Acute Hypertension

1. Acute Hypertension Jay Patel, MD CR FIRM C

2. Initial Evaluation • What are the vitals? • EKG • Is this new or old? • What has the rate of increase been? • Is the patient mentating well? • Are there signs of acute end-organ damage?

3. Acute Hypertension • Is it urgent or emergent? • Urgent  SBP >180 or DBP >120 • Emergent  Urgent + End-organ damage • End-organ damage • Cardiac: pulmonary edema, ACS, aortic dissection • Renal: ARF, proteinuria, hematuria ATN • Neuro: cerebral edema, CVA, TIA, ICH • Many patients will have headache from hypertensive urgency but no other end organ damage. • Ophtho: retinal hemorrhage/exudate, papilledema

4. Acute Hypertension • Presentations c/w hypertensive emergency: • BP >180/100 • AND • Encephalopathy • Dyspnea • Chest pain

5. Things Not to miss… • Aortic Dissection • Intracranial Bleeding • Acute Coronary Syndromes

6. Treatment: Hypertensive urgency • Titrate up current medications, Q2H BP checks until <160/100 • Add rapid onset/rapid offset oral medications to assess response • Captopril: ~6.25-12.5mg • Clonidine: ~0.2mg • In this situation, try to avoid starting IV drips • DO NOT USE HYDRALAZINE • The goal is BP <160/100 in HOURS to DAYS

7. Physiology: Hypertensive Emergency • As blood pressure rises, arterial/arteriolar vasoconstriction occurs (autoregulation) to protect distal arterioles and maintain perfusion. • With increasing blood pressure, autoregulation fails. The vascular endothelium loses integrity, and plasma contents enter the vessel wall. • The vascular lumen is narrowed or obliterated, leading to ischemia.

9. Treatment: Hypertensive Emergency • Use IV bolus/drips to rapidly correct blood pressure • Labetalol: 20mg initially, with repeat boluses (20-80mg) Q10min to total 300mg. Then gtt 0.5-2mg/min. • Nitroprusside: 0.25-0.5mcg/min, titrate to goal BP with max rate 10mcg/min. • Nitroglycerin: 5-100+mcg/min. • Nicardipine: 5-15mg/hr. • DO NOT USE HYDRALAZINE • The goal is to decrease diastolic BP to 100-105mmHg with initial MAP decrease no greater than 25% in MINUTES to HOURS

10. Nitrates • Nitroglycerin • Good for pulmonary edema and angina • Preload/afterload reduction • Tachyphylaxis occurs quickly • Need high doses to reduce BP • Will cause headache • Nitroprusside • Do not use in renal failure, due to cyanide metabolite

11. Beta-blockers • Labetolol • Good for rapid onset of action (<5 minutes) • Limited by bradycardia, can cause heart block • Do not use in acute CHF • Caution with underlying COPD/Asthma

12. Calcium channel blockers • Nicardipine • Effective, use if contraindications to other agents • Do not use in acute CHF, ACS

13. Case 1 • J.B. is a 55 y.o. AAM with hx of HTN, GERD, in the ER with chest pain and dyspnea • The patient looks extremely uncomfortable but is able to answer questions appropriately… pain is 10/10 and ‘going right through’ his chest • 195/120 105 24 96% RA • What is your initial DDx?

14. Case 1 • Get BP in BOTH arms • R 190/100, L 165/95 • What therapy do you start empirically? • What imaging/labs do you want?

15. Case 1

16. Case 1

17. Case 1 • Therapy: IV labetalol and IV nitrate • Goal SBP <100, goal HR 60s • DO NOT USE HYDRALAZINE • Imaging: • Dissection protocol CT • TEE • Labs: • BMP, CBC, troponin, CK-MB, type/cross, PT, PTT • Consult vascular surgery

18. CT

19. Aortic Dissection • Types: • Type A/Proximal  ascending aorta • Type B/Distal  descending aorta only • Complications: • Valvular insufficiency • CVA/TIA • Tamponade • Renal/bowel ischemia • MI

20. Case 2 • F.M. is a 84 y.o AAF with hx of HTN, DM2, CHF, and CKD in the ER with chest pain and dyspnea • She missed several doses of medication (BB, ACE-I, CCB, ASA) while out of town at a Ham Eating Festival • 205/115 105 24 87% RA • What is your initial DDx?

21. Case 2 • Get BP in BOTH arms • R 205/110 L 210/105 • What therapy do you start empirically? • What imaging/labs do you want?

22. Case 2

23. Case 2

24. Case 2 • Therapy: IV furosemide, IV nitroglycerin, O2 • Goal: improvement in dyspnea, O2 requirement • Avoid beta-blocker in this patient • DO NOT USE HYDRALAZINE • Imaging: • CXR • Labs: • BMP, CBC, troponin, CK-MB, BNP

25. Case 3 • A.C. is a 76 y.o WF with history of HTN, DM2, CAD admitted for hypertension and headache • Initial workup including EKG, Trop, BMP, and CXR are unremarkable… The patient’s HTN remains difficult to control with oral agents. • On HD#1, you are called to see patient for “garbled speech” • What is your initial DDx?

26. Case 3 • BP 220/135 in both arms, HR 90, SaO2/RR stable • Exam notable for inability to follow commands and agitation, no cranial nerve deficits, moving all four extremities • What imaging/labs do you want?

27. Case 3

28. Case 3

29. Case 3 • Therapy: IV labetalol or nicardipine • Goal: improvement in mental status, airway protection, seizure precautions • DO NOT USE HYDRALAZINE • Imaging: • Brain MRI to follow up • Labs: • BMP, CBC, troponin, CK-MB

30. RPLE/RPLS/PRES • Results from disordered cerebral autoregulation, endothelial dysfunction, and ischemia • Hypertensive encephalopathy, eclampsia, and immunosuppressive drugs (esp. cyclosporine) are associated conditions • Therapy involves control of blood pressure, removal of offending agents (delivery, cyclosporine), and management of seizures if they occur

31. CVA/Hemorrhage • Ischemic CVA: • Do not treat HTN unless BP >220/120 OR the patient has concomitant ACS, CHF, aortic dissection, eclampsia • IV labetolol is drug of choice • If lytics are being used, BP has to be <180/105 and maintained there for 24 hours post lytics • Intracranial/subarachnoid hemorrhage • Goal is SBP <200 or MAP <150, use IV labetalol • Call neurosurgery for ICP monitoring

32. Case 4 • D.Y. is a 52 y.o male with history of HTN, DM2, admitted for community acquired pneumonia • You are on night float and get a call that the patient’s BP is 175/95. • How do you approach this?

33. Case 4 • A) Review the patient’s medication list • B) Review the patient’s BP trends • C) A and B • D) Give 5mg IV hydralazine

34. Case 4 • Inpatient hypertension that is not urgent or emergent should be treated like outpatient hypertension. • Add appropriate anti-hypertensives as you would in clinic and don’t aggressively add multiple agents. • Remember, amlodipine, lisinopril, etc. often take several days to reach their effect.

35. Summary • Any patient with hypertension and chest pain or dyspnea needs blood pressure measured BY YOU in both arms. • Evaluate the hypertensive patient for signs of end-organ damage with EKG, troponin, and neurologic exam. • Hypertensive urgency: Oral medications. • Hypertensive emergency: IV medications and consider ICU transfer. • Inpatient hypertension: Treat like you would in clinic.

36. Why Hydralazine is Terrible • Reflex tachycardia can increase myocardial oxygen demand and cause ischemia in patients with CAD. • Unpredictable hypotension can ensue, especially in patient with pulmonary hypertension. • Patient with low GFR may have several dips in blood pressure, resulting in drug stacking—hydralazine is renally cleared. • Drug-induced lupus and neuropathy are long-term risks, but those with HLA-DR4 genotype may be at risk with IV dosing.