1. Hypertensive Emergencies
Leben Tefera, MD
Andrew Harris, MD
PGY2
August 3, 2016

2. Objectives Define emergency vs urgency Overview of HTN urgency
Brief review of classes of anti-hypertensives
Review common scenarios and identify appropriate treatments
Common issues with diuretics

3. Take-home: sneak preview
Hypertensive Urgency  ORAL MEDS!!
Rapid overcorrection can be very harmful
Start low, go slow
IV Hydralazine  BAD
Severe, unpredictable hypotension + reflex tachycardia
Labetalol  GOOD
Except in acute decompensated HF
Dilt gtt  NEVER in acute HFrEF
Always ask: “What is the EF?”

4. Hypertensive Medications
Fast Acting PO Formulations
Hydralazine (25 mg)
Nifedipine (30 mg)
Isosorbide dinitrate (10 mg)
Clonidine (0.1 mg)
Labetolol ( mg)
IV Options on the Floor
Hydralazine 5 mg
Labetolol mg

5. Problems with inpatient HTN
Difficult to determine true hypertensive emergency
Nurses keep paging me!!! It’s not an emergency!!! AAAARGH!
No accepted guidelines for management
Cochrane Review 2008:
Insufficient evidence to support a single drug as being more effective in HTN emergency

6. Emergency vs Urgency
What differentiates emergency from urgency?

7. Hypertensive Urgency Best accepted definition
Systolic BP > 180 OR
Diastolic BP > 120
No evidence of end organ damage (mild headache does not count!)
Most commonly due to poorly controlled chronic hypertension
NOT an indication for hospital admission
DO NOT use IV anti-hypertensives

8. Hypertensive Urgency
If admitted for other reasons, slowly lower BP with oral medications over days
No good evidence to guide timeframe or choice of medication
In general, lower systolic/MAP NMT 25% or to 160/100
Rapid correction below auto-regulatory range can cause ischemia
Cerebral (stroke)
Coronary (MI)
Renal (AKI)
Reasons to potentially lower over hours:
Known aortic or cerebral aneurysm
High risk of MI (known CAD, DMII)

9. Clinical Scenario #1 65 yo F with HTN admitted for PNA.
You are on nightfloat. Nurse calls, BP is 180/110. Your signout says “NTD”
What should you do?

10. Next Steps: Stall: OK, it’s still elevated, now what?
What are the full vitals?
Is she symptomatic?
Can you recheck a manual BP?
What size cuff did you use?
Is she in pain?
Did she get her regularly scheduled meds?
I’m at a code, can I call you back?
OK, it’s still elevated, now what?
Arm circumference 22 to 26 cm, "small adult" cuff, 12 x 22 cm
Arm circumference 27 to 34 cm, "adult" cuff, 16 x 30 cm
Arm circumference 35 to 44 cm, "large adult" cuff, 16 x 36 cm
Arm circumference 45 to 52 cm, "adult thigh" cuff, 16 x 42 cm

11. Hypertensive Urgency Remember: start low, go slow
Fully titrate before adding a second med
Titrate to effect (or side effect)

12. Hypertensive Urgency Good medications Bad Medications Clonidine
Patient’s previous meds (nonadherence)
Amlodipine
ACE/ARB (check renal panel as outpt)
Labetalol (expensive outpatient med)
Diuretics
Bad Medications
Anything IV
Hydralazine, nifedipine (most of the time)
Clonidine
It works, but watch out…..
Severe rebound HTN, must be tapered

13. Hypertensive Emergency
This is an indication for ICU admission!
Types of end organ damage
Encephalopathy:
Headache, altered mental status, visual disturbance
Fundoscopic exam: look for papilledema
Aortic or carotid dissection
MI/ACS/chest pain
Pulmonary edema with respiratory failure
Renal Failure
Pregnancy – ECLAMPSIA/HELLP
Microangiopathic Hemolytic Anemia

14. Hypertensive Emergency
BP Control
Mean arterial pressure should be reduced gradually by about 10 to 20 percent in the first hour
Further 5 to 15 percent over the next 23 hours

15. Classes of Anti-Hypertensives
Beta Blockers
Alpha Blockers
ACE-I/ARBs
Calcium Channel Blockers
Vasodilators
Diuretics

16. Beta Blockers Good in most settings (except HFrEF)
Labetalol: Alpha 1 + non-selective Beta
Onset (IV): 2.5mins
Peak Effect: 15mins
Decrease HR w/o decreasing CO
Good in most settings (except HFrEF)
Esmolol: short acting Beta 1 antagonist
Very quick onset, primarily rate control  better with a vasodilator
Comes with lots of fluid
IV Metoprolol:
Rate control, not anti-hypertensive

17. Calcium Channel Blockers
Dihydropyridine
Nicardipine
SE: reflex tachycardia
Clevidipine (mostly used in ED)
Ultra-short onset (1 minute)
Nifedipine
AVOID – increased mortality
Non-dihydropyridine – negative inotropes
Diltiazem – bad news in HFrEF

18. Vasodilators Nitroglycerin Nitroprusside Hydralazine - BAD
Primarily venodilator, reduces preload
Arterial vasodilator at high doses, modest afterload reduction
Nitroprusside
Arterial and venous dilator
Cyanide toxicity (photodegradation) –
Inhibits oxidative phosph
Hydralazine - BAD
Prolonged, unpredictable drops in blood pressure
Effect lasts up to 10 hours, best avoided
Inhibits oxidative phosphorylation
Causes decreased O2 consumption, so increases venous pO2 (unless cardiac output is decreased, in which case can be cyanotic), so get PINK SKIN AND BRIGHT RED VENOUS BLOODDecreased pO2 due to altered pulmonary hemodynamicsIncreased ICP (rare)Nausea, vomitingCaution in pts w/known renal failure

19. Other ACE-Inhibitors Diuretics (more to come shortly)
Enalaprilat (only IV form)
Diuretics (more to come shortly)
Furosemide
Torsemide
Bumetanide

20. Clinical Scenario #2
65 yo M, PMH of ischemic cardiomyopathy (EF 35%), HTN, DMII presents with acute SOB.
T 98.8, BP 190/120, RR 25, PO2 sat 88%

22. Pulmonary Edema Goals of therapy:
Reduce afterload and preload
Increase or maintain contractility
Maintain stroke volume (permissive tachy)
Low EF  avoid beta blockers/negative inotropes
Nitroglycerin (reduces preload)
IV Diuretic (reduces preload and afterload)
NIPPV – reduces preload and afterload

23. Clinical Scenario #3
65 yo F, PMH of HTN, DMII, PAD presents with chest pain at rest
T 98.8, BP 190/120, RR 25, PO2 sat 94%
ECG:
new TwI in I, II, aVL, V3-V6
What do you want to use?

24. Acute Coronary Syndrome
Goals of therapy:
Reduce Myocardial Oxygen Demand
Reduce Heart Rate
Reduce Afterload
Labetalol (or Esmolol)
Nitroglycerin
Primarily anti-anginal
ACE-Inhibitor if no contraindication
Captopril short acting, easily titrated

25. Clinical Scenario #4
65 yo M, Marfan’s syndrome, HTN, presents with severe CP radiating to back
T 98.8, BP 190/120, RR 25, PO2 sat 94%
CXR: widened mediastinum
CT scan: descending aortic dissection
What do you want to use?

26. Aortic Dissection Goals of therapy: Vasodilator alone will increase HR
Reduce shear stress
Reduce Heart Rate
Reduce Velocity of Blood Flow
Vasodilator alone will increase HR
Vasodilator + beta blocker
Labetalol OR
Nicardipine + Esmolol
OK to aggressively reduce (<120/80)

27. Other Scenarios Encephalopathy (goal: reduce ICP) Sympathetic Crisis
Labetalol or Nicardipine
Sympathetic Crisis
Cocaine, Amphetamines, PCP (Urine Tox!!)
Others: MAO inhibitor + tyramine, clonidine withdrawal
Avoid beta blockers – theoretical risk of sympathetic crisis, unopposed alpha agonism
Good options: Nicardipine or Verapamil + benzo; Labetalol likely safe

28. A Word on Diuresis Threshold Dose Tolerance – hypertrophy of nephrons
Minimum effective dose
0.5-1mg/kg (or 40mg) IV over 1-2 mins
Often 40 IV Lasix
No response w/ in 1 hour double the dose
Tolerance – hypertrophy of nephrons
Add thiazide such as metolazone
Conversions
40 IV Lasix = 20 IV Torsemide = 1 IV Bumex
40 Lasix PO = 20 Lasix IV
Rule of thumb = give PO dose as IV
Threshold Dose
minimum amount of drug that must be present at site of action in order to elicit a response
Ie, minimum effective dose below which diuresis will not be successful
Must titrate diuretics to determine the dose that will deliver enough drug to site of action
Typical dose is 40 mg IV Lasix to achieve maximal response
Tolerance
Long term hypertrophy of distal nephron segments with increased sodium reabsorption
Thiazide diuretics (such as metolazone) block the sites of hypertrophy, can lead to synergistic diuresis

29. Diuretic Drips Equivalent to bolus (DOSE trial)
Good for quick titration in ICU
Always bolus prior to starting drip or adjusting the rate
Furosemide: 40 IV then 10/hr
Torsemide: 20 IV then 5/hr
Bumetanide: 1 IV, then 0.5/hr
Remember: higher doses in renal failure!

30. Take-home Points Hypertensive Urgency  ORAL MEDS!!
Rapid overcorrection can be very harmful
Start low, go slow
IV Hydralazine  BAD
Severe, unpredictable hypotension + reflex tachycardia
Labetalol  GOOD
Except in acute decompensated HF
Dilt gtt  NEVER in acute HFrEF
Always ask: “What is the EF?”