1 / 74

Hypotension and Hypertension

Hypotension and Hypertension. Nisarg Shah, M.D. May, 2005. Hypotension. Inadequacy of tissue oxygen supply versus demand resulting in global tissue hypoperfusion. Hypotension 4 types of shock. Hypovolemic - inadequate circulating volume hemorrhage fluid depletion.

cole-obrien
Download Presentation

Hypotension and Hypertension

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Hypotension and Hypertension • Nisarg Shah, M.D. • May, 2005

  2. Hypotension • Inadequacy of tissue oxygen supply versus demand resulting in global tissue hypoperfusion

  3. Hypotension4 types of shock • Hypovolemic - inadequate circulating volume • hemorrhage • fluid depletion

  4. Hypotension4 types of shock • Cardiogenic – inadequate cardiac pump function • arrhythmia • MI, dilated CM, decreased output from sepsis • mechanical – VSD, aortic stenosis

  5. Hypotension4 types of shock • Obstructive – extra cardiac obstruction to blood flow • pericardial tamponade • pulmonary embolism • severe pulmonary hypertension

  6. Hypotension4 types of shock • Distributive – peripheral vasodilation and maldistribution of blood flow • sepsis • drug overdose • anaphylaxis • neurogenic • endocrinologic

  7. Hypotension • Find the type and treat cause • history – vomiting, bleeding, CP, fever, medication use • physical – temp, heart rate, skin color, jugular veins, respiratory rate

  8. Hypertension

  9. Overview • History • Pathophysiology • Definitions • Hypertension • Hypertensive Urgency • Hypertensive Emergency • • Approach to patients • – Urgency vs Emergency • • ED Management • – Goals of ED treatment • – Pharmacotherapy • – Specific Treatments • – The Discharged Patient

  10. History • 1628 • William Harvey describes blood circulation • 1733 – Stephen Hales first measures blood pressure • 1816 – Rene Laennec invents the stethoscope

  11. History • Measuring blood pressure… • Sphygmograph, 1863 – Sphygmomanometer, 1898 – Karotkoff, 1905

  12. History • Hypertension… • Osler, 1912 • Simple HTN without disease • Atherosclerosis with associated hypertension • Chronic nephritis with secondary hypertension • Framingham and VA studies, 1970’s • Joint National Committee on Detection, Evaluation, and Management of High Blood Pressure

  13. Pathophysiology

  14. Pathophysiology • Essential Hypertension [~94%] • Prevalence >50% • Unknown cause • Secondary Hypertension [~6%] • Prevalence ~6% • Renal • Endocrine • Miscellaneous

  15. Pathophysiology • Prevalence increases with • Age • Male gender • Obesity • African American race

  16. Pathophysiology • Interestingly…

  17. Pathophysiology • The old renin-angiotensin-aldosterone system...

  18. Aside • Leading cause of office visits and the leading use of prescription drugs (aside from vicoden) in the U.S. • Over 100,000,000 office visits in 1997 • HOWEVER • - only 2/3 of Americans with HTN are aware of dx • - almost 75% of known HTNsives are not controlling BP under 140/90 • - only 50% of known HTNsives are taking their meds as prescribed

  19. Definitions

  20. Definitions • JNC-VI, 1997 • Optimal: <120 / and <80 • Normal: <130 / and <85 • High-Normal: 130-139 / or 85-89 • Stage I: 140-159 / or 90-99 • Stage II: 160-179 / or 100-109 • Stage III: ≥180 / or ≥110

  21. Definitions thankfully simplified JNC-VII, 2003 NORMAL: <120/ and <80 Pre-Hypertension: 120-139/ or 80-89 Stage I: 140-159 / or 90-99 Stage II: >160 / or ≥100-109

  22. Definitions • Hypertensive Urgency • Hypertensive Emergency • Accelerated Hypertension • Malignant Hypertension • Accelerated-Malignant Hypertension

  23. Definitions • Hypertensive Crisis • Urgency or Emergency

  24. Hypertensive Urgency • “Severe elevation of blood pressure” • Generally DBP >115-130 • No progressive end organ damage

  25. Hypertensive Emergency • “Severe elevation of blood pressure” • Generally occurs with DBP >130 • WITH significant orprogressive end organ damage • Hypertensive Encephalopathy • CVA – Ischemic versus hemorrhagic • Acute Aortic Dissection • Acute LVF with Pulmonary Edema • Acute MI / Unstable Angina • Acute Renal Failure • Eclampsia

  26. Urgency vs. Emergency • Urgency • 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

  27. Approach to Patients

  28. Approach to patients • Recheck blood pressure! • Appropriate size cuff. • Cuff not over clothing • Check in all limbs • History • Prior crises • Renal disease • Medications • Compliance • MAO inhibitors • Recreational drugs

  29. Approach to patients • Physical Exam • What do you see? • Signs of end organ damage?

  30. End organ damage • Neuro • Cardiac • Renal

  31. Neuro • Hypertensive encephalopathy • Severe Headache • AMS • Nausea/Vomiting • Papilledema • Visual Changes • Seizures • Focal Neurological Deficits • Ischemic vs hemorrhagic CVA

  32. Fundoscopy

  33. Fundoscopy/ Neuro

  34. Fundoscopy/ Vascular

  35. Fundoscopy/ Vascular

  36. Cardiac • Cardiac ischemia • Chest pain • EKG for ischemic changes • Acute left ventricular failure • Pulmonary edema • Rales • Hypoxia • SpO2 • EKG for left ventricular strain pattern • Aortic regurge murmur • CXR?

  37. Renal • Electrolytes • BUN/Cr • Chronic failure/insufficiency vs acute failure • Cause vs effect • UA with micro • Protein • Blood • Casts

  38. Goals of Treatment

  39. Goals of Treatment • Prevent end organ damage • NOT normalize BP • Exceptions?? • IV fluids • Forced natriuresis • Saline may help blunt renin-angiotensin response

  40. Goals of Treatment • Harington, et al, BMJ: 1959 • 94 cases over 7 years • Immediate normalization of BP • 12 not included in study • 30 / 82 with significant neurologic sequelae • Ledingham, et al, QJM: 1979 • Case series of 10 patients • All with papilledema • All with neurologic sequelae • 3 deaths during treatment

  41. Goals of Treatment WHY ?

  42. Cerebral Autoregulation • Strandgaard, et al. BMJ: 1973 Lancet, Hpertensive Emergencies, 2000; 356(9227):411-417

  43. Cerebral Autoregulation • Strandgaard, et al. BMJ: 1973 Cerebral blood flow 60 mmHg 120 mmHg 160 mmHg MAP Adapted from: Chest, 2000; 118:214-227

  44. Goals of Treatment • Within 1-2 hrs • Lower MAP 20-25% • CONTROLLED • IV titratable meds • Sublingual Nifedipine • Too effective • Hydralazine • Not titratable • Eclampsia

  45. Pharmacotherapy

  46. Pharmacotherapy • Nitroprusside • Arterial & venous dilator • Decreases afterload and preload • No direct negative inotropy or chronotropy • Kinetics • Onset: seconds • Duration: 1-2 min • 1/2 life: 3-4 min • Increased ICP (?) • Toxic metabolites • Takes days to accumulate

  47. Pharmacotherapy • Nitroglycerine • Weak anti-hypertensive • Vasodilator • At high doses dilates arteriolar smooth muscle • Better dilation of coronary conductance arteries • Kinetics • Onset: 1-2 min • Duration: 3-4 min • Tolerance • Headache, Tachycardia, Nausea, Vomiting, Hypotension

  48. Pharmacotherapy • Enalaprilat • IV ACE inhibitor • Improves cardiac index and stroke volume without affecting HR • Degree BP reduction associated with pretreatment plasma renin activity • Kinetics • Onset: 15 min • Duration: 6 hours

  49. Pharmacotherapy • Esmolol • Ultra-short acting • Cardioselective β1-blocker • Rapidly metabolized by plasma esterase • Negative chronotropy/inotropy • Kinetics • Onset: 1-5 min • Duration: 10-20 min

  50. Pharmacotherapy • Labetolol • Selective Post-synaptic α blockade • Non-selective β blockade • α: β = 1:7 • Maintains cardiac output • Decreased PVR without reflex tachycardia • Maintains cerebral, renal & coronary blood flow • Kinetics • Onset: 2-5 min • Peak: 5-15 min • Duration: 4-8 hrs

More Related