HYPERTENSIVE CRISES Mini-Lecture
Objectives: • Define the various types of hypertensive crises • Recognize signs and symptoms associated with hypertensive crises • Treatment options
Clinical Vignette • 65 y/o M with past medical history of Type II DM (on oral hypoglycemics), presenting with headache, chest pain and shortness of breath that developed after lunch the day of admission; non-exertional; no alleviating factors. • Physical Exam: • Vitals: 37.3, 195/125, 92, 24, 93% on RA • HEENT: Decreased A:V on retinal exam (<25%) • Heart: S4 heard on exam, no m/r/g • Lungs: mild resp distress, otherwise clear to auscultation What’s the diagnosis and next best step in management?
Definitions: • Hypertension: • Stage I: 140-159/90-99 • Stage II: >160/100 • Hypertensive Urgency: • Systolic BP >180 or Diastolic BP >120 in the absence of end-organ damage
Definitions Continued: • Hypertensive Emergencies: • SBP >180 OR DBP>120 in the presence of end-organ damage • Malignant Hypertension: End-organ damage--eyes, kidneys, brain (hemorrhage/infarct) affected • Hypertensive encephalopathy: Cerebral edema leading to neurological symptoms
Signs and Symptoms: • Hypertensive Urgency: • Can be completely asymptomatic • Some symptoms include: • Severe headache • Shortness of breath • Nosebleeds • Severe anxiety • Signs: • Elevated BP on consecutive readings
S&S Continued • Hypertensive Emergencies • Symptoms: • nausea, vomiting (cerebral edema) • Chest Pain • SOB • Blurry vision • Confusion • Loss of consciousness
Signs: • Retinal hemorrhages, exudates, or papilledema • Renal involvement (malignant nephrosclerosis) with AKI, proteinuria, hematuria • Cerebral edema seizures and coma • Pulmonary Edema • Myocardial Infarction • Hemorrhagic Stroke, lacunar infarcts
Treatment Options • Hypertensive Urgency: • Goal: Reduce BP to <160/100 over several hours to day • Elderly at high risk of ischemia from rapid reduction of BP, therefore slower reduction in BP in this patient population • Previously treated hypertension: • Increase dose of existing med or add another med • Reinstitution of med in non-compliant patients
Treatment continued • Hypertensive Urgency continued: • Previously untreated hypertension: • Slow reduction of BP (one to two days): Amlodipine, Metoprolol XL, lisinopril (po anti-hypertensives usually enough) • Experts recommend: Initiate two agents or a combination agent (one being a thiazide diuretic) • Rationale: Most patients with BP >20/10 above goal will require two agents to control their BP
Treatment Continued • Hypertensive Emergency: • Goal: Lower Diastolic BP to approximately 100-105 over 2-6 hours; max initial fall not to exceed 25% • More aggressive decrease can lead to ischemic stroke and myocardial ischemia • If focal neurological sx presentobtain MRI to r/o acute stroke (rapid BP correction contraindicated) • Parenteral antihypertensives (IV Drip) recommended over oral agents in hypertensive emergency
Treatment • Recommended parenteral antihypertensive agents (IV drip) for Hypertensive Emergencies and admission to ICU • Nitroprusside (cautious about cyanide toxicity), Nicardipine, and Labetalol. • Once BP controlled, switch to oral anti-hypertensives and follow-up closely
Clinical Vignette Revisited • 65 y/o M with past medical history of Type II DM (on oral hypoglycemics), presenting with headache, chest pain and shortness of breath that developed after lunch the day of admission; non-exertional; no alleviating factors. • Physical Exam: • Vitals: 37.3, 195/125, 92, 24, 93% on RA • HEENT: Decreased A:V on retinal exam (<25%) • Heart: S4 heard on exam, no m/r/g • Lungs: mild resp distress, otherwise clear to auscultation What’s the diagnosis and next best step in management?
Summary • Hypertensive Crises are common • Differentiate Hypertensive Urgency from Emergency on the basis of end-organ damage • Can treat hypertensive urgency with oral antihypertensives, but parenteral medications required for hypertensive emergencies • 25% reduction in diastolic BP over 2-6 hours for hypertensive emergencies • Don’t forget to start Oral antihypertensives and follow-up closely!