Hypertension

1. Hypertension

2. Definition • The following definitions have been suggested by the seventh report of the Joint National Committee (JNC 7), which was published in 2003 [7] . Based upon the average of two or more properly measured readings at each of two or more visits after an initial screen, the following classification is used: • Normal blood pressure: systolic <120 mmHg and diastolic <80 • Prehypertension: systolic 120-139 or diastolic 80-89 • Hypertension: •         Stage 1: systolic 140-159 or diastolic 90-99         Stage 2: systolic ≥160 or diastolic ≥100

3. The 3:00 AM Call • Doc the pt has a BP of 175/90 what do you want to do? • Answer a question with a lot more questions

4. Questions • Why is the pt in the hospital? • Are there signs of hypertensive emergency? • Is the pt pregnant? • Is the pt taking antidepressants? • What has his BP been during the hospital stay? • What antihypertensive has the pt been taking? • Possibility of drugs, i.e. cocaine or amphetamine? • How old is the pt • What are my BP goals • Does the pt have IV access? Can you give IV BB on this floor? • Did the pt get his already prescribed medication if so when?

5. I’m on my way to save the day.Elevator thoughts • Aortic dissection • MI • Hypertensive crisis • Pulmonary edema resistant to other treatments • Uncontrolled bleeding • Worsening vision secondary to retinal hemorrhage is there and ophthalmoscope on the floor? • Hypertensive encephalopathy • Eclampsia

6. Selective History • Does pt have signs of Hypertensive emergency? -Headache- (occipital, neck ache lethargy, or blurred vision suggest hypertensive encephalopathy) -CP-MI -SOB- Pulmonary edema -Back or chest pain- Aortic dissection - Unilateral weakness or sensory sx-CVA

7. Physical exam • Does pt look well, sick or critical? • Retake BP in both arms a lower pressure in one arm may be a clue to aortic dissection • Make sure the cuff size is appropriate. • Check heart rate- bradycardia and hypertension in a pt not receiving Beta blockers may indicate increasing intracranial pressure

8. Physical Exam • HEENT- papilledema is an ominous finding. Hypertensive changes- arteriolar narrowing, flame hemorrhages ect • Resp- crackles, pleural effusion (CHF) • CVS- elevated JVP, S3 (CHF) • Neuro- confusion, delirium, agitation, or lethargy (hypertensive encephalopathy) Localized deficits (stroke)

9. Treatment Options • Do nothing if no emergency or unsure • Give additional dose of what pt is already on. • New med based on co morbidities i.e. carvidilol in CHF • BB • CCB • Vasodialators- Hydralizine, Nitroprusside • Diuretics-Thiazide, ACE/ ARB, Loop, K sparing • Central - Clonidine

10. Beta Blockers • Decrease HR, CO, plasma renin • Increase diastolic perfusion • Caution in diabetic, asthmatic or Heart Block • Watch for orthostatic hypotension and other side effects • Metoprolol (lopressor, Toprolol XL) 50-100mg PO BID or 5- 10 mg IV Q 4 hrs put hold parameters for HR and low BP. • Can do labetolol Gtt for HTN emergency • Many other BB options

11. Calcium Channel Blockers • Vasodilates • decrease: - coronary vascular resistance, HR, inotropic. Constipation

12. Diuretics • Thiazides- action at DCT. • caution in renal failure • Hypokalemia, hyponatremia. • Loops- Lasix (last 6 hours) Blocks NA at loop of henle • Potassium sparing- spironolactone

13. Vasodilators Decrease peripheral resistance. No sympathetic block, HR may increase Hydralazine 10 mg IV q 6 hr PRN Nitroprusside- decreased preload and after load therefore improves ventricular function

14. Central • Decrease sympathetic from brain use in combo with other medication • Clonidine 0.1 to 0.3 mg PO (remember rebound HTN for 45-60 mins after dose) sedation, water retention (use with diuretic)

15. Management Most often, elevated BP is an isolated finding in an asymptomatic pt known to have HTN. Although long-term control of HTN has proven benefits acute lowering of BP has not. True emergencies require special management

16. Hypertensive encephalopathy • Almost always accompanied by retinal exudates/ papilledema, focal neurological deficits are unusual early on and suggest that the elevated pressure is most likely associated with a stroke. Remember the risk of lowering pressure too quickly in pt with atherothrombotic cerebrovascular disease can precipitate a stroke. • These pt need to be transferred to the unit remember ABCS give dose of antihypertensive (labetalol 20 mg IV every 10 to 15 minutes max 300 mg only useful if pt not already on BB)

17. Hypertension crisisSBP > 210 or DBP >110 • Urgency = ↑ BP with no organ damage (must r/o end organ damage with PE)…↓ BP slowly over hours may use PO • Emergency = ↑ BP with end organ damage…↓ MAP by 25% in mins to 1 hr • Do not lower BP more than ¼ initially or pt will stroke out. • Signs-Encephalopathy, SAH, papilledema, MS ∆, CHF, Aortic dissection, ARF, hematuria • Renal function may drop with initial decrease in BP

18. Preeclampsia/Eclampsia • Mag sulfate- does not lower BP give 1-2g /hr check mag level Q4 hours and DTRS. • Labetalol/hydralazine can be given in pregnancy • Avoid diuretics as these pt are usually volume depleted

19. SAH • Although there is no proof that lowering the pressure alters the outcome many neurologist administer drugs to control BP. • Consult neuro

20. Aortic Dissection • Transfer to ICU needs intra-arterial BP monitoring • Labetalol as used in HTN encephalopathy • Nitroprusside 0.1 to 5 ug/Kg per minute use with an accompanying beta blocker

21. Catecholamine crisis •  Pheochromocytoma is a rare neuroendocrine tumor, probably occurring in less than 0.2 percent of patients with hypertension • Pheochromocytoma- pallor, palpitations, perspiration. • Intermittent alarmingly high BP- could be cocaine, amphetamine, 2nd or 3rd degree burns, abrupt stopping of antihypertensive, MAOI • TX phentolamine mesilate- 2.5-5mg IV or 5-10ug/kg per minute continuous IV infusion