MODULE 3 CHAPTER 1E

CARDIOVASCULAR EMERGENCIES IN HYPERTENSION

Cardiovascular emergencies in Hypertension

1. Acute severe hypertension- various forms2. Acute Heart failure3. Acute coronary syndromes4. Acute vascular disease- dissection5. Stroke- Hgic, Ischemic and SAH

IGH III DEFINITION (API)

Hypertensive emergency BP >180/120 mm Hg complicated by evidence of impending or progressive end-organ damage

Hypertensive urgency Severe elevation in BP without progressive end-organ damage

>180

Acute Severe Hypertension

• Refer to module 2 chapter 2c for detailed discussion

ACUTE HEART FAILURE

AHF – CHALLENGES AND GOALS• Management of AHFS is challenging given the

heterogeneity of the patient population, absence of a universally accepted definition, incomplete understanding of its pathophysiology, and lack of robust evidence-based guidelines

• Post-discharge mortality and hospitalization rates reach 10% to 20% and 20% to 30%, respectively, within 3 to 6 months

• Improving post discharge mortality and prevention of readmissions are the most important goals in AHFS

ACUTE HEART FAILURE

• Acute HF is defined as a rapid onset or change in the signs and symptoms of HF, resulting in the need of urgent therapy

Causes of AHF• Ischemic Heart disease

Acute Coronary syndromesMechanical complications of acute MIRV Infarction

• ValvularStenosisRegurgitationEndocarditis Aortic Dissection

• MyopathiesPostpartum cardiomyopathyAcute myocarditis

• Hypertension/ArrhythmiaHypertensionAcute arrhythmia

Natural History of Chronic and Acute Heart Failure

Initial phase Last year

Normal heart Chronic Heart Failure

Death

Initial myocardial

injury

First ADHF episode:Pulmonary edema

ER admission

Later ADHF episodes:Rescue therapyICU admission

Gheorghiade M. Am J Cardiol. 2005;96(suppl 6A):1-4G.

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*Patients with acute heart failure frequently develop chronic heart failure*Patients with chronic heart failure frequently decompensate acutely70% of ADHF is acute on chronic

Acute Aortic Dissection: FeaturesSudden or dramatic onset of pain with gradually waningThe character of pain is often ripping, tearing or stabbingCan stimulate the pain of acute MI or unstable angina but is more commonly felt over backRadiates to the neck, shoulders, abdomen, or lower limbs if those arteries are involved in the process of dissectionFeatures of acute M.I if the coronaries are involved in the dissecting processThe murmur of AR if the aortic valve is involvedAsymmetry or absence of arterial pulsesPredisposing conditions like systemic hypertension, marfan’s syndrome

• Immediate (ED/ICU/CCU)*Improve symptoms*Restore oxygenation*Improve organ perfusion and hemodynamics*Limit cardiac /renal damage*Minimize CCU length of stay

• Intermediate (in hospital)#Stabilize patient and optimize treatment strategy#Initiate appropriate (life saving) pharmacological therapy#Consider devise therapy in appropriate patients#Minimize hospital length of stay

• Long term and pre discharge management>Plan follow-up strategy>Provide adequate secondary prophylaxis>Prevent early readmission

>Improve quality of life and survival

Goals of treatment in acute HF

Rapid Assessment of Hemodynamic Status

Congestion at Rest

LowPerfusion

at Rest

NO

NO YES

YES

Warm & Dry

Warm & Wet

Cold & Wet

Cold & Dry

Nohria,J Cardiac Failure 2000;6:64

67%

28%5%

Signs/Symptoms of Congestion

• Orthopnea / PND/Acute Pulmonary Edema• JV Distension• Hepatomegaly• Edema• Rales (rare in chronic heart failure)• Elevated est. PA systolic( loud P2 and RV lift)• Abdominojugular reflux• S3

Ceiling Doses of Loop Diuretics (mg)

Furosemide bumetanide torsemide

IV po IV po IV po

Renal Insufficiency

moderate 80 80 2-3 2-3 20-50 20-50

severe 200 240 8-10 8-10 50-100 50-100

Cirrhosis with normal GFR

40 80-160 1 1 10-20 10-20

CHF with normal GFR 40-80160-240

2-3 2-3 20-50 20-50

(Adapted from Brater C. New Engl J Med 1999)

Rapid Assessment of Hemodynamic Status

Congestion at Rest

LowPerfusion

at Rest

NO

NO YES

YES

Warm & Dry

Warm & Wet

Cold & Wet

Cold & Dry

Nohria,J Cardiac Failure 2000;6:64

67%

28%5%

, Pulsus Alternans

SELECTION OF IONOTROPES• SBP VERY LOW – NOR ADRENALINE• SBP ABOUT 90 – DOPAMINE (RENAL DOSE IS A MYTH)• MORE THAN 90-- ADD DOBUTAMINE• LEVOSIMENDON – BETTER THAN DOBUTAMINE (LESS

ARRHYTHMIAS)• MORE THAN 90 ,PREVIOUS B BLOCKERS- MILRINONE• ACUTE DECOMPENSATION,LOW PERFUSION, SHORT TERM• LONG-TERM ROUTINE USE TO BE AVOIDED

Hemodynamic Status and TreatmentCongestion at Rest

LowPerfusion

at Rest

NO

NO YES

YES

Warm & Dry

Warm & Wet

Cold & Wet

Cold & Dry

Nohria,J Cardiac Failure 2000;6:64

67%

28%5%

DIURETICSVASODILATORSULTRAFILTRATION

IONOTROPESFLUIDSMECHANICAL

DIURETICSIONOTROPESMECHANICAL

ACUTE CORONARY SYNDROMEREFER CHAPTER 3 CHAPTER 1B

DISSECTION OF AORTA

Definition• Aortic dissection is an acute event where blood enters the aortic wall through a tear of the intima followed by extravasation of blood into the media• Currently believed the process begins with an intramural hematoma

Etiology• Degenerative• Hypertension• Pregnancy• Skeletal (scoliosis)• Connective tissue (Marfan’s)• Mycotic aneurysm• Takayasu (giant cell) arteritis• Aortic laceration/coarctation

ClassificationDeBakey: • I

– ascending aorta --> arch +/- descending aorta

• II – ascending aorta only

• III – descending aorta --> thoracic aorta

Classification (cont.)• More commonly used is the Stanford classification,

better linked to clinical outcomeType A: involves the ascending aorta

acute, 70% mortality Type B: not involving the ascending aorta, chronic tx. conservatively

AORTIC DISSECTION CLASSIFICATION TYPE I TYPE II TYPE III

TYPE A TYPE B

DEBAKEY

STANFORD

Schematic

A/B

Acute Aortic Dissection: FeaturesSudden or dramatic onset of pain with gradually waningThe character of pain is often ripping, tearing or stabbingCan stimulate the pain of acute MI or unstable angina but is more commonly felt over backRadiates to the neck, shoulders, abdomen, or lower limbs if those arteries are involved in the process of dissectionFeatures of acute M.I if the coronaries are involved in the dissecting processThe murmur of AR if the aortic valve is involvedAsymmetry or absence of arterial pulsesPredisposing conditions like systemic hypertension, marfan’s syndrome

Type A Dissection• A medical emergency• Imaging may include

– Chest radiograph– TOE best accuracy, in skilled hands, however more

invasive– MRI- ok if pt. stable, otherwise not used in acute

scenario, good at showing early intramural hematoma

– CT- disadvantage restricted to single axial plane, motion artifacts of the aortic root

CT/MRI side by side

MRI of Type A dissection

Dissection • High index of suspicion• If features are prsent do MRI,CT and TEE• Initial magement is b bockers followed by

vasodilators• Surgery depending upon the presence of team• In any hypertensive patient who presents with

severe chest and predominant back pain one should r/o dissection

• Thrombolysis is contraindicated in dissection

Prevention of Cardiac Complications of Hypertension

• It’s not the Blood Pressure alone• Treat Blood Pressure to Goal• Systolic BP Reduction is Probably more

important• Diuretic Trerapy is as good as any• Calcium Channel Blockers/ Alfa Blockers seem

to be less effective in preventing Heart Failure

HYPERTENSION AND CVAREFER MODULE 3 CHAPTER 2B

END OF MODULE 3 CHAPTER 1 E