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Hypertensive Emergencies

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karl
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Hypertensive Emergencies. Jason R. Frank MD MA(Ed) FRCPC Department of Emergency Medicine. HTN – What’s the Big Deal?. KEY objectives: Differentiate malignant HTN from secondary conditions Conduct initial HTN lowering treatment. OBJECTIVES:

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Hypertensive Emergencies
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  1. Hypertensive Emergencies Jason R. Frank MD MA(Ed) FRCPC Department of Emergency Medicine

  2. HTN – What’s the Big Deal?

  3. KEY objectives: Differentiate malignant HTN from secondary conditions Conduct initial HTN lowering treatment OBJECTIVES: Differentiate non-localizing neurologic symptoms Determine presence of other hypertensive emergencies Interpret clinical & lab findings Conduct an effective management plan, including specific Rx MCC OBJECTIVES – HTN EM

  4. Case 1 • 50 woman sent in by community MD & pharmacist for “HTN emergency” • Pharmacy BP = 190/90 • Extremely worried, otherwise well • Q: What is the clinical definition of HTN?

  5. Case 2 • 65 male drove in from cottage • Feeling unwell • Flagged at triage with BP 200/100 • Forgot BP meds at home…missed 3 days • Q: What is a “hypertensive urgency”?

  6. Case 3 • 72 male with chronic HTN, PAFib, and arthritis. • Referred to CDU with elev BP “for observation”. • 180/115 at rest • Progressive SOB over the am. • Q: What is the definition of a “hypertensive emergency”?

  7. Case 4 • 45 CEO of an IT firm • Presents with cp, SOB, intense anxiety • Sweating, tacky, BP 200/120 • Admits to cocaine • Q: Management?

  8. Case 5 • 33 F 1 week post-partum • Epigastric pain • Seizure • BP 160/95, P90, T37.2 • Q: Dx? Management?

  9. Case 6 • 60 M presents with tearing RSCP • Rad to back • Assoc with L headache and R leg weakness • BP 190/100, P 95 • Q. Management?

  10. This Session: HTN EM • Define HTN • Classify HTN • Provide a DDx for the acutely hypertensive patient, including 2ndary causes • Describe the findings of a patient with a HTN emergency • Describe high-utility tests for HTN EM • Describe the management of each of the categories of HTN • Describe at least 2 controversies in the management of HTN EM

  11. HYPERTENSION Standard Definition • Based on 3 measurements, each 1 wk apart > 140 systolic > 90 diastolic • Most important #: Diastolic • MAP = 1/3 Systolic, 2/3 Diastolic

  12. Define HTN? Joint National Commission VIVII 2003 “Pre-HTN”

  13. HTN Defined:

  14. Primary or Secondary • Majority (90-95%) essential HTN • Of Secondary: ½ have a potentially curable cause

  15. HTN in the Population vs the ED?

  16. HTN in the Population vs the ED? • Primary HTN • Chronic • “Essential” • >95% • >25% of NA pop’n • 50% adhere to Rx • 75% not optimal • More un-Dx • Pre-HTN

  17. Thinking about a HTN Definitions: • Pre-HTN……………........ • Primary chronic…………. • Transient ……………….. • Secondary………………. • “Tertiary” ...……………… • Malignant…………......... • Also: accelerated, severe, crisis, etc • 130-139/80-89 • >140/90 • white coat, anxiety, pain, etc • Pathologic organ cause • Iatrogenic, ingestion, withdrawal, etc • Bad (enceph & retinal)

  18. HTN in the ED – a Taxonomy • Transient HTN • Chronic HTN • HTN Urgency • HTN Emergency • HTN-associated Crisis

  19. Transient HTN - Examples • Anxiety • Pain • EtOH-withdrawal • White-coat

  20. HTN “Urgency” • HTN “threatening” end organ damage • “End organs at risk” • Various definitions: DBP>110, DBP>115, DBP>120 • Goal: lower BP over hours; rarely requires treatment • Concern: bogus category, may lead to harm (eg CVAs) -see Gallagher 2003

  21. Malignant Hypertension Severe HTN & Evidence of acute end-organ damage • Diastolic BP usually > 130 mm Hg or MAP > 160 • Relative rise much more important than # • Affects 1% of hypertensive patients

  22. MAP is What Matters: • At normal resting heart rates MAP can be approximated using the more easily measured systolic and diastolic pressures, SP and DP • or equivalently • or equivalently • where PP is the pulse pressure: SP − DP -Wikipedia

  23. “The Delta Diastolic Threatens Death” The change in DBP accounts for most of the change in MAP “∆ DBP is where it is at” (for the ED setting)

  24. Hypertensive Emergency? Volhard & Fahr, 1914

  25. HTN Emergency Acute elevation in MAP causing end organ damage: • ARF • CHF, ACS • Encephalopathy (>160 MAP) • CVA, ICH • Hemolysis • Retinal • All have DBP >120 …Mortality ~90% historically

  26. HTN Emergency – Organ Incidence? Acute elevation in MAP causing end organ damage: • CVA (24.5%) • CHF (22.5%) • Encephalopathy (16.3%) • ACS (12%) • ICH (4.5%) • ARF (?) • Hemolysis (?) • Retinal (?) From Zampaglione, 1996

  27. HTN Emergency Pathophysiology: • Failure of autoreg • Rapid rise in SVR • Endothelial injury • Arteriolar necrosis • Ischemia • …Cascade

  28. Secondary HTN DDx

  29. Increased CO RF with fluid overload Acute renal disease Hyperaldosteronism Cushing’s syndrome Coarctation of the Aorta Increased vascular resistance Renal Artery Stenosis Pheochromocytoma Drugs Cerebrovascular (CVA, ICH, SAH) Secondary HTN

  30. Renal Artery Stenosis • most common treatable cause (1-5%) • compromised renal perfusion => activation of RAA • 2 pt groups: • Elderly with atherosclerotic disease • Young females with fibromuscular dysplasia • Clinical: abdo bruit (40-80%), retinopathy, HTN resistant to Rx, hypoK

  31. Aldosteronism • Uncommon but treatable • Na retention, volume expansion, increased CO • Hypernatremia & Hypokalemia typical • Primary: Adrenal adenoma, hyperplasia • Secondary: Cushing’s, CAH, exogenous mineralcorticoids

  32. Pheochromocytoma • Tumour, usually in adrenal medulla • Produces xs catecholamines (epi, NE) • Paroxysmal HTN…difficult to recognize • Episodic HTN, HA, palpitations, diaphoresis, anxiety…not a panic attack! • Easy to diagnose: elevated urinary catecholamines, metanephrines, vandillylmandelic acid

  33. Coarctation of the Aorta • Rare but early surgical intervention can improve prognosis • Clinical triad: • upper extremity HTN • systolic murmur over back • delayed femoral pulses

  34. Drugs • Cocaine, amphetamines • ETOH withdrawal • Withdrawal from clonidine, beta blocker • MAOI + tyramine containing foods or certain Rx (meperidine, TCA, ephedrine) • Tyramine causes release of NE • Usually rapidly destroyed by MAO

  35. Secondary HTN • Neuro: • Autonomic dysfunction (eg GBS, cord injuries) • CNS insult (HI, ICH) • Renal: • Renovascular stenosis • Renal disease (eg GN, Chronic pyelo) • Endocrine: • Pituitary tumours / ectopic ACTH • Pheochromocytoma; renin tumours; Hyperaldosteronism (egCushings) • Hyper & hypo thyroid & thyroid storm • Vascular: • Coarctation of the Ao • Vasculitis; Collagen-vascular (eg Scleroderma) • Pre-/Eclampsia • Sleep apnea

  36. Iatrogenic / Lifestyle HTN (aka “tertiary”) Too Much: Too Little: Clonidine withdrawal Anti-HTN withdrawal EtOH withdrawal • Tyramine-MAOI • Glucocorticoids • Thyroxine • Fluid overload • NSAIDS • Sympathomimetics

  37. HTN – associated Crisis • HTN is a critical issue relating to an emergency Dx: • Aortic Dissection • Pre/Eclampsia • ICH • CVA • Cocaine

  38. HTN in the ED – a Taxonomy 2 • Pre-HTN • Chronic HTN • Transient HTN • HTN Emergency • HTN-associated Crisis • 1’, 2’, 3’

  39. Case 1 • 50 yo woman sent in by community MD & pharmacist for “HTN emergency” • Pharmacy BP = 190/90 • Extremely worried, otherwise well

  40. Case 2 • 65 male drove in from cottage • Feeling unwell • Flagged at triage with BP 200/100 • Forgot BP meds at home…missed 3 days

  41. Case 3 • 72 yo male with chronic HTN, PAFib, and arthritis. • Referred to CDU with elev BP “for observation”. • 180/115 at rest • Progressive SOB over the am.

  42. DDx for the ED Hypertensive Patient • Transient: pain, anxiety, sympathetic outflow • Chronic essential: poorly controlled • Chronic secondary: renovasc, pyelo, GN, pituitary, thyroid • Iatrogenic: fluid overload, pressors • OD/Ingestion: tyramine-MAOI, cocaine, amphetamines, • HTN-associated crises: Ao dissection, PIH, ICH, CVA, etc • HTN emergencies: CNS, ACS, CHF, retinal, RBCs

  43. Assessment of the ED Hypertensive Pt?

  44. Assessing the HTN Patient in the ED: • Hx HTN & Tx • Rx use • PMHx • Symptoms of end-organ damage • Pain • Confirm BP • Good BP reading • End-organ damage • Heart sounds • Pulses • Fundoscopy

  45. ED HTN Testing?

  46. Testing for ED HTN: • CBC, 7 • EKG • CXR • Urine • CT head prn r/o HTN emergency

  47. ED HTN Management

  48. HTN Management by Category: • Pre-HTN……………… • Chronic HTN…………. • Transient HTN……….. • HTN Emergency…...... • HTN-associated Crisis. • Advise • Advise, note, po Rx prn • Assess, observe, benzo prn • Assess, lower 20% ~1 hour • Dx-specific tx

  49. Anti-HTN agents in ED: Rosen

  50. Key Agents for Canadian EM Practice: • Metoprolol • Labetolol • Nitroglycerine Also: • Nitroprusside • Magnesium • Esmolol • Phentolamine • Ramipril • 25-100 po; 5 – 20 IV • 20 mg bolus IV to max 300 mg • 5-100 ug/min • 0.25-10 ug/kg/min [Lancet, 1949] • 2-6g, then 2g/hr infusion • Load 500ug/kg/ 1min, then 50ug/kg/min, titrate • 5-10 mg/min • 2.5-5 mg po