management hps

8/16/2019 Management Hps

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Definition

Hypertensive crisis :• Severe elevation of blood pressure, which must be

reduced immediately

• Hypertensive emergency :– accompanied by acute target organ damage– BP must be reduced within minutes

• Hypertensive urgency :– no acute organ damage– BP must be reduced within hours

Clinical Hypertension, Kaplan 2!


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Definition

• "ot determined by BP level, but rather theimminent compromise vital organ function

• #ormerly when :

– systolic ≥ $% mm Hg– diastolic & $$ mm Hg

'stage ((() *H+ 2!

-he Kidney and Hypertension, Ba.ris, 2/


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High blood pressure in asymptomaticchronic hypertension

(S "+- 0 H1P3-"S(4 C3(SS


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Precipitating factors in hypertensive crisis

1. Accelerated sudden rise in blood pressure inpatient with preexisting essential hypertension

2. Renovascular hypertension

3. lo!erulonephritis"acute#. $cla!psia%. &heochro!ocyto!a'. Antihypertensive withdrawl syndro!es

(. )ead in*uries+. Renin secreting tu!ors,. -ngestion of cathecola!ine precursor in patients

taing /A0 inhibitors


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)ypertensive e!ergency

• Accelerated"!alignant hypertension with papillede!a• erebrovascular conditions

)ypertensive brain infarction with severe hypertension-ntracerebral ubarachnoid

• ardiac conditionsAcute aortic dissectionAcute or i!pending !yocardial infarction

• Renal conditionsRenal crises fro! collagen"vascular diseasesevere hypertension after idney transplantation

• $cla!psia• urgical conditions

evere hypertension in patients re4uiring i!!ediate surgey• evere epistaxis


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Sign and symptom in various types of hypertensive emergency

-ype ofhypertensive emergency

-ypical symptoms -ypical signs Comment

0cute stro.e in evolution

'thrombotic or embolic

*ea.ness, altered

motor s.ill's

#ocal neruological

deficit's

Hypertension not

usually treated

Suibarachnoid hemorrhage Headache,

delerium

0ltered mental

status, meningeal

signs

5umbar puncture

typically shows

6anthochromia or redblood cells

0cute head in7ury8trauma Headache, altered

sensorium or

motor s.ills

5acerations,

ecchymoses,

altered mental

status

Computed

tomographic 'C-

scan is helpful to

determine e6tent of

intracranial in7uryHypertensiveencephalopathy

Headache, alteredmental status

papilledema 9sually a diagnosisof e6clusion

Cardiac

ischemia8infraction

Chest discomfort,

nausea, vomiting

0bnormal K

'esp; -


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-ype ofhypertensive emergency

-ypical symptoms -ypical signs Comment

0cute left ventricular

failure8pulmonary edema

Shortness of

breath

3ales auscultated

in chest

0ortic dissection Chest discomfort *idened aortic

.nob on chest 6<

ray

chocardiogram,

chest C-, or

angiogram usuallyneeded to confirm

3ecent vascular surgery Bleeding,

tenderness at

suture lines

Bleeding at suture

lines

+ften re=uire

surgical revision of

vascular anastamosis

Pheochromocytoma Headache,sweating,

palpitations

Pallor, flushing,rare s.in signs

'pha.omatoses

Phentolamine is veryuseful

>rug related

catecholamine e6cess

state

Headache,

palpilations

tachycardia History regarding

drug e6posure is .ey

Preeclampsia 8 eclampsia Headache, uterine

irritability

dema,

hyperrefle6ia

"ew treatment

guidelines e6ist

Sign and symptom in various types of hypertensive emergency


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/anage!ent of )ypertensive e!ergency

eneral principle 5

• the goal is6 inhibit the progression of organda!age

• parenteral drugs !ust be used• balance the benefit and the organ perfusion6

particularly brain6 !yocardiu! and idney

?(?S Cardiovascular uide, 2@


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7herapeutic guidelines

• do not lower 8& !ore than 2%9 over the first 1 hourunless necessary to protect other organs

• reduce the 8& of 1': !!)g6 D8& of 1:: !!)g6 or/A& of 12: !!)g6 in the first 2# hours

• begin the conco!itant long"ter! therapy soon afterthe initial e!ergency treat!ent

• atte!pt the established nor!otension within a fewdays

MIMS Cardiovascular Guide, 2005


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&arenteral drugs for treat!ent of hypertensive e!ergency

Drug Dose Onset ofactions Durationof action Special indications

Diuretics

Furosemide

20-40 mg in 1-2 min,repeated and higherdoses with renalinsufficiency

5-15 min 2- h !ssually needed tomaintain efficacy ofother drugs

"asodilators#itropruside

0$25-10$00µg%min%&g%min as i$'$

infusion

(mmediate 1-2 min )ost hypertensi'eemergencies* cautionwith high intracranialpressure or a+otemia

#itroglycerin

#itro-id (".

5-100 µg%min as i$'$

infusion

2-5 min 5-10 min /oronary ischemia

#icardipine 5-15 mg%h i$'$ 5-10 min 1-4 h )ost hypertensi'eemergencies* cautionwith acute heart failure


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Drug Dose Onset ofactions

Durationof action

Special indications

ydrala+ine 10-20 mg i$'$ 10-20 min - h clampsia* caution withhigh intracranialpressure

nalaprilat 1$25-5$00 mg e'ery 3 h 15 min 3 h cute left 'entricularfailure

drenergicinhiitors

hentolamine

smolol

6aetalol

5-15 mg i$'$

200-500 µg%&g%min for 4

min, then 50-00

µg%&g%min i$'$

20-0 mg i$'$ olus

e'ery 10 min2 mg%min i$'$ infusion

1-2 min

1-2 min

5-10 min

-10 min

10-20 min

-3 h

/atecholamine e7cess

ortic dissection, afteroperation

)ost hypertensi'e

emergencies e7ceptacute heart failure

/lonidin 85-100 µg%unit 5-10 min -3 h )ost hypertensi'eemergency, highcaution with reoundeffect

&arenteral drugs for treat!ent of hypertensive e!ergency


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Condition Preerred anti!"#ertensive a$ent

%cute #ul&onar" ede&a 'enoldo#a& or nitro#russide in co&(ination )it!

nitro$l"cerin *u# to 60 µ$+&in and a loo# diuretic

%cute &"ocardial isc!e&ia -a(etalol or es&olol in co&(ination )it!

nuitro$l"cerin *u# to 60 µ$+&in

."#ertensive ence#!alo#at!" -a(etalol, nicardi#ine, or enoldo#a&

%cute aortic dissection -a(etalol or co&(ination o nicardi#ine orenoldo#a& and es&olol or co&(ination onitro#russide )it! eit!er es&ool or intravenous&eto#rolol

/clasia -a(etalol or nicardi#ine ."dralaine &a" (e used

in a nonIC settin$

%cute renal ailure+ &icroan$io#at!icane&ia

'enoldo#a& or nicardi#ine

S"at!etic crisis+cocaine overdose era#a&il, diltiae&, or nicardi#inein co&(ination)it! a (enodiae#ine

7able Reco!!ended antihhypertensive agents for hypertensivecrisis


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)ypertensive ;rgency

• &otentially dangerous 8& elevation6 withoutacutelife"threatening end organ da!age

• 8lood pressure for!erly ≥1+: !!)g6 D ≥11: !!)g

• o!e of the circu!stance 5

– )igh 8& with retinal changes


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/anage!ent of )ypertensive urgency

• oal 5 prevent to the target organ da!age

• 7herapeutic consideration 5

– ;se oral drugs

– ub lingual drug >?• Reach the 8& 1':1:: !!)g in 2# hours6 nor!al

after 2#"#+ hours


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ublingual drug• till controversial begin to avoid• ubse4uent studies showed that the bioavailability of

sublingual nifedipione was negligible• @DA reco!!endations 1,,' 5

Bifedipine sublingual should be used with greatcaution6 if at al A

Ba.ris, Kidney and Hypertension 2/


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-able +ral drugs for hypertensive urgencies

Drug /lass Dose Onset Duration h.

/aptopril /apoten. ngiotensin-con'ertingen+yme inhi$

25-50$0 mg 15 min 4-3

/lonidine /atapres. /entral -

agonist

0$2 mg initially,

then 0$1 mg%h,up to 0$ mg

total

0$2-2$0 h 3-

Furosemide 6asi7. Diuretic 20-40 mg 0$5-1$0 h 3-

6aetalol #ormodyne,

9randate.

- and -

:loc&er

100-200 mg 0$5-2$0 h -12

#ifedipine procardia,dalat.

/alciumchannelloc&er

5-10 mg 5-15 min -5

ropanolol (nderal. -:loc&er 20-40 mg 15-0 min -3


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athways for management of patients with se'ere hypertension, defined as

lood pressure :. in e7cess of 10%110 mmg$

Se'ere ypertension

: ; 10 % 110

ncephalopathy

rogressing target organ damage


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-H 3(H- #+93

$;3ight medicine

2;3ight indication

!;3ight dose

/;3ight patient

C03 -+ -H 0>43S ##C-


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management hps

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