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    Hypertensive Crisis

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    AfraDewita
    The document discusses hypertensive crisis and emergencies. It presents three case scenarios of patients presenting with severely elevated blood pressure and symptoms. It then defines hypertensive emergencies and urgencies, noting that emergencies require immediate blood pressure reduction to prevent end organ damage, while urgencies can be treated over hours. The document outlines common causes, clinical manifestations, management principles involving intravenous drugs to rapidly lower blood pressure, and generally good long-term prognosis if blood pressure is controlled.

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    Hypertensive Crisis

    Uploaded by

    AfraDewita
    270 views30 pages
    The document discusses hypertensive crisis and emergencies. It presents three case scenarios of patients presenting with severely elevated blood pressure and symptoms. It then defines hypertensive emergencies and urgencies, noting that emergencies require immediate blood pressure reduction to prevent end organ damage, while urgencies can be treated over hours. The document outlines common causes, clinical manifestations, management principles involving intravenous drugs to rapidly lower blood pressure, and generally good long-term prognosis if blood pressure is controlled.

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    The document discusses hypertensive crisis and emergencies. It presents three case scenarios of patients presenting with severely elevated blood pressure and symptoms. It then defines hypertensive emergencies and urgencies, noting that emergencies require immediate blood pressure reduction to prevent end organ damage, while urgencies can be treated over hours. The document outlines common causes, clinical manifestations, management principles involving intravenous drugs to rapidly lower blood pressure, and generally good long-term prognosis if blood pressure is controlled.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    270 views30 pages

    Hypertensive Crisis

    Uploaded by

    AfraDewita
    The document discusses hypertensive crisis and emergencies. It presents three case scenarios of patients presenting with severely elevated blood pressure and symptoms. It then defines hypertensive emergencies and urgencies, noting that emergencies require immediate blood pressure reduction to prevent end organ damage, while urgencies can be treated over hours. The document outlines common causes, clinical manifestations, management principles involving intravenous drugs to rapidly lower blood pressure, and generally good long-term prognosis if blood pressure is controlled.

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    HYPERTENSIVE CRISIS

    Vidhia Umami
    Division of Nephrology & Hypertension, Department of Internal
    Medicine
    Faculty of Medicine, University of Indonesia Dr. Cipto Mangunkusumo
    Hospital
    Jakarta

    Case Scenarios

    A 56 yo male with no significant PMH


    presents to the ER with headache,found to
    have BP 210/120 mmHg and papilledema.

    An 82 yo male with h/o HTN,chronic renal


    insufficiency
    presents
    for
    a
    routine
    physical,found to have BP of 230/130 mmHg.

    A 76 yo female is brought to the ER by the


    family due to altered mental status.BP is
    240/120 mmHg with no focal neuro findings.

    Hypertension Prevalence (%) in


    Indonesia
    1995 s/d 2007

    Estimated 1 % of hypertension patient developed hypertensive emergency


    (Papadopoulos, Blood pressure 2010)

    Source: SKRT, Surkesnas , Riskesdas


    Note: 1995 and 2001: mercury blood pressure
    2004 and 2007: digital blood pressure

    EPIDEMIOLOGY

    In the US: More than 60 million Americans, about 25-30% of


    the population, have hypertension. Of these individuals,
    70% have mild disease, 20% moderate, and 10% severe
    hypertension (diastolic BP [DBP] >110 mm Hg). Approximately
    1-2% develop a hypertensive emergency with end-organ
    damage.

    Mortality/Morbidity: Morbidity and mortality depend on the


    extent of end-organ damage on presentation and the degree
    to which BP is controlled subsequently. BP control may
    prevent progression to end-organ impairment. I yr mortality
    in untreated pts. >90%.5 yr survival of all presentations
    is 74%.

    Race: African Americans have a higher


    hypertensive emergencies than Caucasians.

    Sex: Males are at greater risk of hypertensive emergencies


    than females.

    Age:Most commonly in middle-aged people.Peak age:40-50yrs.

    incidence

    of

    Epidemiology

    Hypertensive crises represented more than


    fourth of all medical urgencies/emergencies.

    one

    76% urgencies
    24% emergencies

    Hypertensive urgencies frequently present with:

    Headache (22%)
    Epistaxis (17%)
    Faintness and psychomotor agitation (10%)

    Types
    of
    end-organ
    damage
    associated
    hypertensive emergencies include:

    with

    Cerebral infarction (24%)


    Acute pulmonary edema (23%)
    Hypertensive encephalopathy (16%)
    Cerebral hemorrhage (4.5%)
    Blood Pressure, 2010; 19:328-336

    DEFINITION (JNC VII)

    DEFINITIONS

    Systolic blood pressure >180 and diastolic >120mmHg.

    Patients with hypertension can be classified into categories based


    upon their symptoms and the organ systems that are affected at the
    time of presentation:
    -HYPERTENSIVE EMERGENCY:
    is severe hypertension with acute
    impairment of an organ system (e.g., central nervous system [CNS],
    cardiovascular, renal). In these conditions, the blood pressure (BP)
    should be lowered aggressively over minutes to hours.
    Presence of papilledema indicates MALIGNANT HYPERTENSION.
    -HYPERTENSIVE URGENCY: the BP is a potential risk but has not yet
    caused acute end-organ damage. These patients require BP control over
    hours to days.
    -ACCELERATED HYPERTENSION: recent significant increase over baseline
    blood pressure. Examination usually showed vascular damage on
    fundoscopic examination, such as flame-shaped hemorrhages or soft
    exudates, but without papilledema.
    HYPERTENSIVE ENCEPHALOPATHY: sudden, marked elevation of BP with
    severe headache and altered mental status, reversible by reduction of
    BP.

    Hypertensive Crises

    Hypertensive Urgency

    Hypertensive Emergency

    Markedly elevated BP
    Markedly elevated BP
    Without severe symptoms or
    With acute or progressing
    progressive target organ damage
    target organ damage
    BP should be reduced within hours BP should be reduced immediate
    Oral agents
    Parenteral agents

    Kaplan NM ,Hypertensive Crises in : Clinical hypertension

    Precipitating factors in hypertensive crisis


    1.

    Accelerated sudden rise in blood pressure in


    patient with preexisting essential
    hypertension

    2.

    Renovascular hypertension

    3.

    Glomerulonephritis-acute

    4.

    Eclampsia

    5.

    Pheochromocytoma

    6.

    Antihypertensive withdrawl syndromes

    7.

    Head injuries

    8.

    Renin secreting tumors

    9.

    Ingestion of cathecolamine precursor in


    patients taking MAO inhibitors

    Pathophysiology
    Critical Degree of Hypertension
    Local effect
    Prostaglandin,
    freeradical, etc
    Endothelial Damage

    Systemic effect
    RAAS, Catechol,
    Vasopressin
    Pressure Natriuresis

    Platelet deposition

    Hypovolemia

    Mitogenic & migration factors


    Further increase in vasopressor
    Myointimal proliferation

    Further rise in BP & Vascular damage


    Tissue Ischemia

    Kaplans Clinical Hypertension, 2010

    CLINICAL MANIFESTATION

    (Zampaglione, 1996)

    Main Forms Of Presentation Of


    Hypertensive Emergencies in the
    Emergency Department
    Hypertensive Emergencies
    Hypertensive
    encephalopathy

    Symptoms
    Headache, visual
    disturbance, vommiting,
    altered level of
    consciousness

    Severe Hypertension with Neurological deficit,


    stroke/cerebral
    altered level of
    hemorrhage
    consciousness
    Hypertensive left
    ventricular failure

    Cough,

    dyspnea,
    orthopnea, rapidly
    progressive dyspnea

    Accelerated-malignant
    hypertension

    Visual changes,
    headache, renal failure,
    (Angelats, 2010)

    Main Forms Of Presentation Of


    Hypertensive Emergencies in the
    Emergency Department.(2)

    Hypertensive Emergencies

    Symptoms

    Hypertension and aortic


    dissection

    Chest pain and/or


    intense abdominal pain,
    vegetatism, signs of
    poor perfusion

    Hypertension with acute


    coronary syndrome

    Chest pain

    Use of drugs :
    amphetamines, LSD,
    cocaine, xtc

    Tachycardia, sweating,
    altered mood and/or
    level of consciousness

    Severe preeclampsia or
    eclampsia

    Oligouria,
    microangiopathic anemia

    (Angelats, 2010)

    Management Principles:
    Hypertensive Urgency

    No need for hospital admission.

    Slow and controlled reduction in BP

    Treated with oral agents

    Close follow-up as out patients

    Marik PE.Varon J. Chest.2007;131:1949

    JNC VII
    Treatment Recommendations

    Admit to ICU for continuous BP monitoring


    and parenteral administration of appropriate
    agent.
    Initial goal: arterial BP by no more than
    25% within min to 1 hr (aortic dissection 10
    min) or DBP to 110 mmHg over 1 hr.

    Then, if stable, to 160/100-110 mmHg


    within next 2-6 hr.

    Excessive BP reduction precipitating renal, cerebral, or


    coronary ischemia should be avoided.
    Gradual further reduction over next 24-48 hr
    Exception: ischemic stroke.

    Oral agents may


    Cobanian
    AV et al. Hypertension.2003;42:1206
    urgency

    be

    used

    for

    HTN

    MANAGEMENT

    (Rodriguez, 2010)

    Sublingual Drugs for


    Treatment of Hypertensive
    Emergencies

    Captopril

    25 mg SL reduced BP starting at 15 min - 120 min


    success rate 83%

    Nifedipine

    10 mg SL reduced BP starting at 10 120 min


    success rate 90%

    Wu SG et al. Nephron. 1993;65:284


    Haude M et el. Clin Cardiol.1991;14:463

    Parenteral Drugs for Treatment of


    Hypertensive Emergencies based on
    JNC 7

    Drugs

    Dose

    Onset

    Duration
    of Action

    Sodium
    nitroprusside

    0.25-10 ugr/kg/min

    Immediate

    1-2 minutes
    after infusion
    stopped

    Nitroglycerin

    5-500 ug/min

    1-3 minutes

    5-10 minutes

    Labetalol HCl

    20-80 mg every 10-15


    min or 0.5-2 mg/min

    5-10 minutes

    3-6 minutes

    Fenoldopam HCl

    0.1-0.3 ug/kg/min

    <5 minutes

    30-60 minutes

    Nicardipine
    HCl

    5-15 mg/h

    5-10 minutes

    15-90
    minutes

    Esmolol HCl

    250-500 ug/kg/min IV 1-2 minutes


    bolus, then 50-100
    ug/kg/min by
    infusion; may repeat
    bolus after 5 minutes
    or increase infusion
    to 300 ug/min

    10-30 minutes

    Chobanian AV et al, The JNC 7 report, JAMA 2003;389-2560-70

    Overview of intravenous drugs for the treatment of


    hypertensive emergencies
    Drug
    Esmolol

    Onset of
    action
    1 2 min

    Half
    life
    10 - 30
    min

    Dose

    Contraindications and
    adverse effects

    0.5 I mg/kg as bolus; 50 -300 2nd


    or
    3rd
    degree
    AV
    g/kg/min as continuous infusion block,
    systolic
    heart
    failure,
    COPD
    (relative); bradycardia

    Phentolamine 1 2 min

    3 5 min

    1 5 mg, repeat after 5 15 Tachyarrhythmia,


    min, until goal BP is reached;
    pectoris
    0.5 1.0 mg/h as continuous
    infusion

    Ketanserin

    1 2 min

    30 60
    min

    5 mg as bolus injection, repeat Prolonged QT interval,


    after 5 min (max 30 mg); 2 6 2nd
    or
    3rd
    degree
    AV
    mg/h as continuous infusion
    block;
    bradycardia,
    hypokalaemia

    Labetalol

    5 10
    min

    3 6 hr

    0.25 0.5 mg/kg; 2- 4 mg/min 2nd


    or
    3rd
    degree
    AV
    until
    goal
    BP
    is
    reached, block;
    systolic
    heart
    thereafter 5 20 mg/h
    failure,
    COPD
    (relative); bradycardia

    Nicardipine

    5 15
    min

    30 40
    min

    5 15 mg/h as continuous Liver failure


    infusion, starting dose 5 mg/h,
    increase every 15 30 min with
    2.5 mg until goal BP, thereafter
    decrease to 3 mg/h

    Nitroglyceri 1 5 min
    ne

    3 5 min

    200
    g/min,
    increase every 5 min

    Nitroprussid Immediate
    e

    1 2 min

    angina

    g/min

    0.3 10 g/kg/min, increase by Liver/


    kidney
    failure
    0.5 g/kg/min every 5 min until (relative);
    cyanide
    The
    Journal of Medicine;
    goalNetherland
    BP
    intoxication may 2011,

    vo

    Parenteral Drugs for Treatment of


    Hypertensive Emergencies based on CHEST 2007
    Acute Pulmonary
    edema / Systolic
    dysfunction

    Nicardipine, fenoldopam, or nitropruside


    combined with nitrogliceryn and loop
    diuretic

    Acute Pulmonary edema/


    Diastolic dysfunction

    Esmolol, metoprolol, labetalol, verapamil,


    combined with low dose of nitrogliceryn and
    loop diuretics

    Acute Ischemia Coroner

    Labetalol or esmolol combined with


    diuretics

    Hypertensive
    encephalopaty

    Nicardipine, labetalol, fenoldopam

    Acute Aorta Dissection

    Labetalol or combined Nicardipine and


    esmolol or combine nitropruside with
    esmolol or IV metoprolol

    Preeclampsia,
    eclampsia

    Labetalol or nicardipine

    Acute Renal failure /


    microangiopathic
    anemia

    Nicardipine or fenoldopam

    Sympathetic crises/
    cocaine oveerdose

    Marik Paul
    E, Varonor
    Joseph,
    CHEST 2007;131:194
    Verapamil,
    diltiazem,
    nicardipine
    combined with benzodiazepin

    PROGNOSIS

    So,.
    A 56 yo male with no significant PMH presents to the
    ER with headache,found to have BP 210/120mmHg
    and papilledema. - MALIGNANT HYPERTENSION,
    HYPERTENSIVE EMERGENCY

    An 82 yo male with h/o HTN,chronic renal


    insufficiency presents for a routine physical,found to
    HYPERTENSION,
    have BP of 230/130mmHg.- ACCELERATED
    HYPERTENSIVE URGENCY
    76 yo female is brought to the ER by the family due
    to altered mental status.BP is 240/120 mmHg with no
    focal neuro findings. HYPERTENSIVE ENCEPHALOPATY,
    HYPERTENSIVE EMERGENCY

    Thank You

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