$e patient c$a"acte"i)tic)+ It

occ(") in ?J o1 a// p"egnancie)+ O1 t$em- ?J a"e n(//5g"a%i#a) an# ;J a"e m(/ti5g"a%i#a)+

In mo/a" p"egnancie)- p"eec/amp)ia $a) 3een #e)c"i3e# in (p to ?J o1 ca)e)+ .T$i) %a)c(/a" in(" /ea#) to #epo)ition o1 p/ate/et) an# 1i3"in- an# a 3"eak#o!n o1


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t$e no"ma/ a(to"eg(/ato" 1(nction+ T$e "e)(/ting i)c$emia p"ompt) 1("t$e" "e/ea)e o1

%a)oacti%e )(3)tance)- comp/eting a %icio() cc/e+.>

It )$o(/# 3e app"eciate# t$at mo)t patient) !$o p"e)ent to $o)pita/ !it$ an e/e%ate# BP a"e

c$"onica// $pe"ten)i%e- !it$ a "ig$t!a"# )$i1t o1 t$e p"e))("e1/o! 6ce"e3"a/ an# "ena/7

a(to"eg(/ation c("%e 6Fig *7+.?F("t$e"mo"e- mo)t patient) !it$ )e%e"e $pe"ten)ion 6#ia)to/icp"e))("e ** mm Hg7 $a%e no ac(te- en#5o"gan #amage+ Rapi# anti$pe"ten)i%e t$e"ap in

t$i) )etting ma 3e a))ociate# !it$ )igni1icant mo"3i#it+.@.;T$e"e a"e- $o!e%e"- t"(e

$pe"ten)i%e eme"gencie) in !$ic$ t$e "api# 6cont"o//e#7 /o!e"ing o1 BP i) in#icate# 6)ee

3e/o!7+*@*;*


Clinical Manifestations

T$e mani1e)tation) o1 $pe"ten)i%e c"i)e) a"e t$o)e o1 en#5o"gan #)1(nction+Ta3/e ./i)t)t$o)e con#ition) t$at- !$en a))ociate# !it$ )e%e"e/ e/e%ate# BP- a"e "e1e""e# to a)

$pe"ten)i%e c"i)e)eme"gencie)+ O"gan #)1(nction i) (ncommon !it$ #ia)to/ic BP) *;

mm Hg- a/t$o(g$ it ma occ("+

It i) impo"tant to "ecogni4e t$at t$e a3)o/(te /e%e/ o1 BP ma not 3e a) impo"tant a) t$e "ate

o1 inc"ea)e+?;.;;Fo" e2amp/e- patient) !it$ /ong5)tan#ing $pe"ten)ion ma to/e"ate ))to/ic

BP) o1 . mm Hg o" #ia)to/ic inc"ea)e) (p to *= mm Hg !it$o(t #e%e/oping $pe"ten)i%e

encep$a/opat$- !$i/e c$i/#"en o" p"egnant !omen ma #e%e/op encep$a/opat$ !it$

#ia)to/ic BP G * mm Hg+*?

Hea#ac$e- a/te"e# /e%e/ o1 con)cio()ne))- an# /e))5)e%e"e #eg"ee) o1 CNS #)1(nction a"e t$ec/a))ic mani1e)tation) o1 $pe"ten)i%e encep$a/opat$+>?A#%ance# "etinopat$ !it$ a"te"io/a"

c$ange)- $emo""$age) an# e2(#ate)- a) !e// a) papi//e#ema- a"e common/ )een on

e2amination o1 1(n#i in patient) !it$ $pe"ten)i%e encep$a/opat$+ Ca"#io%a)c(/a"

mani1e)tation) o1 $pe"ten)i%e c"i)e) ma inc/(#e angina o" ac(te moca"#ia/ in1a"ction+

Ca"#iac #ecompen)ation ma /ea# to )mptom) o1 #)pnea- o"t$opnea- co(g$- 1atig(e o"

1"ank p(/mona" e#ema+*;


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Initial Evalation of the Patient !ith Hypertensive Crises

T$e ke to )(cce))1(/ management o1 patient) !it$ )e%e"e/ e/e%ate# BP i) to #i11e"entiate

$pe"ten)i%e c"i)e) 1"om $pe"ten)i%e ("gencie)+ T$i) i) accomp/i)$e# 3 a ta"gete# me#ica/

$i)to" an# p$)ica/ e2amination )(ppo"te# 3 app"op"iate /a3o"ato" e%a/(ation+*P"io"

$pe"ten)i%e c"i)e)- anti$pe"ten)i%e me#ication) p"e)c"i3e#- an# BP cont"o/ )$o(/# 3e

a)ce"taine#+ Pa"tic(/a" in8(i" )$o(/# inc/(#e t$e ()e o1 monoamine o2i#a)e in$i3ito") an#

"ec"eationa/ #"(g) 6ie- cocaine- amp$etamine)- p$encc/i#ine7+ T$e BP in all lim)$o(/# 3e

mea)("e# 3 t$e p$)ician+ In o3e)e patient)- app"op"iate/ )i4e# c(11) )$o(/# 3e ()e#+

F(n#()copic e2amination i) man#ato" in a// ca)e) to #etect t$e p"e)ence o1 papi//e#ema+

A CBC co(nt- e/ect"o/te)- BUN- c"eatinine- an# ("ina/)i) )$o(/# 3e o3taine# in a// patient)

p"e)enting !it$ $pe"ten)i%e c"i)e)+*A pe"ip$e"a/ 3/oo# )mea" )$o(/# 3e o3taine# to #etect

t$e p"e)ence o1 a mic"oangiopat$ic $emo/tic anemia+ In a##ition- a c$e)t "a#iog"ap$- EC'-

an# $ea# CT a"e ()e1(/ in patient) !it$ e%i#ence o1 )$o"tne)) o1 3"eat$- c$e)t pain- o"

ne("o/ogic c$ange)- "e)pecti%e/+ An ec$oca"#iog"am )$o(/# 3e o3taine# to a))e)) /e1t%ent"ic(/a" 1(nction an# e%i#ence o1 %ent"ic(/a" $pe"t"op$+ In man in)tance)- t$e)e te)t)

a"e pe"1o"me# )im(/taneo()/ !it$ t$e initiation o1 anti$pe"ten)i%e t$e"ap+


Therapetic Approach

Patient) !it$ $pe"ten)i%e eme"gencie) "e8(i"e imme#iate cont"o/ o1 t$e BP to te"minate

ongoing en#5o"gan #amage- ut not to return B to normal leel+.;


6/44

p"og"e))ing to an in5(te"o #eat$ o" to pe"inata/ a)p$2ia+ A1te" #e/i%e"- an ac(te- "api#

#ec"ea)e in BP ()(a// mean) )(3)tantia/ 3/oo# /o)) an# not a c("e o1 t$e #i)ea)e p"oce))+

It )$o(/# 3e emp$a)i4e# t$at on/ patient) !it$ $pe"ten)i%e c"i)e)eme"gencie) 6Ta3/e .7

"e8(i"e imme#iate "e#(ction o1 a ma"ke#/ e/e%ate# BP+ In a// ot$e" patient)- t$e e/e%ate# BP

can 3e /o!e"e# )/o!/ ()ing o"a/ agent)+ In patient) !$o $a%e )(11e"e# a mao"ce"e3"o%a)c(/a" e%ent- t$e BP )$o(/# not 3e /o!e"e#- e2cept in e2ceptiona/ ci"c(m)tance)

6)ee 3e/o!7+

Pharmacologic Management

A g"o!ing n(m3e" o1 agent) a"e a%ai/a3/e 1o" management o1 $pe"ten)i%e c"i)e)+ T$e

app"op"iate t$e"ape(tic app"oac$ !i// #epen# on t$e c/inica/ p"e)entation o1 t$e patient+

Ho!e%e"- agent) t$at can 3e a#mini)te"e# IV t$at a"e "api# acting- a"e ea)i/ tit"ata3/e- an#

$a%e a )$o"t $a/15/i1e a"e "ecommen#e# 6Ta3/e ;7+


Antihypertensive Drgs "sed in Hypertensive Crises

#$isted Alphabetically%

Clonidine

C/oni#ine i) a%ai/a3/e a) an o"a/ an# t"an)#e"ma/ 1o"m(/ation+ O"a/ c/oni#ine 6+* mg po

e%e" . min7 $a) 3een ()e# 1o" t$e t"eatment o1 $pe"ten)i%e ("gencie)+


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$a) gaine# pop(/a"it 1o" ()e in )ome $pe"ten)i%e eme"gencie)+=;===>=?=@=Ena/ap"i/at $a) an

on)et o1 action !it$in *= min- !it$ a #("ation o1 action o1 *. to .< $+ Hi")c$/ an#

co//eag(e)=?$a%e #emon)t"ate# t$at t$e #eg"ee o1 t$e BP "e#(ction !it$ IV ena/ap"i/at i)

co""e/ate# !it$ t$e p"et"eatment concent"ation o1 angioten)in II an# p/a)ma "enin acti%it+ No

a#%e")e )i#e e11ect) o" )mptomatic $poten)ion $a) 3een "epo"te# !it$ IV ena/ap"i/at

$o!e%e"- ACE in$i3ito") a"e cont"ain#icate# in p"egnanc+=;=?

Esmolol

E)mo/o/ i) a ca"#io)e/ecti%e- :5a#"ene"gic 3/ocking agent t$at $a) an e2t"eme/ )$o"t #("ation

o1 action+>>*>.T$e meta3o/i)m o1 e)mo/o/ i) %ia "api# $#"o/)i) 3 RBC) an# i) not

#epen#ent on "ena/ o" $epatic 1(nction+ T$e on)et o1 action i) !it$in > )- !it$ a #("ation o1

action o1 * to . min+>>*>.T$e p$a"macokinetic p"ope"tie) o1 e)mo/o/- make it t$e i#ea/ :5

a#"ene"gic 3/ocke" 1o" ()e in c"itica// i// patient)+ T$i) agent i) a%ai/a3/e 1o" IV ()e- 3ot$ a)

a 3o/() an# a) an in1()ion+ It i) o1 pa"tic(/a" %a/(e 1o" )ome )(p"a%ent"ic(/a" #)"$t$mia)-

an# "ecent/ $a) 3een ()e# in patient) !it$ $pe"ten)i%e c"i)e) an# po)tope"ati%e

$pe"ten)ion+>;>=>>>?>@>E)mo/o/ $a) p"o%en )a1e in patient) !it$ ac(te moca"#ia/ in1a"ction-

e%en t$o)e !$o $a%e "e/ati%e cont"ain#ication) to :53/ocke")+?T$e "ecommen#e# initia/ #o)e

i) += mgkg 1o//o!e# 3 an in1()ion at .= to ; gkgmin+

(enoldopam

T$i) agent $a) "ecent/ 3een app"o%e# 1o" t$e management o1 ac(te $pe"ten)ion in t$e

Unite# State)+ It i) a #opamine 6DA7* agoni)t t$at i) )$o"t acting an# $a) t$e a#%antage) o1

inc"ea)ing "ena/ 3/oo# 1/o! an# )o#i(m e2c"etion+ Feno/#opam $a) "e/ati%e/ (ni8(e action)

an# "ep"e)ent) a ne! catego" o1 anti$pe"ten)i%e me#ication+ 9$i/e t$e )t"(ct("e o1

1eno/#opam i) 3a)e# on DA- t$e 1o"me" i) $ig$/ )peci1ic 1o" on/ DA* "ecepto") an# i) *time) mo"e potent t$an DA a) a "ena/ %a)o#i/ato"+?*T$e )peci1ic "ecepto" acti%ation i) o1

pa"amo(nt %a/(e in t$e #i11e"entiation o1 action) 3et!een DA an# 1eno/#opam+ A)

1eno/#opam inte"act) on/ !it$ DA* "ecepto")- it) ()e i) not a))ociate# !it$ t$e a#%e")e

e11ect) "e/ate# to *5 an# :*5acti%ation+

Feno/#opam acti%ate) #opamine"gic "ecepto") on t$e p"o2ima/ an# #i)ta/ t(3(/e)- in$i3it)

)o#i(m "ea3)o"ption- an# "e)(/t) in #i("e)i) an# nat"i("e)i)+?.?;Feno/#opam i) "api#/ an#

e2ten)i%e/ meta3o/i4e# 3 con(gation in t$e /i%e"- !it$o(t pa"ticipation o1 ctoc$"ome P5


8/44

pa"amete") 1a// in patient) t"eate# !it$ nit"op"())i#e+?;?@Feno/#opam ma t$e"e1o"e 3e t$e

#"(g o1 c$oice in )e%e"e/ $pe"ten)i%e patient) !it$ impai"e# "ena/ 1(nction+@*

$abetalol

La3eta/o/ i) a com3ine# 3/ocke" o1 5 an# :5a#"ene"gic "ecepto")+ 'i%en IV- t$e :53/ocking"atio i) *[email protected]$e mao"it o1 t$e #"(g i) meta3o/i4e# 3 t$e /i%e" to 1o"m an inacti%e

g/(c("oni#e con(gate+@;T$e $poten)i%e e11ect o1 /a3eta/o/ 3egin) !it$in . to = min a1te" an

IV #o)e- "eac$e) it) peak at = to *= min- an# pe")i)t) 1o" a3o(t . to < $ +@;@ $+

Se%e"a/ )t(#ie) $a%e e2amine# t$e ac(te e11ect) o1 nica"#ipine !$en a#mini)te"e# to patient)

!it$ )e%e"e $pe"ten)ion+..@


9/44

O"a/)(3/ing(a/ t$e"ap !it$ )$o"t5acting ni1e#ipine $a) 3een !i#e/ ()e# in t$e management

o1 $pe"ten)i%e eme"gencie)- )e%e"e $pe"ten)ion a))ociate# !it$ c$"onic "ena/ 1ai/("e-

pe"iope"ati%e $pe"ten)ion- an# p"egnanc5in#(ce# $pe"ten)ion+;


10/44

1oca/ ne("o/ogic a3no"ma/itie)+*@*.It $a) a/)o 3een

#emon)t"ate# t$at $#"o2oco3a/amin 6%itamin *.a7 i) )a1e an# e11ecti%e in p"e%enting an#t"eating cani#e to2icit a))ociate# !it$ t$e ()e o1 nit"op"())i#e+ T$i) ma 3e gi%en a) a

contin(o() in1()ion at a "ate o1 .= mg$+ H#"o2oco3a/amin i) (n)ta3/e an# )$o(/# 3e )to"e#

#" an# p"otecte# 1"om /ig$t+ Canoco3a/amin 6B*.7- $o!e%e"- i) ine11ecti%e a) an anti#ote

an# i) not capa3/e o1 p"e%enting cani#e to2icit+

Phentolamine

P$ento/amine i) an 5a#"ene"gic 3/ocking agent t$at i) 1"e8(ent/ ()e# 1o" management o1

catec$o/amine5in#(ce# $pe"ten)i%e c"i)e) 6ie- p$eoc$"omoctoma7+;?*@;.;;;>T$i) me#ication

i) gi%en IV in *5 to =5mg 3o/()e)+ T$e e11ect i) imme#iate an# ma /a)t (p to *= min+Contin(o() IV in1()ion) $a%e a/)o 3een ()e# !it$ %a"ia3/e e11ect)+ T$i) agent ma ca()e

tac$#)"$t$mia) o" angina+ Once t$e initia/ BP i) (n#e" cont"o/- o"a/ p$eno23en4amine- a

/ong5acting 5a#"ene"gic 3/ocking agent- ma 3e gi%en+

Trimethaphan Camsylate

T"imet$ap$an cam)/ate i) a non#epo/a"i4ing gang/ionic 3/ocking agent+ It 3/ock) t$e

t"an)mi))ion o1 imp(/)e) at t$e )mpat$ic an# pa"a)mpat$ic gang/ia 3 competing !it$

acet/c$o/ine 1o" c$o/ine"gic "ecepto")+?T$i) acco(nt) 1o" 3ot$ it) e11icac an# it) n(me"o()

)i#e e11ect)+ T$e "e#(ction in BP o3)e"%e# !it$ t$i) agent i) ca()e# 3 t$e a#"ene"gic

3/ocka#e "e)(/ting in %a)o#i/atation+ T$e on)et o1 action i) !it$in * to = min- !it$ a #("ationo1 action o1 * min+ T$e a#mini)t"ation i) 3 con)tant IV in1()ion 6= mg i) mi2e# in =

mL o1 =J #e2t"o)e !ate"7- an# i) gi%en a) initia/ #o)age o1 += to * mgmin+ T$e #o)e i) t$en

tit"ate# to ac$ie%e t$e #e)i"e# BP (p to a ma2im(m o1 *= mgmin+ Tac$p$/a2i) i) a

common )i#e e11ect !it$ t$i) me#ication+ It ()(a// occ(") !it$in t$e 1i")t . #a) o1

a#mini)t"ation+

ther Agents

Nit"og/ce"in an# $#"a/a4ine a"e )ometime) ()e# in t$e t"eatment o1 $pe"ten)i%e c"i)e)- an#

nit"og/ce"in ma p/a a )igni1icant "o/e in t$o)e patient) !it$ ca"#iac i)c$emia+ Ho!e%e"- it

i) impo"tant to emp$a)i4e t$at nit"og/ce"in i) not an e11ecti%e %a)o#i/ato"+ *.=Nit"og/ce"in i)

a potent %eno#i/ato"- an# on/ at $ig$ #o)e) a11ect) a"te"ia/ tone+ Nit"og/ce"in "e#(ce) BP 3


11/44

"e#(cing p"e/oa# an# ca"#iac o(tp(t- (n#e)i"a3/e e11ect) in patient) !it$ comp"omi)e#

ce"e3"a/ an# "ena/ pe"1()ion+ In a##ition- it "e8(i"e) )pecia/ t(3ing 1o" a#mini)t"ation+

H#"a/a4ine $a) 3een ()e# a) an anti$pe"ten)i%e agent 1o" G *.?A/t$o(g$ t$e ci"c(/ating $a/15/i1e o1 t$e #"(gi) a3o(t ; $- t$e $a/15time o1 it) e11ect on BP i) a3o(t * $+ *.@H#"a/a4ine $a) 3een

#emon)t"ate# to 3in# to t$e !a//) o1 m()c(/a" a"te"ie)+ *.*;*;*T$i) ma e2p/ain t$e p"o/onge#

p$a"maco/ogic e11ect o1 t$e #"(g+ Beca()e o1 t$e p"o/onge# an# (np"e#icta3/e

anti$pe"ten)i%e e11ect) o1 t$e #"(g- an# t$e ina3i/it to e11ecti%e/ tit"ate it) $poten)i%e

e11ect- $#"a/a4ine )$o(/# 3e a%oi#e# in t$e management o1 $pe"ten)i%e eme"gencie)+ Ot$e"

"egimen) (ti/i4ing me#ication) )(c$ a) "e)e"pine- met$/#opa- o" g(anet$i#ine $a%e /a"ge/

3een "ep/ace# 3 t$e agent) #e)c"i3e# a3o%e+


Treatment in +pecial +itations

Acte Aortic Dissection

IV anti$pe"ten)i%e t"eatment )$o(/# 3e )ta"te# in t$e eme"genc #epa"tment in a// patient)

6e2cept patient) !it$ $poten)ion7 a) )oon a) t$e #iagno)i) o1 ac(te ao"tic #i))ection i)

)()pecte# 6Ta3/e


12/44

can#i#ate) 1o" eme"genc )("gica/ "epai"+ Comp/ication) o1 tpe B #i))ection)- )(c$ a)

/eakage o1 3/oo# 1"om t$e ao"ta- impai"ment o1 3/oo# 1/o! to an o"gan o" /im3- o" pe")i)tent

pain #e)pite an a#e8(ate me#ica/ "egimen a"e 3e)t t"eate# 3 )("ge"+ o(nge" patient) !it$

Ma"1an) )n#"ome ma 3ene1it 1"om )("ge" in t$e )(3ac(te p$a)e an# a%oi# "(pt("e o1 a

"e)i#(a/ )acc(/a" ane(")m in t$e 1(t("e+

Patient) !it$ (ncomp/icate# #i)ta/ #i))ection) a"e 3e)t manage# me#ica// in t$e ac(te p$a)e

!it$ anti$pe"ten)i%e t$e"ap- a) )("%i%a/ "ate i) a"o(n# ?=J !$et$e" patient) a"e t"eate#

me#ica// o" )("gica//+;*A/)o- t$e)e patient) a"e gene"a// in t$e o/#e" age g"o(p- !it$ a

$i)to" o1 ca"#iac- p(/mona"- o" "ena/ #i)ea)e)+

Hypertension After a Cerebrovasclar Accident

In $ea/t$ $(man)- ce"e3"a/ a(to"eg(/ation maintain) con)tant CBF 3et!een a mean ))temic

a"te"ia/ p"e))("e o1 > an# *. mm Hg+ Ho!e%e"- in patient) !it$ c$"onic $pe"ten)ion-

a(to"eg(/ation i) )et at a $ig$e" /e%e/ 6app"o2imate/ *. to *> mm Hg7- p"e)(ma3/ to

p"otect t$e 3"ain 1"om t$e e11ect) o1 pe")i)tent $pe"ten)ion6Fig *7+.?A1te" a )t"oke- t$e

no"ma/ mec$ani)m) o1 ce"e3"a/ a(to"eg(/ation a"e impai"e#+ Pe"1()ion in t$e i)c$emic

pen(m3"a 3ecome) p"e))("e #epen#ent+ A "i)e in ))temic a"te"ia/ p"e))("e ma 3e an

a#apti%e "e)pon)e to maintain t$e 3/oo# 1/o! to t$i) %(/ne"a3/e a"ea+ In a )e"ie) o1 ;;*=?In )t(#ie) o1 cocaine into2ication in anima/)- /a3eta/o/ inc"ea)e# )ei4("e acti%it an#

mo"ta/it+*=@*=F("t$e"mo"e- e2pe"imenta/ )t(#ie) $a%e #emon)t"ate# t$at /a3eta/o/ #oe) not

a//e%iate cocaine5in#(ce# co"ona" %a)ocon)t"iction+*>La3eta/o/ $a) 3een "epo"te# to $a%e a

$pe"ten)i%e "e)pon)e in patient) !it$ p$eoc$"omoctoma+*>*Cont"o/ o1 BP in t$e)e patient)

i) 3e)t ac$ie%e# !it$ nica"#ipine- %e"apami/- o" 1eno/#opam+*==*>.*>;P$ento/amine an#

nit"op"())i#e a"e a/te"nati%e agent)+*>=Patient) ma "e8(i"e eme"gent (/t"a1i/t"ation in o"#e" to

cont"o/ t$e BP+ Bi/ate"a/ nep$"ectom $a) 3een "epo"te# to c("e ma/ignant $pe"ten)ion in

$emo#ia/)i) patient)+*>>


Conclsion

T$e ke to t$e )(cce))1(/ management o1 patient) !it$ )e%e"e/ e/e%ate# BP i) to

#i11e"entiate $pe"ten)i%e c"i)e) 1"om $pe"ten)i%e ("gencie)+ Patient) !it$ $pe"ten)i%e

("gencie) $a%e )e%e"e $pe"ten)ion 6#ia)to/ic G ** mm Hg7- 3(t !it$o(t c/inica/ e%i#ence o1

ac(te en#5o"gan #amage+ Rapi# anti$pe"ten)i%e t$e"ap i) not !a""ante# in t$e)e patient)+

Hpe"ten)i%e c"i)e) con)tit(te a #i)tinct g"o(p o1 c/inicopat$o/ogic entitie) a))ociate# !it$ac(te ta"get o"gan in("+ T$e)e patient) "e8(i"e imme#iate BP "e#(ction to p"e%ent

p"og"e))i%e en#5o"gan #amage+ Hpe"ten)ion a))ociate# !it$ ce"e3"a/ in1a"ction o"

int"ace"e3"a/ $emo""$age on/ "a"e/ "e8(i"e) t"eatment+ Patient) !it$ $pe"ten)i%e c"i)e) a"e

3e)t t"eate# in an ICU !it$ tit"ata3/e IV $poten)i%e agent)+ Se%e"a/ "api#5acting IV

anti$pe"ten)i%e agent) a"e a%ai/a3/e- inc/(#ing /a3eta/o/- e)mo/o/- 1eno/#opam- nica"#ipine-

an# )o#i(m nit"op"())i#e+ 9$i/e nit"op"())i#e i) common/ ()e# to t"eat )e%e"e $pe"ten)ion-

it i) an e2t"eme/ to2ic #"(g t$at )$o(/# 3e ()e# on/ in "a"e ci"c(m)tance)+


Vie! t$i) ta3/e

In t$i) !in#o!

In a ne! !in#o!

Ta3/e *+

C/a))i1ication o1 P"eec/amp)ia

Vie! t$i) ta3/e

In t$i) !in#o!

In a ne! !in#o!
http://www.chestjournal.org/content/118/1/214/T1.expansion.htmlhttp://www.chestjournal.org/content/118/1/214/T1.expansion.htmlhttp://www.chestjournal.org/content/118/1/214/T2.expansion.htmlhttp://www.chestjournal.org/content/118/1/214/T2.expansion.htmlhttp://www.chestjournal.org/content/118/1/214/T1.expansion.htmlhttp://www.chestjournal.org/content/118/1/214/T1.expansion.htmlhttp://www.chestjournal.org/content/118/1/214/T2.expansion.htmlhttp://www.chestjournal.org/content/118/1/214/T2.expansion.html


15/44

Ta3/e .+

Hpe"ten)i%e Eme"gencie)

Vie! /a"ge" %e")ion

In t$i) page

In a ne! !in#o!

Do!n/oa# a) Po!e"Point S/i#e

Fig("e *+

Ce"e3"a/ a(to"eg(/ation in no"ma/ an# $pe"ten)i%e patient)+

Vie! t$i) ta3/e

In t$i) !in#o!

In a ne! !in#o!

Ta3/e ;+

Do)age) o1 IV Anti$pe"ten)i%e Me#ication)

Vie! t$i) ta3/e

In t$i) !in#o!

In a ne! !in#o!

Ta3/e


16/44

o Recei%e# ,(/ - *+

P"e%io() Section

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17/44

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18/44

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19/44

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Co$n LH+ Ao"tic #i))ection ne! a)pect) o1 #iagno)i) an# t"eatment+ Ho)p P"act 6O11

E#7 *


21/44

C"o))Re1Me#/ine

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22/44

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