1. This lecture was conducted during the Nephrology Unit Grand Ground by a Sub-intern under Nephrology Division, Department of Medicine in King Saud University. Nephrology Division is NOT responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. Urgency & emergency hypertension Alhnouf Alaloola King saud university 441 medicine nephrology

3. Outlines  Definition and classifications of hypertension  Definition of Urgency &Emergency HTN  Patient clinical Presentation  Points should be covered in history taking  Management

4. Hypertension  chronic medical condition in which the blood pressure is above 140/90 mmHg. ClassificationSystolic pressure mmHg Diastolic pressure mmHg Normal90–11960–79 Pre-HTN120–13980–89 Stage 1 HTN 140–15990–99 Stage 2 HTN ≥160 ≥100 HTN crises >180>120

5. HTN Classification  Primary (essential)  Secondary 90-95 %5-10 % Increased total peripheral resistance while cardiac output remains normal. No obvious cause.  Renal disease  endocrine conditions ( Cushing's syndrome, hyperthyroidism, acromegaly, hyperaldosteronism)  obesity, sleep apnea, pregnancy, coarctation of the aorta,

6. Urgency & Emergency HTN  Urgency HTN : BP is >180/120 mm Hg with minimal / NO target-organ damage.  Emergency HTN : BP is >180/120 mm Hg with target-organ damage.

7. Clinical Presentation

8.  Persistent BP > 180/120 mm Hg.  Cerebral infarction (24.5%) Pulmonary edema (22.5%) Hypertensive encephalopathy (16.3%) Congestive heart failure (12%)  Others: intracranial hemorrhage, aortic dissection, and eclampsia, acute myocardial infarction. Emergency HTN

9. Points to cover in history

10. Important in clinical History  When he/she was diagnosed with HTN.  Baseline BP.  antiHTN therapy and compliance.  Abrupt stoppage of one of the medications or delay in a dose. ( rebound hypertension )  Intake of over the counter medications or illicit drug use. NSAID, cocaine Hypertension

11. Important in clinical History  Symptoms suggestive of end-organ damage Chest or back pain. Shortness of breath, headache, blurred vision, altered mental status.  Previous end-organ damage.  Other medical conditions ( SLE, Cushig disease, thyroid disease ) End – Organ damage

12. Management

13. Urgency HTN  BP should should be lowered gradually over 12 to 24 hours.  target level approximately 160/110 mm Hg.  Oral antihypertensive agent.  Outpatient or same-day observation & follow up in 2-4 days.

14. Urgency HTN  Hypertensive agents Captopril ( ACE inhibitor ) Nicardipine ( Ca channel blocker ) Labetalol ( a- B blocker ) Clonidine ( a2 agonist )

15. Emergency HTN  Precise and rapid control of blood pressure is critical. (not very rapid)  Requires the use of parenteral agents  Managed in an intensive care unit

16. Emergency HTN  Rate of reduction : recommended reduction in MAP 10%  first hour 15%  next 2 to 3 hours. ( Ideal unclear ) More rapid reduction in blood pressure may result in cardiac or cerebrovascular hypo- perfusion.  BP should not be lowered to less than 140/90 mm Hg, except in patients with aortic dissection or eclampsia.

17. Neurologic emergencies  Hypertensive encephalopathy : Reduce 25% of MAP over 8 hrs. Labetalol, Fenoldepam, Esmolol.  Ischemic stroke : labetalol and nicardipine.  Acute intracerebral hemorrhage : labetalol, nicardipine, and esmolol.

18. Neurologic emergencies Avoid nitroprusside and hydralazine In ICP

19. Cardiovascular emergencies  Aortic dissection Labetalol, nicardipine, nitroprusside, esmolol.  Acute MI Labetalol, nitroglycerin, esmolol.

20. Eclampsia  hydralazine, labetalol, and nifedipine. Avoid Nitroprusside, ACE inhibitors, esmolo. Cyanide toxicity and fetal abnormalities

21. Others  Cocaine toxicity Diazepam, phentolamine, and nitroprusside.  Pheochromocytoma a blocker (Phentolamine) then B- blocker.  Acute renal failure Fenoldepam, nicardipine.

23. References  http://emedicine.medscape.com/article/1952052- overview#aw2aab6b2.  http://en.wikipedia.org/wiki/Hypertension#Secondary_hy pertension_2.  C. Vaidya, J. Ouellette, Hypertensive Urgency and Emergency. Hospital Physician 2007; 43-50.  K. Kuppasani, A. Reddi. Emergency or urgency? How to effectively manage a hypertensive crisis. JAAPA 2010.