Hypertensive Crises Diagnosis and Treatment

2. Hypertensive Crises Diagnosis and Treatment

3. Hypertensive Crises • Severely elevated(BP>220/130mmhg) blood pressure with signs and symptoms of acute end organ damage • Requires hospitalization • Requires parenteral medication

4. Hypertensive Urgency • Severely elevated blood pressure(BP>=220/130 mmhg) without signs and symptoms of acute end organ damage • Can be managed as an outpatient • Can be managed with short acting oral medications

5. Severe Hypertension • BP 180/110 to 220/130 without symptoms or acute organ damage • Almost always occur in chronic HTN patients who stop their medication • Treat with long acting oral drugs

6. Hypertensive Crises CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy Heart - CHF, MI, angina • Damage Kidneys - acute kidney injury, microscopic hematuria Vasculature - aortic dissection, eclampsia Vasculature

7. Epidemiology • Hypertensive emergencies are common • Occur in 1-2% of the hypertensive population • But, 50 million hypertensive Americans • 500,000 hypertensive emergencies/year • Higher in the elderly • Incidence in men 2 times higher than in women

8. Initial Evaluation • Assess for end-organ damage • Vascular Disease • Assess pulses in all extremities • Auscultate over renal arteries for bruits • Cardiopulmonary • Listen for rales (CHF) • Murmurs or gallops

9. Initial Evaluation • Neurologic Exam • Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures • Lateralizing signs uncommon and suggest cerebrovascular accident • Retinal Exam

10. Retinopathy Grading • Grade 1 • Mild narrowing of the arterioles • “Copper Wire” • Grade 2 • Moderate narrowing - Copper wire and AV nicking

11. Retinopathy Grading • Grade 3 • Severe Narrowing - Silver wire changes, hemorrhage, cotton wool spots, hard exudates • Grade 4 • Grade 3 + Papilledema • Grade 3 and 4 highly correlated with progression to end organ damage and decreased survival

12. Normal

13. Grade 1

15. Grade 3 Retinopathy

17. Lab Testing • ECG • LVH, look for signs of ischemia, injury, infarct • Renal Function Tests (urine included) • Elevated BUN, Creatinine, proteinuria, hematuria • CBC • CXR - pulmonary edema, aortic arch, cardiac enlargement

18. Lab Testing • Aortic Dissection? • Suspect with severe tearing chest pain, unequal pulses, widened mediastinum • Contrast Chest CT Scan or MRI • Pulmonary Edema/CHF • Transthoracic Echocardiogram

19. Cerebral Blood Flow Autoregulation • Cerebral Blood Flow Autoregulation • Cerebral Blood constant in normotensive individuals over range of MAPs of 60 -120 mm Hg. • In chronically hypertensive patients autoregulatory range is higher • MAP Range 100-120 to 150-160 mm Hg • Autoregulation also impaired in the elderly and those with cerebrovascular disease

20. Management • Hypertensive Crises(elevated BP with target organ damage) • Parenteral meds • Goal - Reduce diastolic BP by 10-15% or to 110 mm Hg over a period of 30 - 60 minutes

21. Management • Where? • ICU with close monitoring • Severe requires intra-arterial BP monitoring • Which Parenteral meds? • Depends on the situation

22. Sodium nitroprusside • Disadvantages of sodium nitroprusside • Decrease cerebral blood flow and increases intracranial pressure • Can reduce regional blood flow in coronary artery disease • Risk of cyanide toxicity • Use when other agents not effective • Monitor thiocyanate levels • Avoid in renal or hepatic dysfunction • Choice in Aortic Dissection,CHF • 0.3-10 microgm/kg/min

23. Urapidil • New central sympatholytic drug • Selective alpha -1 receptor blocks • Dose12.5-25 mg /kg bolus and 5-40 mg/hr iv infusion • Choice in HTN after CABG&After craniotomy

24. Labetalol • Alpha&Beta Blocker(Beta>Alpha) • Choice in Hypertensive encephalopathy,Ischemic&Hemorrhagic Stroke,Severe preeclampsia/eclampsia,Aortic Dissection • 2-4 mg/min

25. Management • HTN crises with advanced retinopathy without reduction of consciousness(labetalol,nitroprusside,urapidil,nicardipine) • HTN crises with encephalopathyBrain edema(posterior region)+ reduce of consciousness(10% reduction of BP in first hour and 15% in next 12 hours to 160/110

26. Management • HTN crises with acute or hemorrhagic stroke • With thrombolytic therapyBP <185/110 • Without thrombolytic therapy15% reduction in BP • In hemorrhagic strokeSBP<180 • Urapidil,nicardipine,labetalol • Avoid of nitroprusside ,hydralazine

27. Management • Acute coronary syndrome • TNG +IV motoral or esmolol • Labetalol or urapidil • Nitroprusside is cotraindicated • Acute heart failure Nitroprusside is choice(+Lasix)

28. Management • Adernergic crisis(pheochromocytomaphentolamine+beta blocker or nitroprusside ,urapidil • Clonidine withdrawal clonidine • Cocaine or methamphetamine- induced HTN benzodiazepine +phentolamine

29. Aortic Dissection • Standard therapy • Beta-adrenergic blocker plus vasodilator • Esmolol + Nicardipine • Nitroprusside can be used as well

30. Management • Elevated BP without target organ damage • Hypertensive urgency • Oral meds • Goal - gradual reduction of BP over 24 - 48 hours

33. Thank you!Questions?