1. Management of Hypertensive Emergencies Dr. Abdulkareem Alsuwiada, FRCPC, MSc

2. Learning Objectives • To identify and triage severe hypertensive states accurately • To effectively manage hypertensive crises with drug therapy

3. Hypertensive Urgency • “Severe elevation of blood pressure” • Generally DBP >115-130 • No progressive end organ damage

4. Hypertensive Emergency • Hypertensive Emergency: Severe elevation in blood pressure in the presence of acute or ongoing end-organ damage.

5. “Recognition of hypertensive emergency depends on the clinical state of the patient, not on the absolute level of blood pressure”

6. Target Organs

7. Hypertensive Emergency Key Points • Cardiac Emergencies • Acute CHF • Acute coronary insufficiency • Aortic dissection

8. Hypertensive Emergency Key Points • CNS Emergencies • Hypertensive encephalopathy • Intracerebral or subarachnoidal hemorrhage • Thrombotic brain infarction with severe HTN

9. Hypertensive Emergency Key Points • Renal Emergencies • Rapidly progressive renal failure

10. Fundoscopy/ Neuro • Hemorrhages • Exudates • Papillodema

11. Urgency vs. Emergency • Distinguishing between hypertensive emergency and urgency is a crucial step in appropriate management

12. Urgency vs. Emergency • Urgency • No need to acutely lower blood pressure • May be harmful to rapidly lower blood pressure • Death not imminent • Emergency • Immediate control of BP essential • Irreversible end organ damage or death within hours

13. Approach to Patients

14. Approach to patients • Recheck blood pressure! • Appropriate size cuff • Cuff not over clothing • Check in all limbs • History • Prior crises • Renal disease • Medications • Compliance • Recreational drugs

15. Approach to patients • Physical Exam • Signs of end organ damage?

16. Neuro • Hypertensive encephalopathy • Severe Headache • Nausea/Vomiting • Papilledema • Visual Changes • Seizures • Focal Neurological Deficits • Ischemic vs hemorrhagic CVA

17. Fundoscopy/ Neuro

18. Cardiac • Cardiac ischemia • Chest pain • EKG for ischemic changes • Acute left ventricular failure • Pulmonary edema • Hypoxia • EKG for left ventricular strain pattern • CXR

19. Renal • Electrolytes • BUN/Cr • Chronic failure/insufficiency vs acute failure • Cause vs effect • UA with micro • Protein • Blood • Casts

20. Major Causes of Hypertensive Emergencies and Urgencies • Untreated essential hypertension • Withdrawal / non-adherence to antihypertensive drug therapy • Development of secondary hypertension

21. Major Causes of Hypertensive Emergencies and Urgencies • Renal Disease • Renal artery stenosis • Pregnancy • Endorine • Pheochromocytoma • Primary aldosteronism • Glucocorticoid excess • Renin-secreting tumors

22. Pathogenesis for Hypertension • Arterial and arteriolar vasoconstriction • Prevents the increase in pressure from being transmitted to the smaller, more distal vessels • With increasingly severe hypertension • Autoregulation failure • Vascular endothelial injury • Plasma constituents (including fibrinoid material) to enter the vascular wall • narrowing or obliterating the vascular lumen. • Tissue edema and activation of endothelial vasoactive system

23. Goals of Treatment

24. Goals of Treatment • Prevent end organ damage • NOT normalize BP • Exceptions??

25. HTN Urgencies: Goals of Therapy • No proven benefit of rapid BP reduction in asymptomatic patients • Goal BP <160/110 mm Hg over several hours, oral therapy • Initial BP fall less than 25% in first six hours • can be managed using oral antihypertensive agents in an outpatient or same-day observational setting • Ensure follow-up: Long-term management

26. HTN Urgencies: Therapy • Captopril , 25-mg oral dose initially, followed by incremental doses of 50 to 100 mg 90 to 120 min later • The calcium channel blocker nicardipine, 30 mg, q 8 hours until the target BP • Labetolol, the starting dose is 200 mg orally, which can be repeated every 3 to 4 hours • Clonidine is a central sympatholytic a 0.1 to 0.2 mg loading dose followed by 0.05 to 0.1 mg every hour until target BP is achieved (Max 0.7 mg).

27. Hypertensive Emergency • ICU with close monitoring • IV and Short acting medications • Avoid sublingual or IM • Arterial line

28. Goals of Treatment • Within 1-2 hrs • Lower MAP 20-25% • CONTROLLED • IV titratable meds

29. Complications for rapid BP Reduction in Severe Hypertension • Widening Neurologic Deficits • Retinal ischemia and Blindness • Acute MI • Deteriorating renal function

30. Goals of Treatment WHY ?

31. Cerebral Autoregulation • Strandgaard, et al. BMJ: 1973 Cerebral blood flow 60 mmHg 120 mmHg 160 mmHg MAP Adapted from: Chest, 2000; 118:214-227

32. Pharmacotherapy

33. Given by continuous infusion Antihypertensive Drugs for Hypertensive Crisis • Sodium nitroprusside • Nitroglycerin • Nicardipine • Labetalol • Esmolol • Fenoldapam

34. Specific Treatment

35. Hypertensive Encephalopathy • Nitroprusside • Fenoldopam • Nicardipine • Labetolol • Symptoms of encephalopathy should improve with treatment

36. CVA • Nicardipine • Labetolol • Fenoldopam • Decrease DBP no more than 20% in 24hrs

37. Cardiac Ischemia • Nitroglycerine • Nitroprusside • Fenoldopam • Nifedipine • Reflex tachy • Increases myocardial O2 demand • May aggravate ischemia

38. Acute LVF • Nitroprusside • Afterload reduction • Fenoldopam • Nitroglycerine • If ischemia is suspected • Furosemide • Loop diuretic • Opioids

39. Acute Aortic Dissection • Nitroprusside • Nicardipine, Fenoldopam • Afterload reduction • Increases ventricular contraction velocity • Requires B blockade • Esmolol, metoprolol • Labetolol • Goal: SBP ~100 mmHg • Monitor patient closely

40. Acute Aortic Dissection • β-block FIRST! • Esmolol • Metoprolol

41. Sympathetic Crisis • Nicardipine • Nitroprusside • Phentolamine

42. Acute Renal Failure • Nicardipine • Nitroprusside • “Use with caution” • toxic metabolites... • Thiocyanate excreted via kidneys • Fenoldopam • Labetolol

43. Eclampsia • Hydralazine • Used historically • Arterial vasodilator • Maintains placental blood flow • Nicardipine • Labetolol • Magnesium

44. The Discharged Patient

45. The discharged patient • JNC-VII Recommendations • Stage 2 • Combination tx • Thiazide + ACEI, ARB, BB, CCB • “Compelling Indications”...

46. The discharged patient • JNC-VII Recommendations • “Compelling Indications” • URGENCY: • ALL PATIENTS WITH HTN URGENCY BEING DISCHARGED HOME SHOULD BE PLACED ON COMBINATION THERAPY AND HAVE RAPID FOLLOW UP. • THIAZIDE • ACEI / ARB / BB / CCB

47. The discharged patient Follow-up • Follow up... • Stage I: • 140-159 / or 90-99 • Stage II: • >160 / or ≥100 • “Higher”: • ≥180 / ≥110 2 Months 1 Months < 1 week

48. Goals of therapy in JNC7 & Euro Guidelines • Maximum reduction in long-term total risk of cardiovascular morbidity and mortality: • Smoking • Life style modification • Lipid • Diabetes • Blood pressure • < 140/90 • If DM or renal disease • <130/80

49. The following 5 patients in ER • Patient A is a 65-year-old man with nausea, vomiting, and confusion. • Patient B is a 73-year-old woman with sudden shortness of breath, pink sputum, and heavy chest pain. • Patient C is a 56-year-old man with sharp, tearing chest and back pain. • Patient D is a 64-year-old woman with a 6-hour history of right-sided weakness. • Patient E is a 51-year-old woman with a mild headache, concerned about her history of hypertension.

50. all 5 patients arrive with identical vital signs: BP of 209/105 mm Hg • Which of the 5 patients require emergent hypertension treatment?