Primary hypertension (hypertensive urgencies) Management of severe asymptomatic hypertension (hypertensive urgencies) Shiva Seyrafian IKRC- IUMS 16-10-2014 __ 24-7-93

Severe hypertension Definition: systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥120 mmHg) Can produce a variety of acute, life- threatening complications( hypertensive emergencies). Relatively asymptomatic (other than perhaps headache) and have no acute signs of end- organ damage (hypertensive urgency).

Hypertensive emergencies-1 Accelerated-malignant hypertension with papilloedema Renal Cerebrovascular Acute glomerulonephritis Hypertensive encephalopathy Renal crises from collagen vascular diseases Atherothrombotic brain infarction with severe hypertension Severe hypertension after kidney transplantation Intracerebral hemorrhage Subarachnoid hemorrhage Cardiac Acute aortic dissection Acute left ventricular failure Acute or impending myocardial infarction After coronary bypass surgery

Hypertensive emergencies -2 Excessive circulating catecholamines Eclampsia Pheochromocytoma crisis Surgical Food or drug interactions with monoamine-oxidase inhibitors Severe hypertension in patients requiring immediate surgery Sympathomimetic drug use (cocaine) Postoperative hypertension Rebound hypertension after sudden cessation of antihypertensive drugs Postoperative bleeding from vascular suture lines Severe body burns Severe epistaxis

Severe hypertension Most commonly in patients who are: Nonadherent with their chronic antihypertensive regimen or those who are nonadherent with a low sodium diet. Medication-adherent patients following ingestion of large quantities of salt.  it seems to occur most commonly among patients who have been nonadherent with their chronic antihypertensive regimen or those who are nonadherent with a low sodium diet [ 3 ]. Severe hypertension can also occur in medication-adherent patients following ingestion of large quantities of salt

Treatment (ht urgency) Quickly confirmed with a repeat measurement  Blood pressure reduction goals: In the absence of symptoms, a more gradual reduction in pressure. Sublingual nifedipine is now contraindicated  Blood pressure may decline spontaneously simply with rest in a quiet room. Cerebral or myocardial ischemia or infarction can be induced by aggressive antihypertensive therapy. cerebral or myocardial ischemia or infarction can be induced by aggressive antihypertensive therapy if the blood pressure falls below the range at which tissue perfusion can be maintained by autoregulation

Treatment (ht urgency)… In the absence of signs of acute end-organ damage, the goal of management is to reduce the blood pressure to ≤160/100 mmHg over several hours to days. An elderly patient may be at particularly high risk for cerebral or myocardial ischemia from excessively rapid reduction of blood pressure. This patient who often have a high pulse pressure (eg, diastolic blood pressure <90 mmHg with systolic blood pressure ≥180 mmHg), the initial goal blood pressure of ≤160/100 mHg,  achieved even slower. The individual patient's risk for an adverse event and the probable duration of severe hypertension must be considered when deciding how quickly to reduce the blood pressure. As an example, an elderly patient may be at particularly high risk for cerebral or myocardial ischemia from excessively rapid reduction of blood pressure. In such a patient, who often will have a high pulse pressure (eg, diastolic blood pressure <90 mmHg with systolic blood pressure ≥180 mmHg), the initial goal blood pressure of ≤160/100 mmHg may need to be achieved even slower.

Treatment (ht urgency)… All patients should be provided a quiet room to rest, fall in BP of 10 to 20 mmHg or more. If treated previously: Increase the dose of existing antihypertensive medications, or add another agent. Reinstitution of medications in non-adherent patients. Addition of a diuretic, and reinforcement of dietary sodium restriction, in patients who have worsening hypertension due to high sodium intake.

Treatment (ht urgency)… If Untreated hypertension:  Relatively rapid initial blood pressure reduction (over several hours): oral furosemide (if the patient is not volume depleted) at a dose of 20 mg (or higher if the renal function is not normal), a small dose of oral clonidine (0.2 mg); or a small dose of oral captopril (6.25 or 12.5 mg). A low dose of a calcium channel blocker, beta blocker or ACE inhibitor, but not a diuretic alone. Oral nifedipine XL 30 mg once daily (of the long-acting preparation), oral metoprolol XL 50 mg daily, or ramipril 10 mg once daily.

Treatment (ht urgency)… Monitoring and follow-up: managed in the emergency room, since exclusion of acute end-organ damage laboratory testing, may require administration of medications several hours of observation. in the physician's office if the evaluation and management can be carried out. observed for a few hours, sent home with close follow-up over the subsequent days evaluation for symptoms related to hypertension or hypotension.

Treatment (ht urgency)… Monitoring and close phone follow-up. does not have a physician, follow-up may need to be in the emergency room. Over the course of weeks to months, the dose and selection of medications is modified to achieve desired goals usually with longer acting agents.

Cardiovascular risks of hypertension Hypertension accounts for an estimated 54 percent of all strokes and 47 percent of all ischemic heart disease events globally. Hypertension: the most important risk factor for premature cardiovascular disease, More common than cigarette smoking, dyslipidemia, and diabetes.

Components of cardiovascular risk factors in patients with hypertension Major risk factors Target organ damage Hypertension Heart disease Cigarette smoking Left ventricular hypertrophy Obesity (BMI ≥30 kg/m2) Angina or prior myocardial infarction Physical inactivity Prior coronary revascularization Dyslipidemia Heart failure Diabetes mellitus Stroke or transient ischemic attack Microalbuminuria or estimated GFR <60 mL/min Chronic kidney disease Age >55 years for men, >65 years in women Peripheral arterial disease Family history of premature coronary disease Retinopathy Men - <55 years Women - <65 years The JNC 7 report. JAMA 2003; 289:2560.

Primary hypertension Diet Shiva Seyrafian IKRC- IUMS 16-10-2014 __ 24-7-93

dietary modifications in the treatment of hypertension Reduction of sodium intake, Moderation of alcohol, weight loss in the overweight or obese, Diet rich in fruits, vegetables, legumes, Low-fat dairy products and low in snacks, sweets, meat, and saturated fat. Individual dietary factors: Increased intakes of potassium, calcium, fish oil, fiber. Milk-based and vegetable-based protein, folate, flavonoids (cocoa, tea). 

Non-dietary modifications Cessation of smoking Institution of an aerobic exercise regimen.

Life style change In prehypertension or stage 1 hypertension, lifestyle changes may control the blood pressure adequately. In higher BP or additional risk (eg, diabetes or chronic kidney disease), drug therapies should first be used to more quickly and effectively control the blood pressure.   Once blood pressure is well controlled, lifestyle changes should be strongly advised. If these are successfully achieved, reduction of medications may be possible.

DIETARY MODIFICATION DASH trial (Dietary Approaches to Stop Hypertension ): A combination diet rich in fruits, vegetables, legumes, and low-fat dairy products and low in snacks, sweets, meats, and saturated and total fat (this combination diet is called the “DASH diet”). The DASH diet is comprised of four-five servings of fruit, four-five servings of vegetables, two- three servings of low-fat dairy per day, and <25 percent fat.

Low sodium DASH study Three different sodium content(3.5, 2.3, and 1.2 g) for 30 days each. With the high, intermediate, and low sodium intakes, the systolic pressure was 5.9, 5.0, and 2.2 mmHg lower with the DASH diet than with the control diet, respectively. Comparable values for the diastolic pressure were 2.9, 2.5, and 1.0 mmHg lower with the DASH diet.

Diet Diet plays an important role in many susceptible patients in the genesis and maintenance of hypertension. Potassium restriction in healthy humans and patients with essential hypertension induces sodium chloride retention and an increase in blood pressure. Low dietary potassium intake (below 40meq/day): an increased risk or exacerbation of hypertension and an increased risk of stroke. We would not recommend potassium supplementation or a high potassium diet to attain these goals in patients at risk for hyperkalemia. Potassium supplements, 40 to 80 meq/day, lower blood pressure, an effect that is largely lost in patients who are also on a low sodium diet Short-term potassium restriction in healthy humans and patients with essential hypertension induces sodium chloride retention and an increase in blood pressure

Six lifestyle and dietary factors lower risk of developing hypertension (14 years F/U): Body mass index of less than 25kg/m2,  A daily mean of 30 minutes of vigorous exercise, Adherence to the DASH diet, Modest alcohol intake, Infrequent use of nonnarcotic analgesics, Intake of 400microg/d or more of folate . The presence of all six factors: a marked decrease in the risk for hypertension.

Perioperative management of hypertension Primary hypertension Perioperative management of hypertension SHIVA SEYRAFIAN IUMS, IKRC

Perioperative management of hypertension Of 76 patients who died of a cardiovascular cause within 30 days of elective surgery, a preoperative history of hypertension was four times more likely than among 76 matched controls.

BLOOD PRESSURE RESPONSE DURING ANESTHESIA Induction of anesthesia: systolic blood pressure can increase by 90 mmHg and heart rate by 40 beats per minute.  period of anesthesia: The mean arterial pressure tends to fall, intraoperative hypotension.  Immediate postoperative: Blood pressure and heart rate slowly increase. 

PERIOPERATIVE RISKS ASSOCIATED WITH HYPERTENSION Diastolic dysfunction from left ventricular hypertrophy, systolic dysfunction leading to congestive heart failure, renal impairment, and cerebrovascular and coronary occlusive disease. Mild to moderate hypertension: (diastolic pressure less than 110 mmHg) do not appear to be at increased operative risk

Six independent predictors of major cardiac complications High-risk type of surgery (examples include vascular surgery and any open intraperitoneal or intrathoracic procedures) History of ischemic heart disease (history of MI or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present) History of HF History of cerebrovascular disease Diabetes mellitus requiring treatment with insulin Preoperative serum creatinine >2.0 mg/dL (177 µmol/L)

Safety of antihypertensive drugs preoperatively Abruptly discontinuing some medications (eg, beta blockers, clonidine ) may be associated with significant rebound hypertension. Most antihypertensive agents can be continued until the time of surgery, taken with small sips of water on the morning of surgery.  ACEI,ARB: withhold them on the morning of surgery in patients who are taking them for congestive heart failure in whom the baseline blood pressure is low, OR in renal failure patients to avoid significant hypotension during the induction of anesthesia.

Safety of antihypertensive drugs preoperatively Calcium channel blockers :  increased incidence of postoperative bleeding, probably due to inhibition of platelet aggregation, Withdrawal syndromes: clonidine, methyldopa, guanfacine and the beta blockers are associated with acute withdrawal syndromes that can lead to adverse perioperative events. These drugs should not be abruptly stopped perioperatively.

Safety of antihypertensive drugs preoperatively Centrally acting sympatholytic drugs: Rebound hypertension usually occurs after abrupt cessation of fairly large oral doses (eg, greater than 0.8 mg/day), but has also been noted with transdermal clonidine. Beta blockers:  reduce intraoperative myocardial ischemia, recommended that patients with one or more risk factor for CHD be given beta blockers perioperatively.

POSTOPERATIVE HYPERTENSION Hypertension usually begins within 30 minutes of the completion of surgery and lasts approximately two hours. History of hypertension preoperatively Pain Excitement on emergence from anesthesia Hypercarbia Type of surgery

Indications for therapy A marked rise in blood pressure following surgery should be treated immediately. Remedial causes: pain, agitation, hypercarbia, hypoxia, hypervolemia, and bladder distention  Chronic antihypertensive therapy should resume with their usual medications. Therapy should be considered for patients with a sustained systolic blood pressure above 180 mmHg or diastolic blood pressure greater than 110 mmHg, once remedial causes have been excluded or treated.

Choice of drugs Patients taking diuretics may be given parenteralfurosemide or bumetanide . Patients taking beta blockers may be given parenteral propranolol , labetalol , or esmolol . Patients taking an ACE inhibitor may be given parenteral enalaprilat . Patients taking centrally acting agents can be given a clonidine patch. Patients taking calcium channel blockers can be given intravenous nicardipine . Uptodate® Oct 2013

SUMMARY 1  The ideal circumstance is to normalize blood pressure (eg, to less than 140/90 mmHg) for several months prior to elective surgery. It is not necessary to postpone elective procedures in patients with a blood pressure below 170/110 mmHg. Elective surgery should be postponed in patients with blood pressures above 170/110 mmHg. Such patients who require urgent surgery should be treated with a parenteral drug acutely. Patients with well-controlled hypertension preoperatively are less likely to experience intraoperative blood pressure lability and postoperative complications than patients with poorly controlled hypertension. The ideal circumstance is to normalize blood pressure (eg, to less than 140/90 mmHg) for several months prior to elective surgery. However, it is not necessary to postpone elective procedures in patients with a blood pressure below 170/110 mmHg. Elective surgery should be postponed in patients with blood pressures above 170/110 mmHg. Such patients who require urgent surgery should be treated with a parenteral drug acutely.

SUMMARY  2 Patients who are taking chronic antihypertensive medications should continue taking their medication until the time of surgery. The drug can be administered with a sip of water on the morning of surgery and resumed postoperatively as needed. Alternative parenteral agents can be prescribed for patients who are unable to resume oral medications.

SUMMARY  3 In particular, beta blockers and centrally acting agents such as clonidine should not be stopped acutely. If necessary, Intravenous propranolol or labetalol can be administered to patients taking beta blockers Or transdermal clonidine can be administered to patients taking clonidine.

SUMMARY  4 Remedial causes of postoperative hypertension such as pain, agitation, hypercarbia, hypoxia, hypervolemia, and bladder distention should be excluded or treated. Once this has been done, therapy should be considered for patients with a persistent systolic blood pressure above 180 mmHg or a diastolic blood pressure above 110 mmHg.

Essential hypertension in women

Prevalence in women Before age 50, women have a lower prevalence of hypertension than men, but after age 55, they have a higher prevalence. The prevalence rises with age, approaching 80 to 90 percent in women over the age of 70. Incidence of coronary heart disease(1/2). Left ventricular hypertrophy is less common. At equal degrees of hypertension, women were at lower risk than men in all age groups from 40 to 70.

factors associated with a lower risk of developing hypertension Body mass index of less than 25 kg/m 2 A daily mean of 30 minutes of vigorous exercise Adherence to the DASH diet, modest alcohol intake Infrequent use of nonnarcotic analgesics Folate intake of 400 microg/day or more The importance of risk factors for essential hypertension in women was evaluated in a prospective cohort study of 83,882 adult women from the second Nurses' Health Study who did not have a history of hypertension, cardiovascular disease, or diabetes [ 11 ]. Six lifestyle and dietary factors were independently associated with a lower risk of developing hypertension during 14 years of follow-up: Body mass index of less than 25 kg/m 2 A daily mean of 30 minutes of vigorous exercise Adherence to the DASH diet, modest alcohol intake Infrequent use of nonnarcotic analgesics Folate intake of 400 microg/day or more

Women and men respond similarly to antihypertensive therapy. All women should follow a health lifestyle and periodically monitored for rises in blood pressure and end-organ damage. Other cardiovascular risk factors (smoking, hypercholesterolemia, and diabetes mellitus): an important determinant of the need for antihypertensive medications. The presence of left ventricular hypertrophy (LVH) by echocardiography carries an increased risk of cardiac events in women that is equivalent to that in men.