Hypertension Dr. Stella Yiu Staff Emergency Physician

LMCC objectives: Hypertension Diagnose and determine severity Investigate target organ damage and 2 nd causes List medical management (po and iv)

1. Diagnosis

Cdn 2012 guidelines > 160 or > 100 x 3 Or > 140 or > 90 x 5

Most HTN = Essential HTN 5-10% 2 nd – curable More demand on pump or Stiff pipes

2. 2 nd causes

2 nd Causes:  Cardiac output (pump demand) Renal failure + fluid overload ++ aldosterone Aortic coarctation

2 nd Causes:  Vascular resistance (stiff pipes) Renal artery stenosis Pheochromocytoma Drugs Brain (CVA, ICH, SAH)

MCQ 8: What is the most common treatable 2 nd cause for HTN? A.Hyperaldosteronism B.Renal artery stenosis C.Pheochromocytoma D.Aortic coarctation E.Sympathomimetic use

CDMQ: What are the clinical clues and investigations for 2 nd causes?

 Cardiac output (pump stress) Renal failure + fluid overload ++ Aldosterone Aortic coarctation

 Vascular resistance (stiff pipes) Renal artery stenosis Pheochromocytoma Drugs Brain (CVA, ICH, SAH)

Investigations Renal failure + fluid overload Creatinine, CXR

Investigations ++ aldosterone High Na, Low K Cushingoid on exam

Investigations Aortic coarctation HTN in Upper extremity Systolic murmur over back Delayed Femoral Pulse Echo, Angio

 Vascular resistance (stiff pipes) Renal artery stenosis Young female + fibromuscular dysplasia Resistant to HTN meds Most common treatable cause Abdo bruits, low K, Abdo US

 Vascular resistance (stiff pipes) Pheochro- mocytoma Episodes of HTN + HA + palp +diaphoresis Urine catecholamines, metanephrines

 Vascular resistance (stiff pipes) DrugsAmphetamines, sympathomimetics MAOI Clinical exam: toxidrome Urine tox ECG

 Vascular resistance (stiff pipes) Brain (CVA, ICH, SAH) CT head

3. Manage HTN emergency

What are the target organs?

MCQ 9: Which is not an HTN emergency? A.35 M 220/140, dizzy, normal neuro exam B.50 M 200/120, chest pain, CXR wide mediastinum C.25 F 28 wks pregnant, 150/80, seizure D.80 F 220/120, left arm weakness E.45 F 200/120, crackles to apex, JVP 6cm

ACS Pulmonary edema Aortic Dissection

Bleeds, seizures Encephalopathy (not just headache, dizzy) Acute renal failure

CDMQ: List Investigations for HTN emergency

Investigations for HTN emergency ACS Pulmonary edema Aortic Dissection Bleeds, seizure, encephalopathy ARF

Treat HTN emergency: General BP: Reduce MAP by 25% Iv medications: Labetolol Nitroprusside Hydralazine

CDMQ: 45 F 220/120, bilateral crackles, JVP 6cm, Sat 80%, treatment?

Specific Treatment: Pulmonary Edema BiPAP Nitrates iv Furosemide iv

Specific Treatment: ACS ASA NTG Beta-blockers

Specific Treatment: Dissection Iv Nitroprusside + beta-blocker Iv labetolol Surgery if ascending aorta

Specific Treatment: Seizure+ preg (Eclampsia) MgSO4 Iv Hydralazine Delivery

3. Manage HTN in Ambulatory setting

Diagnosis > 160 or > 100 x 3 or > 140 or > 90 x 5

MCQ 10: What test is not needed in ambulatory testing for HTN? A.Urine, urine albumin (DM) B.Lytes + creatinine C.Fasting glucose + cholesterol D.CBC + diff E.ECG

Treatment HTN ambulatory Non-pharmacological management

First line med, dosage and side effects? No other comorbidities? CAD? Diabetes? Asthma? Renal failure?

No co-morbid – 1 st line Thiazide (HCTZ 25 1 ) Beta-blocker (Metoprolol 25 2 ) CCB (Amlodipine 5 1 ) ARB (Losartan 25mg )

DM + Renal: ACEI/ARB CCB Thiazide

Asthma Avoid beta-blocker

CRF (non-DM) ACEI/ARB Thiazide

CAD ACEI /ARB Angina/recent MI: Beta-blocker

Improving compliance Fit daily routine Once daily dosing Single pill combination Dosette

LMCC objectives: Hypertension Diagnose and determine severity Investigate target organ damage and 2 nd causes List medical management (po and iv)