dr.Marwan Nasri,M.

Ked (Cardio), SpJP-FIHA

 3
Lilly,Pathophysiology of Heart Disease,2011
HTN and the company it keeps

HTN* is associated with:

• 69% of all first myocardial infarctions
• 74% of cases of HF/ ~2- to 3-fold ↑risk for HF
• 77% of all first strokes
• 277,000+ US deaths annually
• Estimated US costs: $66.4 billion annually

*BP >140/90 mm Hg Rosamond W et al. Circulation. 2007;115:e69-171.

 Hypertensive emergencies are situations where very high BP
values are associated with acute hypertension-mediated
organ damage, and therefore, require immediate BP
reduction to limit extension or promote regression of target
organ damage

 Key target organs of acute hypertension-mediated damage

are the heart, retina, brain, kidneys, and large arteries

 The type of target organ damage is the principal determinant

of the choice of treatment, target BP, and timeframe by which
BP should be lowered
 Malignant hypertension is a hypertensive emergency characterized by the
presence of a severe BP elevation (usually >200/120 mmHg) and advanced
retinopathy, defined as the bilateral presence of flame-shaped haemorrhages,
cotton wool spots, or papilloedema

 Hypertensive encephalopathy is a hypertensive emergency characterized by

severe hypertension and (one or more of the following): seizures, lethargy,
cortical blindness and coma, and in the absence of an alternative explanation

 Thrombotic microangiopathy: any situation where severe BP elevation

coincides with a Coombs-negative haemolysis (elevated lactic dehydrogenase
levels, unmeasurable haptoglobin, or schistocytes) and thrombocytopenia in
the absence of another plausible cause and with improvement during BP-
lowering therapy
 The term hypertensive urgency has been previously used to refer to
situations where very high BP values, usually >180/110 mmHg, prompt ED
referral, but acute hypertension-mediated target organ damage is absent.

 Because, there is no evidence that treatment in patients who lack acute

hypertension-mediated organ damage is different from patients with
asymptomatic uncontrolled hypertension, the Task Force considers that
it is preferable not to use the term ‘hypertensive urgency’ and only use
hypertensive emergency to refer to those situations where immediate
treatment is warranted.

 This also means that the term hypertensive crisis that was meant to
discriminate between hypertensive urgencies and emergencies becomes
obsolete.
Despite improved treatment for hypertension in the
past decades, the incidence of hypertensive
emergencies has not declined
Many pathophysiological mechanisms are involved in
the development and maintenance of malignant
hypertension , but the initiating events for the sudden
escalation in BP are not completely understood.

Marked activation of the renin–angiotensin system is

often present and associated with the degree of
microvascular damage
 There is no specific BP threshold to define hypertensive emergencies
because at the same BP level hypertension-mediated organ damage
can be present or absent.

 The rate of BP increase appears to be more important than the

absolute BP value in the development of hypertensive emergencies

 Emergency symptoms include headache, visual disturbances, chest

pain, dyspnoea and focal, or general neurological symptoms. Other
frequent, but less specific, symptoms include dizziness, resulting
from impaired cerebral autoregulation, and gastrointestinal
complaints (abdominal pain, nausea and anorexia)
 The treatment goal is to prevent or limit further hypertensive damage by
a controlled BP reduction
 In most cases, this can be best achieved by intravenous medication in a
clinical area with facilities for close haemodynamic monitoring

 The management of hypertensive emergencies is challenging because

immediate treatment depends on the degree and extent of hypertension-
mediated damage to key target organs.

 Rapid BP lowering is not recommended, as this can lead to

cardiovascular complications.

 Once the decision to add medication is taken, an observation period of at

least 2 h is suggested to evaluate BP lowering efficacy and safety.
Rapid BP lowering is required in patients with
pulmonary oedema and acute aortic dissection,
whereas BP-lowering medication is generally withheld
in patients with ischaemic stroke.

Whether BP should be acutely lowered in patients

presenting with severe hypertension and acute
intracranial haemorrhage is still subject of debate.
 SBP >180 mm Hg and/or
DBP >120 mm Hg

Target organ damage new/

progressive/worsening

Yes No

Hypertensive
Markedly elevated BP
emergency

Admit to ICU
(Class I) Reinstitute/intensify oral
antihypertensive drug therapy
and arrange follow-up

Conditions:
• Aortic dissection
• Severe preeclampsia or eclampsia
• Pheochromocytoma crisis

Yes No

Reduce SBP to <140 mm Hg Reduce BP by max 25% over first h†, then
during first h* and to <120 mm Hg to 160/100–110 mm Hg over next 2–6 h,
in aortic dissection† then to normal over next 24–48 h
(Class I) (Class I)

Colors correspond to Class of Recommendation in Table 1.

*Use drug(s) specified in Table 19.
†If other comorbidities are present, select a drug specified in Table 20.
BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care
unit; and SBP, systolic blood pressure.
 Recommendations for Hypertensive Crises and
COR LOE
Emergencies
In adults with a hypertensive emergency, admission to an
intensive care unit is recommended for continuous monitoring
I B-NR of BP and target organ damage and for parenteral
administration of an appropriate agent.

For adults with a compelling condition (i.e., aortic dissection,

severe preeclampsia or eclampsia, or pheochromocytoma
I C-EO crisis), SBP should be reduced to less than 140 mm Hg during
the first hour and to less than 120 mm Hg in aortic dissection.

For adults without a compelling condition, SBP should be

reduced by no more than 25% within the first hour; then, if
I C-EO stable, to 160/100 mm Hg within the next 2 to 6 hours; and
then cautiously to normal during the following 24 to 48 hours.
 Acute (<72 h from symptom onset) ischemic
stroke and elevated BP

Patient
qualifies for IV
thrombolysis
therapy

Yes No

Lower SBP to <185 mm Hg and

DBP <110 mm Hg before
initiation of IV thrombolysis
BP ≤220/110 mm Hg BP >220/110 mm Hg
(Class I)

And

Initiating or reinitiating treatment of Lower BP 15%

Maintain BP <180/105 mm Hg for
first 24 h after IV thrombosis hypertension within the first 48-72 during first 24 h
hours after an acute ischemic stroke is (Class IIb)
(Class I)
ineffective to prevent death or
dependency
(Class III: No Benefit)

For preexisting hypertension,

reinitiate antihypertensive drugs
after neurological stability
(Class IIa)

Colors correspond to Class of Recommendation in Table 1.

BP indicates blood pressure; DBP, diastolic blood pressure; IV, intravenous; and SBP,
systolic blood pressure.
 Acute (<6 h from symptom onset)
spontaneous ICH

SBP 150–220 mm Hg SBP >220 mm Hg

SBP lowering with

SBP lowering to
continuous IV infusion and
<140 mm Hg
close BP monitoring
(Class III:Harm)
(Class IIa)

Colors correspond to Class of Recommendation in Table 1.

BP indicates blood pressure; ICH, intracerebral hemorrhage; IV,
intravenous; and SBP, systolic blood pressure.
Prognostic factors for major adverse cardiac or
cerebrovascular events in patients presenting with a
hypertensive emergency are elevated cardiac
troponin-I levels and renal impairment at
presentation, whereas BP control and the amount of
proteinuria during follow-up are the main risk factors
for renal survival during follow-up.
 Hypertensive emergencies are those situations where very high
blood pressure (BP) values are associated with acute organ
damage, and therefore, require immediate, but careful, BP
reduction.
 The type of acute organ damage is the principal determinant of:
(i) the drug of choice, (ii) the target BP, and (iii) the timeframe in
which BP should be lowered.
 Key target organs are the heart, retina, brain, kidneys, and large
arteries.
 Patients who lack acute hypertension-mediated end organ
damage do not have a hypertensive emergency and can usually be
treated with oral BP-lowering agents and usually discharged after
a brief period of observation.