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Hypertensive Crises Diagnosis and Treatment
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Hypertensive Crises Severely elevated(BP>220/130mmhg) blood pressure with signs and symptoms of acute end organ damage Requires hospitalization Requires parenteral medication
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Hypertensive Urgency Severely elevated blood pressure(BP>=220/130 mmhg) without signs and symptoms of acute end organ damage Can be managed as an outpatient Can be managed with short acting oral medications
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Severe Hypertension BP 180/110 to 220/130 without symptoms or acute organ damage Almost always occur in chronic HTN patients who stop their medication Treat with long acting oral drugs
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Hypertensive Crises Damage
CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy Damage Heart - CHF, MI, angina Kidneys - acute kidney injury, microscopic hematuria Vasculature - aortic dissection, eclampsia Vasculature
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Epidemiology Hypertensive emergencies are common Higher in the elderly
Occur in 1-2% of the hypertensive population But, 50 million hypertensive Americans 500,000 hypertensive emergencies/year Higher in the elderly Incidence in men 2 times higher than in women
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Initial Evaluation Assess for end-organ damage Vascular Disease
Assess pulses in all extremities Auscultate over renal arteries for bruits Cardiopulmonary Listen for rales (CHF) Murmurs or gallops
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Initial Evaluation Neurologic Exam Retinal Exam
Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures Lateralizing signs uncommon and suggest cerebrovascular accident Retinal Exam
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Retinopathy Grading Grade 1 Grade 2 Mild narrowing of the arterioles
“Copper Wire” Grade 2 Moderate narrowing Copper wire and AV nicking
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Retinopathy Grading Grade 3 Grade 4
Severe Narrowing Silver wire changes, hemorrhage, cotton wool spots, hard exudates Grade 4 Grade 3 + Papilledema Grade 3 and 4 highly correlated with progression to end organ damage and decreased survival
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Normal
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Grade 1
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Grade 3 Retinopathy
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Lab Testing ECG Renal Function Tests (urine included) CBC
LVH, look for signs of ischemia, injury, infarct Renal Function Tests (urine included) Elevated BUN, Creatinine, proteinuria, hematuria CBC CXR - pulmonary edema, aortic arch, cardiac enlargement
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Lab Testing Aortic Dissection? Pulmonary Edema/CHF
Suspect with severe tearing chest pain, unequal pulses, widened mediastinum Contrast Chest CT Scan or MRI Pulmonary Edema/CHF Transthoracic Echocardiogram
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Cerebral Blood Flow Autoregulation
Cerebral Blood constant in normotensive individuals over range of MAPs of mm Hg. In chronically hypertensive patients autoregulatory range is higher MAP Range to mm Hg Autoregulation also impaired in the elderly and those with cerebrovascular disease
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Management Hypertensive Crises(elevated BP with target organ damage)
Parenteral meds Goal - Reduce diastolic BP by 10-15% or to 110 mm Hg over a period of minutes
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Management Where? Which Parenteral meds? Depends on the situation
ICU with close monitoring Severe requires intra-arterial BP monitoring Which Parenteral meds? Depends on the situation
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Sodium nitroprusside Disadvantages of sodium nitroprusside
Decrease cerebral blood flow and increases intracranial pressure Can reduce regional blood flow in coronary artery disease Risk of cyanide toxicity Use when other agents not effective Monitor thiocyanate levels Avoid in renal or hepatic dysfunction Choice in Aortic Dissection,CHF microgm/kg/min
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Urapidil New central sympatholytic drug
Selective alpha -1 receptor blocks Dose mg /kg bolus and 5-40 mg/hr iv infusion Choice in HTN after CABG&After craniotomy
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Labetalol Alpha&Beta Blocker(Beta>Alpha)
Choice in Hypertensive encephalopathy,Ischemic&Hemorrhagic Stroke,Severe preeclampsia/eclampsia,Aortic Dissection 2-4 mg/min
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Management HTN crises with advanced retinopathy without reduction of consciousness(labetalol,nitroprusside,urapidil,nicardipine) HTN crises with encephalopathyBrain edema(posterior region)+ reduce of consciousness(10% reduction of BP in first hour and 15% in next 12 hours to 160/110
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Management HTN crises with acute or hemorrhagic stroke
With thrombolytic therapyBP <185/110 Without thrombolytic therapy15% reduction in BP In hemorrhagic strokeSBP<180 Urapidil,nicardipine,labetalol Avoid of nitroprusside ,hydralazine
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Management Acute coronary syndrome TNG +IV motoral or esmolol
Labetalol or urapidil Nitroprusside is cotraindicated Acute heart failure Nitroprusside is choice(+Lasix)
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Management Adernergic crisis(pheochromocytomaphentolamine+beta blocker or nitroprusside ,urapidil Clonidine withdrawal clonidine Cocaine or methamphetamine- induced HTN benzodiazepine +phentolamine
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Aortic Dissection Standard therapy Nitroprusside can be used as well
Beta-adrenergic blocker plus vasodilator Esmolol + Nicardipine Nitroprusside can be used as well
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Management Elevated BP without target organ damage
Hypertensive urgency Oral meds Goal - gradual reduction of BP over hours
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Thank you! Questions?
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