HYPERTENSIVE CRISES

DEFINITIONS: Hypertension: Hypertensive Urgency: Stage I: 140-159/90-99 Stage II: >160/100 Hypertensive Urgency: Systolic BP >180 or Diastolic BP >120 in the absence of end-organ damage

DEFINITIONS CONTINUED: Hypertensive Emergencies: SBP >180 OR DBP>120 in the presence of end-organ damage Malignant Hypertension: End-organ damage--eyes, kidneys, brain (hemorrhage/infarct) affected Hypertensive encephalopathy: Cerebral edema leading to neurological symptoms

SIGNS AND SYMPTOMS: Hypertensive Urgency: Can be completely asymptomatic Some symptoms include: Severe headache Shortness of breath Epistaxis. Severe anxiety Signs: Elevated BP on consecutive readings

S&S CONTINUED Hypertensive Emergencies Symptoms: nausea, vomiting (cerebral edema) Chest Pain SOB Blurry vision Confusion Loss of consciousness

SIGNS Papilledema, Retinal hemorrhages, exudates. Malignant nephrosclerosis with AKI, proteinuria, hematuria. Cerebral edema causing seizures and coma Pulmonary Edema. Myocardial Infarction. Hemorrhagic Stroke, lacunar infarcts.

TREATMENT OPTIONS Hypertensive Urgency: Goal: Reduce BP to <160/100 over several hours to day Elderly at high risk of ischemia from rapid reduction of BP, therefore slower reduction in BP in this patient population Previously treated hypertension: Increase dose of existing med or add another med Reinstitution of med in non-compliant patients

TREATMENT CONTINUED Hypertensive Urgency continued: Previously untreated hypertension: Slow reduction of BP (one to two days): Amlodipine, Metoprolol XL, lisinopril . Initiation of two agents or a combination with thiazide diuretic in patients with B.P of > 200/100.

TREATMENT CONTINUED Hypertensive Emergency: Goal: Lower Diastolic BP to approximately 100-105 over 2-6 hours; max initial fall not to exceed 25% More aggressive decrease can lead to ischemic stroke and myocardial ischemia If focal neurological sx presentobtain MRI to r/o acute stroke (rapid BP correction contraindicated) Parenteral antihypertensives (IV Drip) recommended over oral agents in hypertensive emergency

TREATMENT Recommended parenteral antihypertensive agents (IV drip) for Hypertensive Emergencies and admission to ICU Nitroprusside (cautious about cyanide toxicity), Nicardipine, and Labetalol. Once BP controlled, switch to oral anti-hypertensives and follow-up closely

SUMMARY Hypertensive Crises are common Differentiate Hypertensive Urgency from Emergency on the basis of end-organ damage Can treat hypertensive urgency with oral antihypertensive, but parenteral medications required for hypertensive emergencies 25% reduction in diastolic BP over 2-6 hours for hypertensive emergencies To start Oral antihypertensive and follow-up closely.