1. Severely Increased Blood Pressure In The ED: Treating The Mercury? Rick Blubaugh, D.O. Cornerstone Physician’s Management Group Skaggs Community Health Center Branson, MO

2. Case History 50 y/o male 50 y/o male History of hypertension History of hypertension Hasn’t taken meds in 1 year Hasn’t taken meds in 1 year C/O headache & malaise for 2 days C/O headache & malaise for 2 days Exam: remarkable only for BP 210/120 & grade I retinopathy Exam: remarkable only for BP 210/120 & grade I retinopathy

3. Questions For EP Is patient stable? Is patient stable? Is further WU indicated? & if so, what? Is further WU indicated? & if so, what? Does pt require immediate intervention? & if so, what? Does pt require immediate intervention? & if so, what? Does pt require admission or monitoring, or if D/C’d, how soon should he be seen in follow up? Does pt require admission or monitoring, or if D/C’d, how soon should he be seen in follow up?

4. Background Prolonged & severely increased BP causes cerebral, cardiovascular, and renal disease (Target Organs). Prolonged & severely increased BP causes cerebral, cardiovascular, and renal disease (Target Organs). Morbidity & mortality can be improved with treatment Morbidity & mortality can be improved with treatment Limited data concerning acutely elevated blood pressure Limited data concerning acutely elevated blood pressure

5. Physiology Affects heart, brain, kidneys, & large arteries Affects heart, brain, kidneys, & large arteries Chronic HTN causes right shift in pressure flow autoregulation curve Chronic HTN causes right shift in pressure flow autoregulation curve When BP decreases, cerebral vasodilation occurs When BP decreases, cerebral vasodilation occurs When BP increases, constriction occurs When BP increases, constriction occurs Cerebral perfusion pressure remains constant despite fluctations in MAP Cerebral perfusion pressure remains constant despite fluctations in MAP

6. Normal individuals: cerebral blood flow remains constant for MAP of 60-150 mm Hg Normal individuals: cerebral blood flow remains constant for MAP of 60-150 mm Hg When MAP decreases to less than lower limits of autoregulation, the brain becomes hypoperfused & cerebral hypoxia occurs. When MAP decreases to less than lower limits of autoregulation, the brain becomes hypoperfused & cerebral hypoxia occurs. MAP = Diastolic + 1/3 (Systolic – Diastolic) MAP = Diastolic + 1/3 (Systolic – Diastolic) Cerebral perfusion pressure = MAP – Intracranial pressure Cerebral perfusion pressure = MAP – Intracranial pressure Chronic hypertension: lower limit of autoreguation is increased Chronic hypertension: lower limit of autoreguation is increased Autoregulation might fail at MAPs well tolerated in normotensive individuals Autoregulation might fail at MAPs well tolerated in normotensive individuals

7. Lower limit of autoregulation is approximately 25% of MAP Lower limit of autoregulation is approximately 25% of MAP Therefore, MAP should not be lowered by more than 20-25% Therefore, MAP should not be lowered by more than 20-25%

8. Copyright ©1998 American Physiological Society Gao, E. et al. Am J Physiol Heart Circ Physiol 274: H1023-H1031 1998 Fig. 4. Autoregulation Curve

9. Clinical Evaluation BP 180/110: immediate or evaluation within 1 week (Joint National Committee- VI Guidelines) BP 180/110: immediate or evaluation within 1 week (Joint National Committee- VI Guidelines) Recheck BP: many spontaneously reduce Recheck BP: many spontaneously reduce Seated, arm at level of heart, both arms Seated, arm at level of heart, both arms Automated cuff inaccurate in A-Fib or irreg Automated cuff inaccurate in A-Fib or irreg Manage pain or underlying causes Manage pain or underlying causes

10. Fundoscopic exam: retinal hemorrage or papilledema Fundoscopic exam: retinal hemorrage or papilledema Cardiovascuar exam: Identify heart failure Cardiovascuar exam: Identify heart failure Neuro exam: LOC, visual fields, motor & sensory deficits Neuro exam: LOC, visual fields, motor & sensory deficits Serum creatinine Serum creatinine ECG ECG Med History including OTC Med History including OTC Urine drug screen: cocaine, amphetamine Urine drug screen: cocaine, amphetamine

11. Stratification of Hypertensive Events Emergent Emergent Urgent Urgent Uncontrolled hypertension Uncontrolled hypertension

12. Hypertensive Emergency Rapid, progressive decompensation or damage of target organs Rapid, progressive decompensation or damage of target organs Hypertensive encephalopathy, or brain hemorrage Hypertensive encephalopathy, or brain hemorrage Acute aortic dissection, acute LV failure, AMI, unstable angina, symptomatic aortic aneurysm. Acute aortic dissection, acute LV failure, AMI, unstable angina, symptomatic aortic aneurysm. Acute glomerulonephritis,kidney transplant Acute glomerulonephritis,kidney transplant

13. Hypertensive Emergency Pheochromocytoma Pheochromocytoma Sympathomimetic use Sympathomimetic use Severe burns Severe burns Severe epistaxis Severe epistaxis Eclampsia/preeclampsia Eclampsia/preeclampsia

14. Requires immediate (1-2 hours) BP reduction Requires immediate (1-2 hours) BP reduction Parenteral agent Parenteral agent Nitroprusside – most events Nitroprusside – most events Labetalol – intracranial disorders (does not dilate cerebral vessels) Labetalol – intracranial disorders (does not dilate cerebral vessels) B- blockers – aortic dissection (blocks reflex tachycardia) B- blockers – aortic dissection (blocks reflex tachycardia) Oral agents – should not be used (limited data, high failure rates, not titratable, uncontrolled hypotension) Oral agents – should not be used (limited data, high failure rates, not titratable, uncontrolled hypotension)

15. Emergent Blood Pressure Reduction Should not exceed 20%-25% of pretreatment BP Should not exceed 20%-25% of pretreatment BP 1 st 30-60 Min: Reduce MAP to 110-115 1 st 30-60 Min: Reduce MAP to 110-115 Further reduction over next 24 hours Further reduction over next 24 hours

16. Hemorrhagic & Ischemic CVA When systolic BP is reduced, cerebral autoregulation might fail leading to extension of CVA When systolic BP is reduced, cerebral autoregulation might fail leading to extension of CVA Some believe that elevated MAP is protective in CVA Some believe that elevated MAP is protective in CVA AHA: reduce BP in CVA only when MAP is > 130mm Hg or SBP > 220 mm Hg AHA: reduce BP in CVA only when MAP is > 130mm Hg or SBP > 220 mm Hg Esmolol & labetalol are good choices Esmolol & labetalol are good choices Nipride – cerebral vasodilation Nipride – cerebral vasodilation

17. Cardiovascular Emergencies CHF – nitroprusside & ACE inhibitor CHF – nitroprusside & ACE inhibitor ACS – nitroglycerine – reduce BP to normal levels ACS – nitroglycerine – reduce BP to normal levels Aortic Dissection – nitroprusside + B- blocker. Aortic Dissection – nitroprusside + B- blocker.

18. Hypertensive Urgency Controversial Controversial History of prior target organ disease (CHF, CAD, angina, renal insuff, TIA, or CVA) History of prior target organ disease (CHF, CAD, angina, renal insuff, TIA, or CVA) Treatment strategy should be initiated in ED, although BP does not necessarily need to be reduced in ED Treatment strategy should be initiated in ED, although BP does not necessarily need to be reduced in ED Reliance on specific numbers is inadequate Reliance on specific numbers is inadequate

19. Hypertensive Urgency VA Cooperative Study: no adverse outcomes within first 3 months in patients who had DBP 115-130mm Hg VA Cooperative Study: no adverse outcomes within first 3 months in patients who had DBP 115-130mm Hg No evidence to support practice of treating hypertension by reducing BP acutely in ED No evidence to support practice of treating hypertension by reducing BP acutely in ED Numerous reports of adverse outcomes with acute, rapid reduction of BP in ED. Numerous reports of adverse outcomes with acute, rapid reduction of BP in ED.

20. Uncontrolled Hypertension Asymptomatic elevated BP without evidence of target organ disease Asymptomatic elevated BP without evidence of target organ disease Represents majority of patients with elevated BP in ED Represents majority of patients with elevated BP in ED Goal: lifelong BP control Goal: lifelong BP control Treat pain or infection Treat pain or infection Refer for recheck after primary problem resolved ( 1 week) Refer for recheck after primary problem resolved ( 1 week)

21. Uncontrolled Hypertension If patient has quit taking antihypertensive meds – then restart them If patient has quit taking antihypertensive meds – then restart them 1/3 of patients in ED with DBP > 95 mmHg were normotensive at follow-up 1/3 of patients in ED with DBP > 95 mmHg were normotensive at follow-up

22. Initial Oral Drug Choices

24. Case Revisited Tx: analgesia for headache Tx: analgesia for headache Lab: Serum creatinine, UA, ECG Lab: Serum creatinine, UA, ECG CT: if findings on H&P suggest CNS involvement CT: if findings on H&P suggest CNS involvement

25. If history or CT scan shows prior CVA, then patient qualifies as hypertensive urgency – justifying initiation of maintenance treatment If history or CT scan shows prior CVA, then patient qualifies as hypertensive urgency – justifying initiation of maintenance treatment Best regimen is one that previously worked Best regimen is one that previously worked Otherwise – diuretic & B-blocker Otherwise – diuretic & B-blocker Follow up in 1 week or observation Follow up in 1 week or observation

26. Case If clinical exam & work up is negative & BP remains elevated after resolution of headache, then patient is stratified as uncontrolled hypertension If clinical exam & work up is negative & BP remains elevated after resolution of headache, then patient is stratified as uncontrolled hypertension Follow –up with PCP Follow –up with PCP

27. Summary Hypertensive Emergency – rapidy, progressive end-organ damage. Hypertensive Emergency – rapidy, progressive end-organ damage. Needs parenteral meds & ICU Needs parenteral meds & ICU Caution in cerebrovascular events Caution in cerebrovascular events

28. Summary Hypertensive Urgency – BP elevated > 180/110 & history of end- organ disease. Hypertensive Urgency – BP elevated > 180/110 & history of end- organ disease. Initiate oral meds & short term follow up or observation Initiate oral meds & short term follow up or observation Uncontrolled Hypertension – asymptomatic Uncontrolled Hypertension – asymptomatic Referral to PCP & education Referral to PCP & education