1. Hypertensive Crises Nadim J Lalani 08.03.2007 Thanks to Dr Sarah McPherson Dr Trevor Langhan [who usually presents this talk]

2. Famous Last words? “I have a terrific headache” April 12 1945

3. Clues: Survived Assassination Feb 1933 “we have nothing to fear but fear itself” President during Pearl Harbor

4. FDR Arguably the greatest US President of all time Only US President to be elected to 4 terms “New Deal” brought the US back from the Great Depression  Social Security Suffered from complications of GBS and was a paraplegic Started the “March of Dimes”  is on the dime Dies April 12 1945 of ICH from Hypertension

5. West J Med. 2001 August; 175(2): 119–124.

6. Objectives Definitions Pathophys [briefly] Cases Q/A format:

7. Definitions? Normal BP? – sys BP < 120 mm Hg – dias BP < 80 mm Hg Hypertension? –sBP > 140 mm Hg –dBP > 90 mm Hg In Between = “prehypertension” Hypertension acc to Rosen: –SBP > 160 –DBP > 95

8. Definitions? Hypertensive Crisis? Hypertensive Urgency? Hypertensive emergency? Malignant Hypertension? Severe Hypertension?

9. Definitions

10. Malignant/Severe Hypertension Malignant: Older term [no longer used]  but often asked for it by attendings Essentially Hypertensive Emergency  with the end organ effects Severe: Sys BP > 180 Dias BP > 120 No end organ effects

11. What Counts as “End organ Damage”? HEADTOTOEHEADTOTOE

12. Hypertensive “syndromes” Encephalopathy Stroke Pulmonary edema ACS Aortic dissection Pregnant Renal failure Other end-organ [retinal findings, hemolysis]

14. BP Measurement

15. If no extinguishment NB Cuff Size 10 minutes in between Pt supine/ lights off &c.

16. Increased BP in the ED Things that cause “reactive” HTN in the ED? –Anxiety –Pain –Drugs (illicit - cocaine, amphetamines, LSD, PCP & OTC’s) –ETOH withdrawal –BP cuff too small –Machine vs sphygmomanometer

17. Hypertension Classified into: –Primary = Essential Hypertension [95%] –Secondary [5%] Secondary more likely to cause severe HTn

18. Essential hypertension Cause not entirely understood –Theories…. Alterations in contractile properties of vascular smooth muscle Change in vascular smooth muscle from chronic elevated BP from primary failure of normal autoregulation Change in RAAS p-way

19. Secondary Hypertension

20. Specific 2 0 causes 1)Renal Disease: [most prevalent]  Renal artery stenosis  high renin state  Fibromuscular dysplasia of the renal artery –Young white women –Flank bruits  Primary renal disease (e.g chronic pyelo) ? From local ischemia  Renin secreting tumors

21. 2) Arterial disease: large artery abN can lead to HTn Coarctation of the aorta TRIAD? Upper extremity hypertension Possible delayed femoral pulses Systolic murmur heard over the back Loss of elasticity of the arteries with age

22. 3) Glucocorticoids: Iatrogenic Cushing’s –1 0 Pituitary tumor  ACTH –ACTH – secreting tumor [>50% lung] –Adrenal tumors Primary hyperaldosteronism [Conn’s] –hypokalemia

23. 4)Pheochromocytoma: Catecholamine-secreting tumors Also w/ Neurofibro & MEN type ii Clinically –Paroxysms of HTN –Tachycardia –Fatigue –Malaise –Sweating –Apprehension Elevated urine catecholamines and metanephrines Nb any incidental adrenaloma  screen for pheo

24. 4) Drugs  Sympathomimetics &c.  MAOI and tyramine  Withdrawal  and  blockers ETOH, benzos 

25. ED Presentation Four general ways: –Hypertensive emergencies Requires BP reduction in 1h –Hypertensive urgency –Mild-moderate hypertension –Transient hypertension

26. Approach ABC’s Assess whether the reading is correct Hx &P/E: –Pulmonary Oedema? –CHF / Ischemia/ dissection? –High ICP/ SAH/ Neuro deficits? Diagnostix –Lytes, Urine +/ - TNT, EKG, CXR, +/- CT head Is this a Hypertensive Emergency?

27. Fundoscopy

29. Case 1 84 yo F presents to the ED c/o HA feeling unwell for 1 week Hx HTn O/e: BP 190/130, HR 80, rest of exam N Approach?

30. Hypertensive Urgency No benefit to treating in the ED Real risk of harm even with appropriate MAP reduction Most will have lower BP on f/u exams Bottom Line : DON’T TREAT  but refer

32. Recommendations

33. Case 2 53-year-old M presents To ED w/ increased SOB, headache, N/V and visual changes, worsening for several days. O/e: Confused, BP 253/140 mm Hg. Approach?

34. Hypertensive encephalopathy Pathophys: –Acute increase in BP [ MAP usually > 160] –Overwhelms cerebral autoregulation [resistance vessels can’t cope] –Eventually leads to vasospasm & ischemia. –Ischemia leads to leaky capillaries and edema Clinically –Acute and reversible –Headache, vomiting, drowsiness, confusion, seizures, focal neuro deficits blurred vision –Normal CT head and bloodwork, elevated opening pressure on LP

35. Management: –Sodium Nitroprusside or Labetalol –Goal: decrease MAP by 25% in 1 hour –Keep DBP > 110 –Admit

36. Case 3  40 y female family hx HTN, CVA  Presents w/ L sided weakness  BP 190/120, HR 94, RR 14, sats 99%  O/E left facial droop, L dense hemi-plegia  Considerations?

37. Hypertensive Emergency- Stroke  Most (85%) are ischemic not hemorrhagic strokes  Elevated BP usually result of the stroke itself  May have mild to moderate BP elevation  NB!!  Lowering BP may worsen ischemic brain injury  watershed areas sensitive to hypoperfusion  Do not treat [exception is stroke 2 0 Ao Dissection]

38. Hypertensive Stroke - lytics  BP >185/110 is a contraindication to tPA  Lower BP 1st

39. Hypertensive stroke Management: –Labetalol agent of choice –Titrate slowly to goal reduction in MAP by a max of 20%

40. Hypertension + hemarrhagic Stroke  No data on acute BP lowering in ICH  ICH causes inc ICP  So May be inadvertently lowering CPP if you lower BP  My bottom line: treat only in concert with ICU/Nsx  If lowering is done, use an agent that dose not vasodilate  Avoid nitrates  Labetolol is best (ACE-I have some benefit)

41. Case 4 50 yo M at a “rave” comes into ED with ALOC [Pmhx: takes phenelzine] O/E: HR 100, BP 190/130, diaphoretic, GCS 9 and rigid extremeties Approach?

42. MAOI – drug interactions sympathetic surge Avoid B-blockers Management: ABCDEF’s of tox –Phentolamine 5mg IV over 1min repeat Q5-10min –Sodium nitroprusside 0.3 mcg/kg/min

43. Case 5 55 year male known LV dysfunction (EF 30%), Chronic HTN, smoker Has not been able to buy meds Presents to ED w/ incr SOB, leg swelling HR 95, BP 190/120, sats 89%, RR 25, Rales Approach?

44. Hypertension – Pulmonary edema Pts w/ CHF have incr PVR  so have HTn Poor control  LVH  LV failure Management: –Standard therapy for CHF –NTG / nitroprusside –Low dose ACE-i

45. Case 6  32 y female presents to ED c/o H/A, palpitations and feeling uneasy  BP 170/90, HR 150 sinus, RR 18, diaphoretic, pupils 6mm  Approach?  Patient leaves AMA

46. Case 7 Same lady comes back the next day with SOB, Palpitations after doing cocaine O/E: BP 190/100, HR 130, RR 28, sats 96%  EKG ST segment elevation V1-V3  Considerations?

47. Pheochromocytoma/Cocaine  Treatment:  Avoid Beta blockade  unopposed alpha  Nitroprusside if emergency  Phentolamine – 1-5 mg IV boluses (alpha- block)  With cocaine can use benzos to counteract sympathetic drive

48. Case 8  55 year male smoker, HTN, DM,  c/o left RSCP that radiated to his jaw after 1 st training run for his 10k this summer.  HR 120, BP 190/90, RR 19, sats 99%

49. EKG Approach?

50. HTn + ACS Management:  Immediate lowering of BP indicated to prevent myocardial damage  NTG agent of choice  Beta block [labetalol]  CCB (if BB is contraindicated)

51. Case 9  19 y pregnant primip presents to ED with increasing swelling to hands and face  O/e: Hr 100 BP 130/80  Approach?  5% pregnacies complicated by PIH  Preeclampsia = HTN, proteinuria + edema  Eclampsia = preeclampsia + coma/Sz  Both are Hypertensive Emergencies

52.  HTN in pregnancy Defined as BP > 140/90  W/u includes:  CBC, Creat, Urinalysis, Liver enzymes  Mild PIH  trial bed rest + close follow  If Persistently > 140/90 and symptomatic  admit

53.  When do you need drugs?  SBP > 160  DBP > 100  HELLP  Treatment:  Hydralazine 5mg Iv bolus + 5-10 mg q15 prn  Labetalol  Control Sz [Mg IM or Iv protocol]  Early Obs consult

54. Case 10 66 yo M Hx HTN presents to ED c/o ripping CP radiating to back O/E: BP 200/100, HR 120 CXR wide mediastinum Considerations?

55. Goal is to reduce shear forces Treat tachycardia and HTN –Labetalol + –Nitroprusside

56. drugs drugdoseonse t duratio n indicationContra- indication nitroprusside 0.3-10 ug/kg/min 1-2 min Any hypertensive emergency Pregnancy Prolong use Renal failure nitroglycerin 10-100 ug/min 2-5 min 3-5 minAMI, CHF hydralazine 5 mg 5-10mg q20min 10-20 min 3-8 hpreganancyAMI, aortic dissection esmolol 500ug/kg then 50-300 ug/kg/min 1-2 min 10-20 minCAD, aortic dissection CHF, heart block, asthma, catecholamine excess labetalol 20mg then 20-80 q10 min to max 300 OR 1-2 mg/min 2-10 min 2-4 hCAD, aortic dissection, eclampsia, hypertensive crisis CHF, heart block, asthma, catecholamine excess phentolamine 5 mg q 1-2 min 1-2 min 10-30 minCatecholamine excess AMI

57. References