Hypertension

Phone Call Why is patient in hospital? Is patient pregnant (preeclampsia)? How high is BP and what has it been previously?

Phone Call Does the patient have symptoms of hypertensive emergency? –Chest/back pain: aortic dissection –Chest pain: MI –SOB: PE –Headache, neck stiffness: subarachnoid hemorrhage –HA, vomit, confusion, seizure: hypertensive encephalopathy What antihypertensive has the patient been on?

Thoughts Benign Hypertensive urgency: SBP>210 or DBP>120 with no end organ damage Hypertensive emergency: end organ damage Life threatening: –Eclampsia –Aortic dissection –Pulmonary edema –MI –Hypertensive encephalopathy

Bedside Evaluation Vitals –BP in both arms: if atherosclerosis artifactually low, aortic dissection –HR: tachycardia in catecholamine crisis, bradycardia in increased intracranial pressure Symptoms of hypertensive emergency?

Bedside Evaluation HEENT: arteriolar narrowing, hemorrhages, papilledema Lung: crackles, pleural effusions CV: elevated JVP, S3 Neuro: confusion, delirium, agitation, focal deficits

Management Essential hypertension: –In asymptomatic patient no acute lowering of BP needed Hypertensive urgency: –Decrease MAP 25% in hours (can use PO meds) Hypertensive emergency: –Call your senior-transfer pt to ICU/CCU –Decrease MAP 25% in minutes to 2 hours using IV agents

Management AgentDose *Nitroprusside microgram/kg/min Nitroglycerine micrograms/min Labetalol 20-80mg bolus q 10 min or mg/min Hydralazine 10-20mg q min Phentolamine 5-15 mg q 5-15 min IV Agents *Cyanide toxicity-ms change,lactic acidosis, death AgentDose Captopril mg Labetalol mg Clonidine0.2 mg load, 0.1 mg qh Hydralazine10-25 mg PO Agents