1. Post Graduate Interns Grand Rounds

2. Objectives To define Hypertensive Urgency To discuss relation of epistaxis and hypertension To discuss efficacy of sublingual Clonidine and Nicardipine drip in managing acute elevations in blood pressure To present an algorithm regarding management of this particular case

3. Outline History and Physical Examination Laboratory and Ancillary Procedures Primary Impression Define Hypertensive Urgency Discuss Epistaxis and Hypertension Clonidine, sublingual and Nicardipine drip:role in acute elevation in BP Algorithm

4. Identifying Data 60 y/o female Single, RC, from Santol QC Works as a general service clerk Known hypertensive for 4 yrs

5. Temporal Profile Clonidine 75mg/tab sublingual Metoprolol 50mg/tab

6. Past Medical History Hypertension- diagnosed 4 yrs ago, admitted at delos Santos Hospital, maintained on Metoprolol 50 mg OD however with poor compliance, highest BP 250/100, regular BP 130-140/80-90 Hyperlipidemia- diagnosed 4 yrs ago, took unrecalled medication for 3 mos

7. Family History Hypertension, kidney failure -paternal Personal and Social History Non smoker, non alcohol drinker Dressmaker for 42 yrs Regular exercise, walks 3 floors everyday Regular diet

8. Salient Features Known hypertensive, hyperlipidemic for 4 yrs Poor compliance to medication 1 day history of epistaxis Elevated BP 220-230/130 (-) headache, vomiting, chest pain, numbness, blurring of vision, decrease in urine output (-) palpitation, heat intolerance (-) history of contraceptive intake Last urine output- 1 hr ago: 2 glasses

9. Physical Examination Vital SignsBP= 220/139 HR= 80 RR= 20 Temp= 36.8 0 C GeneralAwake, alert, coherent, comfortable, BMI=29.8(overweight) HEENTAnicteric sclerae, pink palpebral conjunctiva, no cervical lymphadenopathies, moist oral mucosa Funduscopy(+)ROR, AV ratio=2:3, Cup disk ratio=0.3, no hemorrhages, no papilledema Chest and Lungs Equal chest expansion, Clear breath sounds CardiovascularAdynamic precordium, PMI and apex beat at 5 th ICS LMCL, Normal rate regular rhythm, distinct S1 and S2, no murmur

10. Physical Examination AbdomenFlabby, Normoactive bowel sounds, soft, non tender, no masses, no organomegaly ExtremitiesFull equal pulses, CRT < 2 sec, (-)cyanosis, edema Neurological Exam Essentially normal

11. Laboratory and Ancillaries

12. Primary Impression

13. Differential diagnosis

14. Hypertensive Urgency

15. Definition of Hypertensive Urgency Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, Seventh Report, 2003 Severe elevations in BP without progressive target organ dysfunction Examples include upper stage II hypertension associated with severe headache, shortness of breath, epistaxis, or severe anxiety. Although not specifically addressed in the JNC 7 Report, patients with a SBP greater than 179 mmHg or DBP greater than 109 mmHg are usually defined as having 'severe or accelerated' hypertension. (Clinical review: The management of hypertensive crises, Joseph Varon 1 et al. 2003)

16. Definition of Hypertensive Urgency Harrison’s Principle of Internal Medicine Severe Hypertension

17. Definition of Hypertensive Urgency Emergency Medicine Practice: An Evidence-Based Approach to Medicine, Distinguishing And Managing Hypertensive Emergencies And Urgencies, July 2005 Elevated blood pressure, without evidence of acute, ongoing target organ damage, that requires urgent — but not emergent — blood pressure reduction Patients who have known end-organ disease, but no active compromise

18. Definition of Hypertensive Urgency Elevated BP/Severe Hypertension but without evidence of end-organ damage; many article still use SBP>180 and DBP>120. Clinical review: The management of hypertensive crises. Varon, 2003 Current diagnosis and management of hypertensive emergency. Haas, 2006 Hypertensive crises: challenges and management. Marik PE, 2007 Hypertensive emergency and urgency: clinical update. Milan,2010

19. Evaluation and Treatment of Severe Asymptomatic Hypertension, CHAD S. KESSLER, MD, and YAZEN JOUDEH, MD, University of Illinois at Chicago College of Medicine, Chicago, Illinois, Volume 81, Number 4, February 15, 2010

20. Back to our patient... BP=230/130 No signs of end organ damage What is the appropriate diagnosis? Hypertensive Urgency Severe Uncontrolled Hypertension Severe Hypertension

21. Importance of Defining Hypertensive Urgency: Management What are the appropriate drugs to be used? How fast and how low should BP be corrected? What are the indications for admission?

22. EPISTAXIS and HYPERTENSION Does the hypertension cause epistaxis OR does the epistaxis cause hypertension?

23. The Controversy Hypertension may contribute to epistaxis, but this theory is controversial. A cross-sectional, population-based study showed no association between hypertension and epistaxis. In a prospective study of patients with hypertension who had epistaxis, the incidence of epistaxis was not related to the severity of hypertension. In contrast, other studies have reported elevated blood pressure in patients with epistaxis. When the onset of epistaxis is abrupt, it is difficult to determine whether hypertension is the cause, since many patients with active bleeding have anxiety that leads to elevated blood pressure. The New England Journal of Medicine: Epistaxis. Rodney, February 2009

24. The Controversy Epistaxis incidence in hypertensive patients is NOT associated to hypertension severity International Journal of Cardiology: Association Between Epistaxis and Hypertension- A one year follow up after an index episode of nose bleeding in hypertensive patients, Jose K. 2009 Hypertension does NOT appear to be statistically significant causal factor and/or a factor of severity of serious spontaneous epistaxis, although the patophysiology of serious spontaneous epistaxis remains to be unclear Unbound Medline: Spontaneous Epistaxis in Hospitalized patients, Page. Dec.2011

25. The Controversy The most common systemic causes of epistaxis are hypertension, aberrations in clotting ability, inherited bleeding diatheses, and vascular/cardiovascular diseases. Although the mechanistic relationship of hypertension and epistaxis is still being debated, the 2 are undeniably associated. Hypertension is the most common associated finding in cases of severe or refractory epistaxis. The Ochsner Journal: Epistaxis- A common Problem, Adil F. 2010

26. The Controversy As of 2010, medical researchers disagree on whether or not stage 1 hypertension causes nosebleeds. In the February 2009 issue of the "New England Journal of Medicine," Dr. Rodney J. Schlosser writes that while there is some evidence connecting hypertension to epistaxis, or nosebleeds, hypertensive patients often have underlying illnesses or genetic conditions that may trigger the symptom. Also, the severity of hypertension does not appear to affect the frequency of nosebleeds in hypertensive patients. Symptoms of Stage I Hypertension,Sydney Hornby, M.D. Nov 30, 2011

27. Let us welcome our Head and Neck specialist to enlighten us regarding this matter...

28. Clonidine Sublingual and Nicardipine drip Role in management of acute elevations in BP

29. Some patients with hypertensive urgencies may benefit from treatment with an oral, short-acting agent such as captopril, labetalol, or clonidine followed by several hours of observation Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, Seventh Report, 2003

30. When to treat? ACEP guidelines- No initiation of BP meds in ED EMCREG panel (published in Annals)-Initiate treatment if SBP>200 / DBP >120mm Hg May individualize based on patient situation, i.e. availability of follow-up, etc.

31. There are no controlled studies demonstrating long-term improved outcomes with acute treatment of severe asymptomatic hypertension. Severely elevated blood pressure likely does not develop abruptly, but rather over days, weeks, or months. Aggressive dosing with intravenous medications or fast-acting oral agents, such as nifedipine (Procardia) or hydralazine, can lead to hypotension. Reducing severely elevated blood pressure below the autoregulatory zone too quickly can result in markedly decreased perfusion to the brain Evaluation and Treatment of Severe Asymptomatic Hypertension, CHAD S. KESSLER, MD, and YAZEN JOUDEH, MD, University of Illinois at Chicago College of Medicine, Chicago, Illinois, Volume 81, Number 4, February 15, 2010

32. There is no evidence regarding the best time to lower blood pressure in hypertensive urgencies or among incidental hypertensives Emergency Medicine Practice: An Evidence-Based Approach to Medicine, Distinguishing And Managing Hypertensive Emergencies And Urgencies, Nguyen T. July 2005

33. Unfortunately, the term “urgency” has led to overly aggressive management of many patients with severe, uncomplicated hypertension Aggressive dosing with intravenous drugs or even oral agents to rapidly lower BP is not without risk. Oral loading doses of antihypertensive agents can lead to cumulative effects causing hypotension, sometimes following discharge from the emergency room. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, Seventh Report, 2003

34. Hypertensive Urgencies can generally be managed with oral medications and requires BP lowering over 24-48 hours Important to prevent too-rapid lowering due to autoregulation of flow by pressure in brain, heart, and kidneys Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, Seventh Report, 2003

35. Target BP JNC 7 AHA

36. Algorithm