1. HYPERTENSIVE CRISES
Mini-Lecture

2. Objectives: Define the various types of hypertensive crises
Recognize signs and symptoms associated with hypertensive crises
Treatment options

3. Clinical Vignette
65 y/o M with past medical history of Type II DM (on oral hypoglycemics), presenting with headache, chest pain and shortness of breath that developed after lunch the day of admission; non-exertional; no alleviating factors.
Physical Exam:
Vitals: 37.3, 195/125, 92, 24, 93% on RA
HEENT: Decreased A:V on retinal exam (<25%)
Heart: S4 heard on exam, no m/r/g
Lungs: mild resp distress, otherwise clear to auscultation
What’s the diagnosis and next best step in management?
TELL THEM TO THINK ABOUT IT, COME BACK TO IT LATER ON. This patient is having chest pain and shortness of breath. Patient has diabetes which is a risk factor for CAD, therefore looking at the clinic picture (EKG, h/o smoking etc), ACS should be ruled out. CXR should be obtained. Patient should be started on an IV antihypertensive and admitted to ICU for closer monitoring.

4. Definitions: Hypertension: Hypertensive Urgency:
Stage I: /90-99
Stage II: >160/100
Hypertensive Urgency:
Systolic BP >180 or Diastolic BP >120 in the absence of end-organ damage

5. Definitions Continued:
Hypertensive Emergencies:
SBP >180 OR DBP>120 in the presence of end-organ damage
Malignant Hypertension: End-organ damage--eyes, kidneys, brain (hemorrhage/infarct) affected
Hypertensive encephalopathy: Cerebral edema leading to neurological symptoms
End-organ damage is important to differentiate Emergency from Urgency, as treatment options can be very different.

6. Signs and Symptoms: Hypertensive Urgency:
Can be completely asymptomatic
Some symptoms include:
Severe headache
Shortness of breath
Nosebleeds
Severe anxiety
Signs:
Elevated BP on consecutive readings
Blood pressure should be repeated whenever a high value is obtained on the initial reading; consecutive elevated BP readings should lead the physician to titrate medications for optimal BP control

7. S&S Continued Hypertensive Emergencies Symptoms:
nausea, vomiting (cerebral edema)
Chest Pain
SOB
Blurry vision
Confusion
Loss of consciousness

8. Signs: Retinal hemorrhages, exudates, or papilledema
Renal involvement (malignant nephrosclerosis) with AKI, proteinuria, hematuria
Cerebral edema  seizures and coma
Pulmonary Edema
Myocardial Infarction
Hemorrhagic Stroke, lacunar infarcts

9. Treatment Options Hypertensive Urgency:
Goal: Reduce BP to <160/100 over several hours to day
Elderly at high risk of ischemia from rapid reduction of BP, therefore slower reduction in BP in this patient population
Previously treated hypertension:
Increase dose of existing med or add another med
Reinstitution of med in non-compliant patients
Patients coming to the ED with hypertensive urgency can be given po antihypertensives, monitored for reduction in BP, and sent home after their medication dosage has been titrated.

10. Treatment continued Hypertensive Urgency continued:
Previously untreated hypertension:
Slow reduction of BP (one to two days): Amlodipine, Metoprolol XL, lisinopril (po anti-hypertensives usually enough)
Experts recommend: Initiate two agents or a combination agent (one being a thiazide diuretic)
Rationale: Most patients with BP >20/10 above goal will require two agents to control their BP
-Rapid vs slow reduction depends on patient’s risk factors (elderly, h/o stroke, h/o CAD etc)—in such patients BP should be reduced slowly to avoid ischemia
-These patients should be started on po antihypertensive agents for better BP control once they leave the hospital; close follow-up with a PCP is necessary.

11. Treatment Continued Hypertensive Emergency:
Goal: Lower Diastolic BP to approximately over 2-6 hours; max initial fall not to exceed 25%
More aggressive decrease can lead to ischemic stroke and myocardial ischemia
If focal neurological sx presentobtain MRI to r/o acute stroke (rapid BP correction contraindicated)
Parenteral antihypertensives (IV Drip) recommended over oral agents in hypertensive emergency

12. Treatment
Recommended parenteral antihypertensive agents (IV drip) for Hypertensive Emergencies and admission to ICU
Nitroprusside (cautious about cyanide toxicity), Nicardipine, and Labetalol.
Once BP controlled, switch to oral anti-hypertensives and follow-up closely
Nitroprusside, Nicardipine, and labetalol are commonly used medications in an ICU setting. Nicardipine and Labetalol are contraindicated in acute heart failure. Nitroprusside can cause cyanide toxicity.

15. Clinical Vignette Revisited
65 y/o M with past medical history of Type II DM (on oral hypoglycemics), presenting with headache, chest pain and shortness of breath that developed after lunch the day of admission; non-exertional; no alleviating factors.
Physical Exam:
Vitals: 37.3, 195/125, 92, 24, 93% on RA
HEENT: Decreased A:V on retinal exam (<25%)
Heart: S4 heard on exam, no m/r/g
Lungs: mild resp distress, otherwise clear to auscultation
What’s the diagnosis and next best step in management?
This patient is having chest pain and shortness of breath. Patient has diabetes which is a risk factor for CAD, therefore looking at the clinic picture (EKG, h/o smoking etc), ACS should be ruled out. CXR should be obtained. Patient should be started on an IV antihypertensive and admitted to ICU for closer monitoring.

16. Summary Hypertensive Crises are common
Differentiate Hypertensive Urgency from Emergency on the basis of end-organ damage
Can treat hypertensive urgency with oral antihypertensives, but parenteral medications required for hypertensive emergencies
25% reduction in diastolic BP over 2-6 hours for hypertensive emergencies
Don’t forget to start Oral antihypertensives and follow-up closely!