MODULE 3 CHAPTER 1E

CARDIOVASCULAR EMERGENCIES IN HYPERTENSION

Cardiovascular emergencies in Hypertension 1. Acute severe hypertension- various forms 2. Acute Heart failure 3. Acute coronary syndromes 4. Acute vascular disease- dissection 5. Stroke- Hgic, Ischemic and SAH

IGH III DEFINITION (API) Hypertensive emergency BP >180/120 mm Hg complicated by evidence of impending or progressive end-organ damage Hypertensive urgency Severe elevation in BP without progressive end- organ damage

>180

Acute Severe Hypertension Refer to module 2 chapter 2c for detailed discussion

ACUTE HEART FAILURE

AHF – CHALLENGES AND GOALS Management of AHFS is challenging given the heterogeneity of the patient population, absence of a universally accepted definition, incomplete understanding of its pathophysiology, and lack of robust evidence-based guidelines Post-discharge mortality and hospitalization rates reach 10% to 20% and 20% to 30%, respectively, within 3 to 6 months Improving post discharge mortality and prevention of readmissions are the most important goals in AHFS

ACUTE HEART FAILURE Acute HFis defined as a rapid onset or change in the signs and symptoms of HF, resulting in the need of urgent therapy Acute HF is defined as a rapid onset or change in the signs and symptoms of HF, resulting in the need of urgent therapy

Causes of AHF Ischemic Heart disease Ischemic Heart disease  Acute Coronary syndromes  Mechanical complications of acute MI  RV Infarction Valvular Valvular  Stenosis  Regurgitation  Endocarditis  Aortic Dissection Myopathies Myopathies  Postpartum cardiomyopathy  Acute myocarditis Hypertension/Arrhythmia Hypertension/Arrhythmia  Hypertension  Acute arrhythmia

Natural History of Chronic and Acute Heart Failure Initial phase Last year Normal heart Chronic Heart Failure Death Initial myocardial injury First ADHF episode: Pulmonary edema ER admission Later ADHF episodes: Rescue therapy ICU admission Gheorghiade M. Am J Cardiol. 2005;96(suppl 6A):1-4G. Heart Viability *Patients with acute heart failure frequently develop chronic heart failure *Patients with chronic heart failure frequently decompensate acutely 70% of ADHF is acute on chronic

Immediate (ED/ICU/CCU) Immediate (ED/ICU/CCU) *Improve symptoms *Restore oxygenation *Improve organ perfusion and hemodynamics *Limit cardiac /renal damage *Minimize CCU length of stay Intermediate (in hospital) Intermediate (in hospital) #Stabilize patient and optimize treatment strategy #Initiate appropriate (life saving) pharmacological therapy #Consider devise therapy in appropriate patients #Minimize hospital length of stay Long term and pre discharge management Long term and pre discharge management >Plan follow-up strategy >Provide adequate secondary prophylaxis >Prevent early readmission >Improve quality of life and survival Goals of treatment in acute HF

Rapid Assessment of Hemodynamic Status Congestion at Rest LowPerfusion at Rest NONO NOYES YESYES Warm & Dry Warm & Wet Cold & Wet Cold & Dry Nohria,J Cardiac Failure 2000;6:64 67% 28%5%

Signs/Symptoms of Congestion Orthopnea / PND/Acute Pulmonary Edema JV Distension Hepatomegaly Edema Rales (rare in chronic heart failure) Elevated est. PA systolic( loud P2 and RV lift) Abdominojugular reflux S3

Ceiling Doses of Loop Diuretics (mg) Furosemidebumetanidetorsemide IVpoIVpoIVpo Renal Insufficiency moderate moderate severe severe Cirrhosis with normal GFR normal GFR CHF with normal GFR (Adapted from Brater C. New Engl J Med 1999)

Rapid Assessment of Hemodynamic Status Congestion at Rest LowPerfusion at Rest NONO NOYES YESYES Warm & Dry Warm & Wet Cold & Wet Cold & Dry Nohria,J Cardiac Failure 2000;6:64 67% 28%5%

, Pulsus Alternans

SELECTION OF IONOTROPES NOR ADRENALINE SBP VERY LOW – NOR ADRENALINE DOPAMINE SBP ABOUT 90 – DOPAMINE (RENAL DOSE IS A MYTH) DOBUTAMINE MORE THAN 90-- ADD DOBUTAMINE LEVOSIMENDON – BETTER THAN DOBUTAMINE (LESS ARRHYTHMIAS) LEVOSIMENDON – BETTER THAN DOBUTAMINE (LESS ARRHYTHMIAS) MILRINONE MORE THAN 90,PREVIOUS B BLOCKERS- MILRINONE SHORT TERM ACUTE DECOMPENSATION,LOW PERFUSION, SHORT TERM LONG-TERM AVOIDED LONG-TERM ROUTINE USE TO BE AVOIDED

Hemodynamic Status and Treatment Congestion at Rest LowPerfusion at Rest NONO NOYES YESYES Warm & Dry Warm & Wet Cold & Wet Cold & Dry Nohria,J Cardiac Failure 2000;6:64 67% 28%5% DIURETICS VASODILATORS ULTRAFILTRATION IONOTROPES FLUIDS MECHANICAL DIURETICS IONOTROPES MECHANICAL

ACUTE CORONARY SYNDROME REFER CHAPTER 3 CHAPTER 1B

DISSECTION OF AORTA

Definition Aortic dissection is an acute event where blood enters the aortic wall through a tear of the intima followed by extravasation of blood into the media Currently believed the process begins with an intramural hematoma

Etiology Degenerative Hypertension Pregnancy Skeletal (scoliosis) Connective tissue (Marfan’s) Mycotic aneurysm Takayasu (giant cell) arteritis Aortic laceration/coarctation

Classification DeBakey: I – ascending aorta --> arch +/- descending aorta II – ascending aorta only III – descending aorta --> thoracic aorta

Classification (cont.) More commonly used is the Stanford classification, better linked to clinical outcome Type A: involves the ascending aorta acute, 70% mortality Type B: not involving the ascending aorta, chronic tx. conservatively

AORTIC DISSECTION CLASSIFICATION TYPE I TYPE II TYPE III TYPE A TYPE B DEBAKEY STANFORD

Schematic A/B

Type A Dissection A medical emergency Imaging may include – Chest radiograph – TOE best accuracy, in skilled hands, however more invasive – MRI- ok if pt. stable, otherwise not used in acute scenario, good at showing early intramural hematoma – CT- disadvantage restricted to single axial plane, motion artifacts of the aortic root

CT/MRI side by side

MRI of Type A dissection

Dissection High index of suspicion If features are prsent do MRI,CT and TEE Initial magement is b bockers followed by vasodilators Surgery depending upon the presence of team In any hypertensive patient who presents with severe chest and predominant back pain one should r/o dissection Thrombolysis is contraindicated in dissection

Prevention of Cardiac Complications of Hypertension It’s not the Blood Pressure alone Treat Blood Pressure to Goal Systolic BP Reduction is Probably more important Diuretic Trerapy is as good as any Calcium Channel Blockers/ Alfa Blockers seem to be less effective in preventing Heart Failure

HYPERTENSION AND CVA REFER MODULE 3 CHAPTER 2B

END OF MODULE 3 CHAPTER 1 E