William B. Felegi, DO, FACEP Emergency Department Patient Hypertensive Emergencies: What treatment...

William B. Felegi, DO, FACEP

Emergency Department Emergency Department Patient Hypertensive Patient Hypertensive

Emergencies:Emergencies: What treatment strategies do What treatment strategies do we as emergency physicians we as emergency physicians

utilize in the ED?utilize in the ED?


2007 EMA Advanced Emergency & Acute Care

Medicine Conference

Atlantic City, NJAtlantic City, NJSeptember 24, 2007September 24, 2007



Vice Chairman

Department of Emergency MedicineMorristown Memorial Hospital

Morristown, NJ


DisclosuresDisclosures• NoneNone


Global ObjectivesGlobal Objectives

• Maximize patient outcomeMaximize patient outcome• Utilize health care resources wellUtilize health care resources well

• Optimize evidence-based medicineOptimize evidence-based medicine• Enhance ED practiceEnhance ED practice


Sessions ObjectivesSessions Objectives• What are HTN emergencies?What are HTN emergencies?• What is the pathophysiology of HTN What is the pathophysiology of HTN

emergencies?emergencies?• How to we identify HTN emergencies and How to we identify HTN emergencies and

in what clinical settings?in what clinical settings?• What tests are useful for identifying & What tests are useful for identifying &

treating HTN emergencies?treating HTN emergencies?• What are management principles?What are management principles?


Hypertensive EmergencyHypertensive EmergencyKey ConceptsKey Concepts

• Clinical Syndrome” rapidly progressive Clinical Syndrome” rapidly progressive end-organ damage with significant end-organ damage with significant elevation of BPelevation of BP

• Goal to reduce Mortality (90%)Goal to reduce Mortality (90%)• Emergencies assoc with DBP > 120Emergencies assoc with DBP > 120• CAVEATCAVEAT: Severe HTN : Severe HTN ≠≠ HTN Emergency HTN Emergency• Minority of patients will require Minority of patients will require intensive intensive

treatmenttreatment


Hypertension DemographicsHypertension DemographicsKey ConceptsKey Concepts

• HTN most common primary diagnosisHTN most common primary diagnosis• 25% of population25% of population• 30% of patients unaware30% of patients unaware• Control rates < 50%Control rates < 50%• > 50 years of age, SBP > 140 mm Hg more > 50 years of age, SBP > 140 mm Hg more

important CVD Risk factor than DBPimportant CVD Risk factor than DBP• Risk of CVD begins at 115/74 mm Hg & Risk of CVD begins at 115/74 mm Hg & doubles doubles

with each increment of with each increment of 20/10 mm Hg20/10 mm Hg


PathophysiologyPathophysiologyKey ConceptsKey Concepts

• Failure of normal autoregulatory functionFailure of normal autoregulatory function• Abrupt increase in systemic vascular Abrupt increase in systemic vascular

resistanceresistance• Concurrent endovascular injury with Concurrent endovascular injury with

fibrinoid necrosis of arteriolesfibrinoid necrosis of arterioles



• Cycle of ischemia, platelet deposition and Cycle of ischemia, platelet deposition and further autoregulatory failure with further autoregulatory failure with release of vasoactive substancesrelease of vasoactive substances

• Specific triggers UNKNOWNSpecific triggers UNKNOWN• TX GOAL – Mitigate damage to whichever TX GOAL – Mitigate damage to whichever

organ system is manifesting the organ system is manifesting the most most diseasedisease



• Normal conditions tissue perfusion Normal conditions tissue perfusion remains relatively constant, despite remains relatively constant, despite normal BP fluctuationsnormal BP fluctuations

• With severe HTN, ability to autoregulate With severe HTN, ability to autoregulate shifts upward – protect exposed organshifts upward – protect exposed organ

• Lower threshold of autoregulation Lower threshold of autoregulation (threshold for hypoperfusion) 20 – 25% (threshold for hypoperfusion) 20 – 25% lower than prevailing BPlower than prevailing BP


Hypertensive EmergencyHypertensive EmergencyDefinitions DBP > 120 mm HgDefinitions DBP > 120 mm Hg

• CrisisCrisis - suggests need for immediate - suggests need for immediate intervention, perhaps de-emphasizing intervention, perhaps de-emphasizing the the termterm

• EmergencyEmergency – acute & rapidly evolving end – acute & rapidly evolving end organ damage, control of BP in hours organ damage, control of BP in hours with with admission to critical careadmission to critical care

• UrgencyUrgency – requires improvement in BP – requires improvement in BP control over 24 – 48 hours, absence of control over 24 – 48 hours, absence of end-end-organ damage, little evidence of organ damage, little evidence of clinical benefitclinical benefit


ED Hypertensive Emergencies ED Hypertensive Emergencies Key ConceptsKey Concepts

• Verify hypertensive emergency

• Assess for end organ damage

• Make clinical diagnoses

• Determine need for therapies

• Establish endpoint for Rx success

• Reassess end organ dysfunction

• Disposition based on Dx, Rx, risk



• Verify hypertensive emergency

• 2 readings 5 minutes apart (seated)

• Recheck BP yourself

• Check manually as needed

• Calculate MAP

• Determine baseline chronic BP



• Assess for end organ damage

• CNS: Encephalopathy, ischemia, ICH

• Cardiopulmonary: ACS, AMI, edema

• Vascular: Aortic dissection, aneurysm

• Renal failure or insufficiency

• Gastrointestinal ischemia

• Pregnancy induced HTN


Pt Case Presentation

• 55 yo white male • Sudden onset “bad” headache • BP 180/120, P-100, R -16, T-37• PMH – “Slightly elevated BP”• Medications - None



• Make clinical diagnoses

• Related to symptoms

• Related to hypertension

• Related to anatomic lesions

• Related to dysfunction



• Determine need for therapies

• BP trend

• Baseline BP

• Diagnosis and end organ damage

• Risk and benefit


Pt Case PresentationPt Case Presentation

• 62 yo black female62 yo black female• Twisted her ankleTwisted her ankle• BP – 170/120, P-90, R-14, T-37BP – 170/120, P-90, R-14, T-37• PMH – AsthmaPMH – Asthma• Medications – Inhaler PRNMedications – Inhaler PRN• No routine medical careNo routine medical care



• Address the issue of urgency – Address the issue of urgency – identification doubtful (helps for choice identification doubtful (helps for choice of drug)of drug)

• EKGEKG• UrinalysisUrinalysis• Blood SugarBlood Sugar• HCTHCT• Serum K+, Creatinine (GFR), CalciumSerum K+, Creatinine (GFR), Calcium


Appropriate Follow-up Asymptomatic Appropriate Follow-up Asymptomatic Patients Without Major End-Organ DamagePatients Without Major End-Organ Damage

BP (mm Hg)BP (mm Hg) Follow upFollow up

140-159/90-99140-159/90-99 Observe, confirm within 2 moObserve, confirm within 2 mo

160-179/100-109160-179/100-109 Confirm & treat within 1 moConfirm & treat within 1 mo

180-209/110-119180-209/110-119 Confirm & treat within 1 Confirm & treat within 1 weekweek

210+/120+210+/120+ Confirm, evaluate & begin Confirm, evaluate & begin TxTx

Data from National Heart, Lung, & Blood Institutes, JNC VIIData from National Heart, Lung, & Blood Institutes, JNC VII


ConclusionsConclusions

• Remember to Tx patients, not numbers

• Treatment goal is long-term control

• Symptoms, HTN, anatomic lesions, physiologic dysfunction

• Blood pressure control critical

• Optimal Rx limits complications, enhances patient outcomes


Questions?Questions?

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William B. Felegi, DO, FACEP Emergency Department Patient Hypertensive Emergencies: What treatment...

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