2. Hypertension affects > 65 million people in the United States and is one of the leading causes of death One to two percent of patients with hypertension have acute elevations of BP that require urgent medical treatment

4. Difference between hypertensive emergency and urgency Management of hypertensive crisis Special conditions of hypertensive crisis Case Scenario

6. End Stage Renal Disease (ESRD) Hypertension (HTN) Systemic Lupus Erythrematosus (SLE) Not compliant to restricted Na intake methyldopa stopped 2 months ago because of the SLE like side effect BP was controlled on the medication Not compliant to restricted Na intake methyldopa stopped 2 months ago because of the SLE like side effect BP was controlled on the medication 8 years on steroid therapy Lupus nephritis Multiple viral warts Leukopenia 8 years on steroid therapy Lupus nephritis Multiple viral warts Leukopenia As complication of lupus nephritis Hemodialysis (HD) 3 times a week for the past 6 months Planned for renal transplant As complication of lupus nephritis Hemodialysis (HD) 3 times a week for the past 6 months Planned for renal transplant

7. SLE: Prednisolone 5 mg PO OD ESRD: Epoeitin 8000 units SC 3 times a week Sevelamer 800 mg PO TID One  0.25 mcg PO OD Multivitamin 1 tab PO OD HTN: Metoprolol 100 mg PO TID Clonidine 200 mcg PO TID Nifedipine LA 60 mg PO TID SLE: Prednisolone 5 mg PO OD ESRD: Epoeitin 8000 units SC 3 times a week Sevelamer 800 mg PO TID One  0.25 mcg PO OD Multivitamin 1 tab PO OD HTN: Metoprolol 100 mg PO TID Clonidine 200 mcg PO TID Nifedipine LA 60 mg PO TID

9. Shortness of breath (orthopnea) for one day Blood pressure 230/120 mmHg Chest x-ray reveled pulmonary interstitial infiltration No history of : Cough Palpitation Chest pain Convulsion Visual disturbance

10. The patient received 40mg IV furosemide Sent to RDU for emergency HD UF 3 kg was removed The patient received 40mg IV furosemide Sent to RDU for emergency HD UF 3 kg was removed

12. SLE and ESRD: same medications HTN: Furosemide 40 mg IV BID Metoprolol 100 mg PO TID Clonidine 200 mcg PO TID Nifedipine LA 60 mg PO TID Labetalol 200 mg PO QID

13. SLE and ESRD: same medications HTN: Labetalol 200 mg PO QID Clonidine 200 mcg PO TID Nifedipine LA 60 mg PO TID Furosemide 40 mg IV BID Labetalol 400 mg PO QID

16. SLE and ESRD: same medications HTN: Enalapril 20 mg PO BID Nitroglycerin 200 mcg/ml IV infusion Labetalol 400 mg PO QID Clonidine 200 mcg PO TID Nifedipine LA 60 mg PO TID Furosemide 40 mg IV BID Clonidine 300 mcg PO TID HTN Urgency < 180/120 mmHg

17. SLE and ESRD: same medications HTN: Labetalol 400 mg PO QID Clonidine 300 mcg PO TID Nifedipine LA 60 mg PO TID Furosemide 40 mg IV BID Enalapril 20 mg PO BID Nitroglycerin 200 mcg/ml IV infusion Nifedipine LA 90 mg PO TID

18. The patient BP was controlled so the patient discharged on the same medications Labetalol 400 mg PO QID Clonidine 300 mcg PO TID Nifedipine LA 90 mg PO TID Enalapril 20 mg PO BID

19. Labetalol 400 mg PO QID Clonidine 300 mcg PO TID Enalapril 20 mg PO BID Nifedipine LA 90 mg PO TID Metoprolol 100 mg PO TID Clonidine 200 mcg PO TID Nifedipine LA 60 mg PO TID Past medications Discharged medications

21. Systolic BP (SBP) > 179 mm Hg or a diastolic BP (DBP) >109 mm Hg “HYPERTENSIVE CRISIS” Absence of acute target- organ involvement Presence of acute end-organ damage “Hypertensive Urgencies” “Hypertensive Emergencies” Important in formulating a therapeutic plan BP should be lowered immediately, although not to “normal” levels BP should be reduced within 24 to 48 h

22. Hypertensive encephalopathy Acute aortic dissection Acute coronary syndrome Pulmonary edema with respiratory failure Severe pre-eclampsia, HELLP syndrome, eclampsia Acute renal failure Microangiopathic hemolytic anemia Hypertensive encephalopathy Acute aortic dissection Acute coronary syndrome Pulmonary edema with respiratory failure Severe pre-eclampsia, HELLP syndrome, eclampsia Acute renal failure Microangiopathic hemolytic anemia

23. The failure to adhere to prescribed antihypertensive regimens Inadequate control of BP The lack of a primary care physician The failure to adhere to prescribed antihypertensive regimens Inadequate control of BP The lack of a primary care physician

24. Autoregulation is a specific form of homeostasis used to describe the tendency of the body to keep blood flow constant when blood pressure varies Normotensive Hypertensive Organ Blood Flow Mean Arterial Blood Pressure (mmHg)

25. The preferred agents include labetalol, esmolol, nicardipine, and fenoldopam Oral and sublingual nifedipine are potentially dangerous in patients with hypertensive emergencies and are not recommended Clonidine and angiotensin-converting enzyme (ACE) inhibitors are long acting and poorly titratable The preferred agents include labetalol, esmolol, nicardipine, and fenoldopam Oral and sublingual nifedipine are potentially dangerous in patients with hypertensive emergencies and are not recommended Clonidine and angiotensin-converting enzyme (ACE) inhibitors are long acting and poorly titratable

26. The onset of action within 2-5 min Duration of action 2-4 hours The onset of action within 2-5 min Duration of action 2-4 hours Labetalol is a combined selective  1 -adrenergic and nonselective  -adrenergic receptor blocker with an alfa to beta blocking ratio of 1:7 Labetalol maintains cardiac output Cerebral, renal, and coronary blood flow are also maintained Labetalol maintains cardiac output Cerebral, renal, and coronary blood flow are also maintained

27. The onset of action within 5-15 min Duration of action 4-6 hours The onset of action within 5-15 min Duration of action 4-6 hours Nicardipine is a second-generation dihydropyridine derivative calcium-channel blocker with high vascular selectivity and strong cerebral and coronary vasodilatory activity IV nicardipine has been shown to reduce both cardiac and cerebral ischemia IV nicardipine has been shown to reduce both cardiac and cerebral ischemia

28. The onset of action within 60 sec Duration of action 10 to 20 min The onset of action within 60 sec Duration of action 10 to 20 min Esmolol is an ultrashort-acting   -adrenergic blocking agent The metabolism of esmolol is via rapid hydrolysis of ester linkages by RBC esterases and is not dependant on renal or hepatic function “ideal  –adrenergic blocker” for use in critically ill patients

29. The onset of action 5 min Duration of action 30 to 60 min The onset of action 5 min Duration of action 30 to 60 min No rebound hypertension Fenoldopam improves creatinine clearance in severely hypertensive patients with both normal and impaired renal function No rebound hypertension Fenoldopam improves creatinine clearance in severely hypertensive patients with both normal and impaired renal function It mediates peripheral vasodilation by acting on peripheral dopamine-1receptors

30. It is a very potent arterial and venous vasodilator that decreases both afterload and preload Intraarterial BP monitoring is recommended It requires special precaution to prevent severe toxicity and adverse events It requires special handling to prevent its degradation by light Intraarterial BP monitoring is recommended It requires special precaution to prevent severe toxicity and adverse events It requires special handling to prevent its degradation by light The onset of action seconds Duration of action 1 to 2 min The onset of action seconds Duration of action 1 to 2 min Factors limiting the use of nitroprusside:

31. Nitroprusside Nonenzymatically release Cyanide (toxic) Thiosulfate Liver Thiocyanate (less toxic) Kidney excretion Contraindications: Increased intracranial pressure Coronary artery disease Hepatic or renal impairment Nitroprusside decreases blood flow Increased risk of cyanide toxicity

32. Precautions: The drug should only be used when other IV antihypertensive agents are not available and in certain circumstances and in patients with normal kidney and liver function The duration of treatment should be as short as possible infusion rate should not be > 2 mcg/kg/min Precautions: The drug should only be used when other IV antihypertensive agents are not available and in certain circumstances and in patients with normal kidney and liver function The duration of treatment should be as short as possible infusion rate should not be > 2 mcg/kg/min

33. It reduces afterload without affecting cardiac filling pressures or causing reflex tachycardia It is third-generation dihydropyridine calcium channel blocker with an ultrashort-acting selective arteriolar vasodilator properties It is rapidly metabolized by RBC esterases. Thus, its metabolism is not affected by renal or hepatic function

34. But Sublingual Oral It has been widely used via oral or sublingual administration in the management of hypertensive emergencies This rout is not FDA approved

35. Nitroglycerin reduces BP by reducing preload and cardiac output It causes hypotension and reflex tachycardia Nitroglycerin reduces BP by reducing preload and cardiac output It causes hypotension and reflex tachycardia It is a potent venodilator and only at high doses affects arterial tone Low-dose administration (60 mg/min) may be used as an adjunct to IV antihypertensive therapy in patients with hypertensive emergencies associated with acute coronary syndromes or acute pulmonary edema Low-dose administration (60 mg/min) may be used as an adjunct to IV antihypertensive therapy in patients with hypertensive emergencies associated with acute coronary syndromes or acute pulmonary edema

36. Following IM or IV administration, there is an initial latent period of 5 to 15 min followed by a progressive and often precipitous fall in BP that can last up to 12 h It is a direct-acting vasodilator

38. Treatment: Vasodilator AlternativeDrug of Choice  -blocker Nitroprusside MetoprololEsmolol Nicardipine fenoldopam If vasodilator alone: reflex tachycardia increase aortic ejection velocity promote dissection propagation

39. Cerebral Ischemia Cerebral Hemorrhage withhold antihypertensive therapy for acute ischemic stroke unless planned thrombolysis evidence of concomitant noncerebral acute organ damage if the BP is excessively high, a SBP 220 mm Hg or a DBP 120 mm

40. Cerebral Hemorrhage The controlled lowering of the BP is currently recommended only when SBP is > 200 mm Hg DBP is > 110 mm Hg MAP is > 130 mm Hg Nicardipine has been demonstrated to be an effective agent for the control of BP in patients with intracerebral hemorrhage

41. Initial treatment for preeclampsia Magnesium sulfate for seizure prophylaxis Blood pressure control Volume expansion Nitroprusside and ACE inhibitors are contraindicated in pregnant patients IV labetalol or nicardipine

42. Hypertensive crisis is medical emergency that requires immediate treatment Target-organ damage differentiates emergency versus urgency Hypertensive emergency should be treated with parenteral medications of rapid onset of action and short duration Blood pressure should not be rapidly reduced Hypertensive crisis is medical emergency that requires immediate treatment Target-organ damage differentiates emergency versus urgency Hypertensive emergency should be treated with parenteral medications of rapid onset of action and short duration Blood pressure should not be rapidly reduced