1. Management of Hypertensive Emergencies
Dr. Abdulkareem Alsuwiada, FRCPC, MSc

2. Learning Objectives
To identify and triage severe hypertensive states accurately
To effectively manage hypertensive crises with drug therapy

3. Hypertensive Urgency “Severe elevation of blood pressure”
Generally DBP >
No progressive end organ damage
RISK OF IMMINENT TARGET ORGAN DAMAGE ALTHOUGH INJURY HAS NOT YET OCCURRED
NO EVIDENCE BASED DATA EXISTS TO GUIDE PRACTITIONER
IN MANY CASES CLINICIANS MAY BE FORCED TO INITIATE ANTI-HTN TREATMENT WITHOUT BEING CERTAIN OF DIAGNOSTIC CLASSIFICATION

4. Hypertensive Emergency
Severe elevation in blood pressure in the presence of acute or ongoing end-organ damage.

5. “Recognition of hypertensive emergency depends on the clinical state of the patient, not on the absolute level of blood pressure”

6. Target Organs

7. Hypertensive Emergency Key Points
Cardiac Emergencies
Acute CHF
Acute coronary insufficiency
Aortic dissection

8. Hypertensive Emergency Key Points
CNS Emergencies
Hypertensive encephalopathy
Intracerebral or subarachnoidal hemorrhage
Thrombotic brain infarction with severe HTN

9. Hypertensive Emergency Key Points
Renal Emergencies
Rapidly progressive renal failure

10. Fundoscopy/ Neuro Hemorrhages Exudates Papillodema
COTTON WOOL EXUDATES
PAPILLEDEMA
Hemorrhages
Exudates
Papillodema

11. Urgency vs. Emergency
Distinguishing between hypertensive emergency and urgency is a crucial step in appropriate management

12. Urgency vs. Emergency Urgency Emergency
No need to acutely lower blood pressure
May be harmful to rapidly lower blood pressure
Death not imminent
Emergency
Immediate control of BP essential
Irreversible end organ damage or death within hours
MAIN CAUSE IS OF HYPERTENSIVE URGENCY IS MEDICATION NON-COMPLIANCE SO GENERALLY FIND OUT WHY NOT TAKING AND RESTART OR CHOOSE NEW AGENTS.

13. Approach to Patients

14. Approach to patients Recheck blood pressure! History
Appropriate size cuff
Cuff not over clothing
Check in all limbs
History
Prior crises
Renal disease
Medications
Compliance
Recreational drugs
Generic approach…

15. Approach to patients Physical Exam Signs of end organ damage?
Is the patient in a resuscitation room or are they smiling and eating cheetos?
In distress?
OVERT signs of end organ damage?
Will cover each organ system in order...

16. Neuro Hypertensive encephalopathy Focal Neurological Deficits
Severe Headache
Nausea/Vomiting
Papilledema
Visual Changes
Seizures
Focal Neurological Deficits
Ischemic vs hemorrhagic CVA
Encephalopathy 2/2 brain edema
Obviously CT of any patient with neuro findings.

17. Fundoscopy/ Neuro
COTTON WOOL EXUDATES
PAPILLEDEMA

18. Cardiac Cardiac ischemia Acute left ventricular failure Chest pain
EKG for ischemic changes
Acute left ventricular failure
Pulmonary edema
Hypoxia
EKG for left ventricular strain pattern
CXR

19. Renal Electrolytes BUN/Cr UA with micro
Chronic failure/insufficiency vs acute failure
Cause vs effect
UA with micro
Protein
Blood
Casts
Most cases of hypertensive emergencies arise in patients with some underlying renal insufficiency or failure

20. Major Causes of Hypertensive Emergencies and Urgencies
Untreated essential hypertension
Withdrawal / non-adherence to antihypertensive drug therapy
Development of secondary hypertension

21. Major Causes of Hypertensive Emergencies and Urgencies
Renal Disease
Renal artery stenosis
Pregnancy
Endorine
Pheochromocytoma
Primary aldosteronism
Glucocorticoid excess
Renin-secreting tumors

22. Pathogenesis for Hypertension
Arterial and arteriolar vasoconstriction
Prevents the increase in pressure from being transmitted to the smaller, more distal vessels
With increasingly severe hypertension
Autoregulation failure
Vascular endothelial injury
Plasma constituents (including fibrinoid material) to enter the vascular wall
narrowing or obliterating the vascular lumen.
Tissue edema and activation of endothelial vasoactive system

23. Goals of Treatment

24. Goals of Treatment Prevent end organ damage NOT normalize BP
Exceptions??
PAUSE: ???
Acute Aortic Dissecton: Need to actually lower BP to less than normal
Hemorrhagic CVA SBP

25. HTN Urgencies: Goals of Therapy
No proven benefit of rapid BP reduction in asymptomatic patients
Goal BP <160/110 mm Hg over several hours, oral therapy
Initial BP fall less than 25% in first six hours
can be managed using oral antihypertensive agents in an outpatient or same-day observational setting
Ensure follow-up: Long-term management

26. HTN Urgencies: Therapy
Captopril , 25-mg oral dose initially, followed by incremental doses of 50 to 100 mg 90 to 120 min later
The calcium channel blocker nicardipine, 30 mg, q 8 hours until the target BP
Labetolol, the starting dose is 200 mg orally, which can be repeated every 3 to 4 hours
Clonidine is a central sympatholytic a 0.1 to 0.2 mg loading dose followed by 0.05 to 0.1 mg every hour until target BP is achieved (Max 0.7 mg).

27. Hypertensive Emergency
ICU with close monitoring
IV and Short acting medications
Avoid sublingual or IM
Arterial line

28. Goals of Treatment Within 1-2 hrs Lower MAP 20-25% CONTROLLED
IV titratable meds
As an aside…always do what your surroundings will allow. Nursing availability, med. availability. Till with NTG in flash pulmonary edema.

29. Complications for rapid BP Reduction in Severe Hypertension
Widening Neurologic Deficits
Retinal ischemia and Blindness
Acute MI
Deteriorating renal function

30. WHY ? Goals of Treatment Harington
82/94 treated; 12 not treated--> died
Treated with ganglion blocking agent
81/82 had papilledema
17 had neuro findings on presentation; non improved with treatment
7 without neuro findings developed them during treatment
6/7 with hemiparesis or other focal sign indicative of CVA
5 developed seizures
1 facial palsey

31. Cerebral Autoregulation
Strandgaard, et al. BMJ: 1973
Cerebral blood flow
EMERGENCY: Far right of RED
Increased ICP, increased cerebral edema, or ICH, or ischemia 2/2 edema
Cerebral autoregulation in HTNsives has been noted to be 25% less than peak, lower and you loose the autoregulatory effects.
Cerebral flow after CVA
Curve depresses and flattens--- loss of autoregulatory system 60
mmHg
120
mmHg
160
mmHg
MAP
Adapted from: Chest, 2000; 118:

32. Pharmacotherapy

33. Given by continuous infusion
Antihypertensive Drugs for Hypertensive Crisis
Given by continuous infusion
Sodium nitroprusside
Nitroglycerin
Nicardipine
Labetalol
Esmolol
Fenoldapam

34. Specific Treatment

35. Hypertensive Encephalopathy
Nitroprusside
Fenoldopam
Nicardipine
Labetolol
Symptoms of encephalopathy should improve with treatment

36. CVA Nicardipine Labetolol Fenoldopam
Decrease DBP no more than 20% in 24hrs
Chest 2000
Varon in Houston review
does not recommend Nitroprusside
20% is arbitrary
Wallace and Levy series of 334 patients in 1981 showed that hypertension after CVA normalizes within 10days of admission
General consensus is to treat only for DBP > 120 or SBP > 200
EXCEPTION IS HEMORRHAGIC STROKE WHICH WE TREAT THE HTN MORE AGGRESSIVELY WANT SBP

37. Cardiac Ischemia Nitroglycerine Nitroprusside Nifedipine Fenoldopam
Reflex tachy
Increases myocardial O2 demand
May aggravate ischemia

38. Acute LVF Nitroprusside Nitroglycerine Furosemide Opioids
Afterload reduction
Fenoldopam
Nitroglycerine
If ischemia is suspected
Furosemide
Loop diuretic
Opioids

39. Acute Aortic Dissection
Nitroprusside
Nicardipine, Fenoldopam
Afterload reduction
Increases ventricular contraction velocity
Requires B blockade
Esmolol, metoprolol
Labetolol
Goal: SBP ~100 mmHg
Monitor patient closely

40. Acute Aortic Dissection
β-block FIRST!
Esmolol
Metoprolol

41. Sympathetic Crisis
Nicardipine
Nitroprusside
Phentolamine

42. Acute Renal Failure Nicardipine Nitroprusside Fenoldopam Labetolol
“Use with caution”
toxic metabolites...
Thiocyanate excreted via kidneys
Fenoldopam
Labetolol

43. Eclampsia Hydralazine Nicardipine Labetolol Used historically
Arterial vasodilator
Maintains placental blood flow
Nicardipine
Labetolol
Magnesium

44. The Discharged Patient

45. The discharged patient
JNC-VII Recommendations
Stage 2
Combination tx
Thiazide + ACEI, ARB, BB, CCB
“Compelling Indications”...
Zeller, et al. UTSW, 1989
Prospective controlled trial
Rapid reduction of severe asymptomatic HTN in ED
Controls got nothing in ED
ALL Discharged with maintenance therapy
No difference in reduction in BP at 24 hrs and 1 weekThe discharged patient
Follow up...
Stage I:
/ or 90-99
Stage II:
>160 / or ≥100
“Higher”:
≥180 / ≥110

46. The discharged patient
JNC-VII Recommendations
“Compelling Indications”
URGENCY:
ALL PATIENTS WITH HTN URGENCY BEING DISCHARGED HOME SHOULD BE PLACED ON COMBINATION THERAPY AND HAVE RAPID FOLLOW UP.
THIAZIDE
ACEI / ARB / BB / CCB
Zeller, et al. UTSW, 1989
Prospective controlled trial
Rapid reduction of severe asymptomatic HTN in ED
Controls got nothing in ED
ALL Discharged with maintenance therapy
No difference in reduction in BP at 24 hrs and 1 week

47. The discharged patient
Follow-up
Follow up...
Stage I:
/ or 90-99
Stage II:
>160 / or ≥100
“Higher”:
≥180 / ≥110
2 Months
JOINT NATIONAL COMMITTEE ON PREVENTION, DETECTION, EVALUATION AND TREATMENT OF HIGH BLOOD PRESSURE
1 Months
< 1 week

48. Goals of therapy in JNC7 & Euro Guidelines
Maximum reduction in long-term total risk of cardiovascular morbidity and mortality:
Smoking
Life style modification
Lipid
Diabetes
Blood pressure
< 140/90
If DM or renal disease
<130/80

49. The following 5 patients in ER
Patient A is a 65-year-old man with nausea, vomiting, and confusion.
Patient B is a 73-year-old woman with sudden shortness of breath, pink sputum, and heavy chest pain.
Patient C is a 56-year-old man with sharp, tearing chest and back pain.
Patient D is a 64-year-old woman with a 6-hour history of right-sided weakness.
Patient E is a 51-year-old woman with a mild headache, concerned about her history of hypertension.

50. all 5 patients arrive with identical vital signs: BP of 209/105 mm Hg
Which of the 5 patients require emergent hypertension treatment?

51. Patient A is a 65-year-old man with nausea, vomiting, and confusion.
Hypertensive encephalopathy
Pure vasodilators like nitroprusside have risks of intracranial shunting, which could increase intracranial pressure.
Drug of choice: Intravenous labetalol, bolus or infusion.
Target: Reduce MAP by 20% to 25% over 2 to 8 hours.

52. Patient B: 73-year-old woman with sudden shortness of breath, pink sputum, and heavy chest pain.
Physical examination reveals bilateral crackles in her lungs, an elevated JVP, and no heart murmurs.
Acute pulmonary edema often presents with extreme hypertension, which overloads cardiac reserve.
Drug of choice: Nitroglycerin infusion; IV enalaprilat or sublingual captopril.
Target: Reduce MAP by 20% to 25% and symptomatic improvement.

53. Patient C: 56-year-old man with sharp, tearing chest and back pain.
Physical examination reveals differential BPs and evidence of a new aortic insufficiency murmur.
Aortic dissection is largely a disease of hypertension.
Drug of choice: Nitroprusside or esmolol infusion;labetalol boluses or infusion.
Target: Rapidly reduce systolic BP to 110 mm Hg if there is no evidence of hypoperfusion.

54. Patient D: 64-year-old woman with a 6-hour history of right-sided weakness.
Marked right-sided hemiplegia is noted.
a higher MAP is essential to maintaining adequate cerebral blood flow and not extending the affected stroke territory.
BP should not be lowered in the acute period except in extreme situations
BP > 220/120 mm Hg in embolic CVA
> 180/100 in hemorrhagic CVA

55. Drug of choice: Labetalol; nicardipine; hydralazine. Target:
Patient D: 64-year-old woman with a 6-hour history of right-sided weakness.
Drug of choice: Labetalol; nicardipine; hydralazine.
Target:
If no thrombolytic is given, reduce BP only if it is greater than 220/120 mm Hg (embolic) or greater than 180/100 mm Hg (hemorrhagic)
If a thrombolytic is given, reduce BP to 180/100 mm Hg.

56. Patient E: 51-year-old woman with a mild headache, concerned about her history of hypertension.
These patients require gradual BP reduction over time on an outpatient basis

57. Summary Accurate history and timeline of onset
Evaluate Target organ injury
Set the time frame for intervention
Appropriate “pace” of therapy
Initial reduction
Stabilization
Follow-up care/ Diagnostic studies

58. Questions...
Comments…