1. Hypertension Dr. Stella Yiu Staff Emergency Physician

2. LMCC objectives: Hypertension Diagnose and determine severity Investigate target organ damage and 2 nd causes List medical management (po and iv)

3. 1. Diagnosis

4. Cdn 2012 guidelines > 160 or > 100 x 3 Or > 140 or > 90 x 5

5. Most HTN = Essential HTN 5-10% 2 nd – curable More demand on pump or Stiff pipes

6. 2. 2 nd causes

7. 2 nd Causes:  Cardiac output (pump demand) Renal failure + fluid overload ++ aldosterone Aortic coarctation

8. 2 nd Causes:  Vascular resistance (stiff pipes) Renal artery stenosis Pheochromocytoma Drugs Brain (CVA, ICH, SAH)

9. MCQ 8: What is the most common treatable 2 nd cause for HTN? A.Hyperaldosteronism B.Renal artery stenosis C.Pheochromocytoma D.Aortic coarctation E.Sympathomimetic use

10. CDMQ: What are the clinical clues and investigations for 2 nd causes?

11.  Cardiac output (pump stress) Renal failure + fluid overload ++ Aldosterone Aortic coarctation

12.  Vascular resistance (stiff pipes) Renal artery stenosis Pheochromocytoma Drugs Brain (CVA, ICH, SAH)

13. Investigations Renal failure + fluid overload Creatinine, CXR

14. Investigations ++ aldosterone High Na, Low K Cushingoid on exam

15. Investigations Aortic coarctation HTN in Upper extremity Systolic murmur over back Delayed Femoral Pulse Echo, Angio

16.  Vascular resistance (stiff pipes) Renal artery stenosis Young female + fibromuscular dysplasia Resistant to HTN meds Most common treatable cause Abdo bruits, low K, Abdo US

17.  Vascular resistance (stiff pipes) Pheochro- mocytoma Episodes of HTN + HA + palp +diaphoresis Urine catecholamines, metanephrines

18.  Vascular resistance (stiff pipes) DrugsAmphetamines, sympathomimetics MAOI Clinical exam: toxidrome Urine tox ECG

19.  Vascular resistance (stiff pipes) Brain (CVA, ICH, SAH) CT head

20. 3. Manage HTN emergency

21. What are the target organs?

23. MCQ 9: Which is not an HTN emergency? A.35 M 220/140, dizzy, normal neuro exam B.50 M 200/120, chest pain, CXR wide mediastinum C.25 F 28 wks pregnant, 150/80, seizure D.80 F 220/120, left arm weakness E.45 F 200/120, crackles to apex, JVP 6cm

24. ACS Pulmonary edema Aortic Dissection

25. Bleeds, seizures Encephalopathy (not just headache, dizzy) Acute renal failure

26. CDMQ: List Investigations for HTN emergency

27. Investigations for HTN emergency ACS Pulmonary edema Aortic Dissection Bleeds, seizure, encephalopathy ARF

28. Treat HTN emergency: General BP: Reduce MAP by 25% Iv medications: Labetolol Nitroprusside Hydralazine

29. CDMQ: 45 F 220/120, bilateral crackles, JVP 6cm, Sat 80%, treatment?

30. Specific Treatment: Pulmonary Edema BiPAP Nitrates iv Furosemide iv

31. Specific Treatment: ACS ASA NTG Beta-blockers

32. Specific Treatment: Dissection Iv Nitroprusside + beta-blocker Iv labetolol Surgery if ascending aorta

33. Specific Treatment: Seizure+ preg (Eclampsia) MgSO4 Iv Hydralazine Delivery

34. 3. Manage HTN in Ambulatory setting

35. Diagnosis > 160 or > 100 x 3 or > 140 or > 90 x 5

36. MCQ 10: What test is not needed in ambulatory testing for HTN? A.Urine, urine albumin (DM) B.Lytes + creatinine C.Fasting glucose + cholesterol D.CBC + diff E.ECG

37. Treatment HTN ambulatory Non-pharmacological management

38. First line med, dosage and side effects? No other comorbidities? CAD? Diabetes? Asthma? Renal failure?

39. No co-morbid – 1 st line Thiazide (HCTZ 25 1 ) Beta-blocker (Metoprolol 25 2 ) CCB (Amlodipine 5 1 ) ARB (Losartan 25mg )

40. DM + Renal: ACEI/ARB CCB Thiazide

41. Asthma Avoid beta-blocker

42. CRF (non-DM) ACEI/ARB Thiazide

43. CAD ACEI /ARB Angina/recent MI: Beta-blocker

44. Improving compliance Fit daily routine Once daily dosing Single pill combination Dosette

45. LMCC objectives: Hypertension Diagnose and determine severity Investigate target organ damage and 2 nd causes List medical management (po and iv)