8/14/2019 HT Crisis-6

1/42

8/14/2019 HT Crisis-6

2/42

A 50 year man presented to EDwith headache and BP 210/115

What is the diagnosis?

8/14/2019 HT Crisis-6

3/42

A 25 year pregnant lady,presented to ED with one attack

of fits, and BP 160/90

What is the diagnosis?

8/14/2019 HT Crisis-6

4/42

A 60 year old man presentedto ED, with weakness of his

upper limb, and BP 200/100,with evidence of infarction onCT.

What is the management?

8/14/2019 HT Crisis-6

5/42

HYPERTENSIVE CRISES

8/14/2019 HT Crisis-6

6/42

HYPERTENSIVE CRISES

Hypertensive Emergency

Hypertensive Urgency

8/14/2019 HT Crisis-6

7/42

HYPERTENSIVE CRISES

Accounted for more than 25% ofall patient visits to an ED

The correct differentiation of thesetwo forms, presents the greatest

challenge to the physician.

8/14/2019 HT Crisis-6

8/42

Why this is a difficult topic

Blood pressure alone is a poorindicator of an emergency

Failing to treat an emergency andtreating a non-emergency can have

serious consequences for the patient

8/14/2019 HT Crisis-6

9/42

Why this is a difficult topic

Different emergencies have differentgoals in BP reduction

The first line agent for one emergencymay be contraindicated for

another

8/14/2019 HT Crisis-6

10/42

General Management

Goals Reduce BP so autoregulation can be

re-established

Typically, this is a 25% reduction in MAPOr, reduce MAP to 110-115

Avoid Lowering the BP too much or too fast.

8/14/2019 HT Crisis-6

11/42

Exceptions:

Aortic dissection and eclampsia

In aortic dissection andeclampsia, BP should be loweredto normal levels

8/14/2019 HT Crisis-6

12/42

HYPERTENSIVE

EMERGENCIES

8/14/2019 HT Crisis-6

13/42

HYPERTENSIVE EMERGENCIES

(Severe) elevations in BP withevidence ofprogressive target organ

dysfunction

Urgent lowering in minutes to hours.

8/14/2019 HT Crisis-6

14/42

Examples include:

Hypertensive encephalopathy andCVA

Unstable angina, or AMIAcute LVF with pulmonary edema

Dissecting aortic aneurysm

Eclampsia.

8/14/2019 HT Crisis-6

15/42

HEresult from either:

An exacerbation of essential hypertension

A secondary cause:

Renal,

Vascular,

Endocrine,

Neurologic, and,

8/14/2019 HT Crisis-6

16/42

The most associatedcomplications:

Acute pulmonary edema 36% and ACS in 12%

Cerebral infarction (25%), encephalopathy (16%),and cerebral or subarachnoid hge (5%).

Eclampsia in 4%.

Aortic dissection in 2%.

8/14/2019 HT Crisis-6

17/42

Diagnosis ofHE

Keep in mind that it is not the degree ofBP elevation, but rather theclinical statusof the patient that defines a hypertensiveemergency.

For example, a BP of 160/100 mm Hg in a

A 25 year pregnant lady, presented to EDwith one attack of fitsrepresents a truehypertensive emergency.

8/14/2019 HT Crisis-6

18/42

ED Evaluation

History Clinical presentation

History of HTN

Prescribed medications

Compliance

Past medical history

Illicit drug use

Headache, vomiting and

blurry vision

Headache alone notsufficient to diagnose HE

Fits, confusion, andaltered consciousness.

Chest pain, severeshortness of breath

8/14/2019 HT Crisis-6

19/42

ED Evaluation

Physical Exam

Appropriate sized cuff

Measure both arms and legs

Focus on areas of potential target-organ damage:

-CNS -Heart -Retina-Pulses -Kidney

8/14/2019 HT Crisis-6

20/42

Laboratory evaluation: Initial tests should be limited and

rapid:A renal function

An immediate chemistry panel

An electrocardiogram.

When suggests Cerebral ischemia or

hemorrhage, or if the patient is comatose,CT scan immediately obtained.

8/14/2019 HT Crisis-6

21/42

TREATMET

The initial goal for BP reduction isnot to obtain a normal BP, But

rather to achieve a gradualreduction in BP

8/14/2019 HT Crisis-6

22/42

TREATMET

Excessively rapid reductions in BPhave been associated with:

Acute deterioration in renal function

Ischemic cardiac or cerebral events

Occasional retinal arterial occlusionand acute blindness.

8/14/2019 HT Crisis-6

23/42

TREATMET

Initial reduction in MAP shouldnot exceed 20%to 25% below the pretreatment BP.As analternative, MAP can be reduced within the first30 to 60 minutes to 110 to 115 mm Hg.

Further gradual reductions toward a normal BPcan be implemented over the next 24 hours.

8/14/2019 HT Crisis-6

24/42

A significant exception to the aboverecommendations should be

recognized (Cerebral ischemic

stroke)

8/14/2019 HT Crisis-6

25/42

What is the management of Patientspresenting to the ED with severe

hypertension?

8/14/2019 HT Crisis-6

26/42

The first step is to establish thepresence of Hypertensiveemergencies with initiation of therapywith parenteral drugs

8/14/2019 HT Crisis-6

27/42

SUMMARY OF

TREATMENT

8/14/2019 HT Crisis-6

28/42

Summary Cardiovascularemergency

Acute LV failure

Acute coronarysyndrome

Aortic dissection

NTG, ACEI, Furosemide

~10-15% reduction of MAP

NTG, beta-blocker

~10-15% reduction of MAP

Nitroprusside + I.V. beta-blocker

SBP ~100

8/14/2019 HT Crisis-6

29/42

Summary Neurologic

emergencies Hypertensive

encephalopathy

Embolic CVA

Hemorrhagic CVA

Nitroprusside,

~25 reduction of MAP

Only if >220/120

Labetalol for ~15-20% reduction ofMAP

8/14/2019 HT Crisis-6

30/42

Summary Other

emergencies

Eclampsia

Catecholamineexcess

magnesium,hydralazine, labetalol,

delivery Goal DBP ~90

Phentolamine +/-beta

blocker ~25% reduction of MAP

8/14/2019 HT Crisis-6

31/42

HYPERTENSIVEUrgency

8/14/2019 HT Crisis-6

32/42

HYPERTENSION Urgency

Severe elevations in BPwithoutacute, ongoing progressive

target organ damage. Evidence of chronic organ damage

may be present

Lower in days to weeks.

8/14/2019 HT Crisis-6

33/42

The important caveat isthat

{Elevated BP alone - even if severe

- rarely requires emergencytherapy}

8/14/2019 HT Crisis-6

34/42

TREATMENT

Initial assessment should identifypatients who have an elevated BP

without any evidence of progressiveTOD for oral medications

In hich of the follo ing

8/14/2019 HT Crisis-6

35/42

In which of the followingwould a SBP of 100-120 be

appropriate? Aortic dissection

Thrombo-embolic CVA

Hemorrhagic CVA

Hypertensive encephalopathy

8/14/2019 HT Crisis-6

36/42

A. Aortic dissection

In all the other scenarios, such arapid drop in BP is likely to worsen

outcome

8/14/2019 HT Crisis-6

37/42

All the following regardingCVAs are true EXCEPT:

Hemorrhagic CVAs tend to havehigher BP than embolic

Lowering the BP in the acutesetting may worsen outcome

If BP needs lowering in

hemorrhagic CVA, Nipride is theagent of choice

8/14/2019 HT Crisis-6

38/42

Labetalolis the agent ofchoice IF BP needs to be

lowered

Nitroprusside and other vasodilatorsare relatively contraindicated inhemorrhagic CVA as they may

worsen ICP.

I HTN ith ll

8/14/2019 HT Crisis-6

39/42

In HTN with pregnancy, allthe following are true EXCEPT:

At a BP of 160/90, a patient mayexperience a HTN emergency

Definitive therapy for eclampsia ismagnesium

Definitive therapy for eclampsia is

delivery

8/14/2019 HT Crisis-6

40/42

Definitive therapy for eclampsia isdelivery of the fetus and

placenta

8/14/2019 HT Crisis-6

41/42

Questions and Comments

8/14/2019 HT Crisis-6

42/42