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Hypertension. Resting BP consistently >140 mmHg systolic or >90 mmHg diastolic. Epidemiology. 20% of adult population ~ 35,000,000 people 25% do not know they are hypertensive Twice as frequent in blacks than in whites 25% of whites and 50% of blacks > 65 y/o. Types.

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Resting BP consistently

>140 mmHg systolic or

>90 mmHg diastolic

  • 20% of adult population
    • ~35,000,000 people
  • 25% do not know they are hypertensive
  • Twice as frequent in blacks than in whites
  • 25% of whites and 50% of blacks > 65 y/o
  • Primary (essential) hypertension
  • Secondary hypertension
primary hypertension
Primary Hypertension
  • 85 - 90% of hypertensives
  • Idiopathic
  • More common in blacks or with positive family history
  • Worsened by increased sodium intake, stress, obesity, oral contraceptive use, or tobacco use
  • Cannot be cured
secondary hypertension
Secondary Hypertension
  • 10 - 15% of hypertensives
  • Increased BP secondary to another disease process
secondary hypertension1
Secondary Hypertension
  • Causes:
    • Renal vascular or parenchymal disease
    • Adrenal gland disease
    • Thyroid gland disease
    • Aortic coarctation
    • Neurological disorders
  • Small number curable with surgery
hypertension pathology
Hypertension Pathology
  • Increased BP  inflammation, sclerosis of arteriolar walls  narrowing of vessels  decreased blood flow to major organs
  • Left ventricular overwork  hypertrophy, CHF
  • Nephrosclerosis  renal insufficiency, failure
hypertension pathology1
Hypertension Pathology
  • Coronary atherosclerosis  AMI
  • Cerebral atherosclerosis  CVA
  • Aortic atherosclerosis  Aortic aneurysm
  • Retinal hemorrhage  Blindness
signs symptoms
  • Primary hypertension is asymptomatic until complications develop
  • Signs/Symptoms are non-specific
    • Result from target organ involvement
  • Dizziness, flushed face, headache, fatigue, epistaxis, nervousness are not caused by uncomplicated hypertension.
htn medical management
HTN Medical Management
  • Life style modification
    • Weight loss
    • Increased aerobic activity
    • Reduced sodium intake
    • Stop smoking
    • Limit alcohol intake
htn medical management1
HTN Medical Management
  • Medications
    • Diuretics
    • Beta blockers
    • Calcium antagonists
    • Angiotensin converting enzyme inhibitors
    • Alpha blockers
htn medical management2

HTN Medical Management

Medical management prevents or forestalls all complications

Patients must remain on drug therapy to control BP

categories of hypertension
Categories of Hypertension
  • Hypertensive Emergency (Crisis)
    • acute  BP with sx/sx of end-organ injury
  • Hypertensive Urgency
    • sustained DBP > 115 mm Hg w/o evidence of end-organ injury
  • Mild Hypertension
    • DBP > 90 but < 115 mm Hg w/o symptoms
  • Transient Hypertension
    • elevated due to an unrelated underlying condition
hypertensive crisis

Hypertensive Crisis

Acute life-threatening increase in BP

Usually exceeds 200/130 mmHg

hypertensive emergency
Hypertensive Emergency
  • Severe hypertension associated with end organ damage
    • Malignant hypertension (htn with retinal hemorrhages, exudates or papilledema, also renal involvement)
    • Hypertensive encephalopathy
    • Subarachnoid/Intracerebral hemorrhage
    • Acute pulmonary edema
    • Dissecting aneurysm
    • Angina
hypertensive urgency
Hypertensive Urgency
  • Diastolic bp equal to or above 130 mm Hg
  • No signs of end organ damage
when you are called
When you are called..
  • Ask about mental status changes, chest pain
  • Obtain all vital signs
  • Determine the reason for admission
  • Ask about the patient’s blood pressure over the last 24 hours
when you get to the bedside
When you get to the bedside
  • Measure the bp again in BOTH ARMS
  • jvd, thyromegaly, fundoscopic exam
  • New cardiac murmer, S3, S4, tachycardia
  • Renal or aortic bruits
  • Edema to the extremities
  • Brief mental status exam, gross motor exam
if you determine this to be a hypertensive urgency
If you determine this to be a hypertensive urgency…
  • There is no evidence of end organ damage
  • There is NO PROVEN BENEFIT to rapid reduction in bp in asymptomatic patients.
  • Aggressive antihypertensive therapy can induce cerebral or myocardial ischemia
if you determine this to be a hypertensive urgency1
If you determine this to be a hypertensive urgency…
  • Your goal is to get the patient to around 160/110 mmHg over several hours with conventional oral therapy
  • Lytes, BUN/CR
  • Cardiac enzymes if pt has angina/chf
  • CXR if indicated if pt in angina/chf
  • EKG if indicated if pt has angina/chf
  • CT head if signs of encephalopathy
  • Sudden withdrawal of anti-hypertensives
  • Increased salt intake
  • Abnormal renal function
  • Increase in sympathetic tone
    • Stress
    • Drugs
  • Drug interactions
    • Monoamine oxidase inhibitors
  • Toxemia of pregnancy
  • Pheochromocytoma
signs symptoms1
Restlessness, confusion, AMS

Vision disturbances

Severe headache

Nausea, vomiting


Focal neurologic deficits

Chest pain


Pulmonary edema

hypertensive crisis can cause
Hypertensive Crisis Can Cause
  • CHF
  • Pulmonary edema
  • Angina pectoris
  • AMI
  • Aortic dissection

Hypertensive Emergencies

Stroke Encephalopathy

Aortic Dissection

Decompensated Heart Failure

Acute Coronary Syndrome

Acute Renal Failure

hypertensive crisis management
Hypertensive Crisis Management
  • Immediate goal: lower BP in controlled fashion
    • No more than 30%  in first 30-60 mins
    • Not appropriate in all settings
  • Oxygen
  • Monitor ECG
  • Drug Therapy
    • Targeted at simply lowering BP, OR
    • Targeted at underlying cause
drug therapy possibilities
Drug Therapy Possibilities
  • Sodium Nitroprusside
    • Potent arterial and venous vasodilator
      • Vasodilation begins in 1 to 2 minutes
    • 0.5 g/kg/min by continuous infusion, titrate to effect
      • increase in increments of 0.5 g/kg/min
      • 50 mg in 250 cc D5W
      • Effects easily reversible by stopping drip
      • Continuous hemodynamic monitoring required
      • Cover IV bag/tubing to avoid exposure to light
    • Used primarily when targeting lower BP only
drug therapy possibilities1
Drug Therapy Possibilities
  • Nitroglycerin
    • Vasodilator
    • Nitropaste simplest method
      • 1 to 2 inches of ointment q 8 hrs
      • easy to control effect but slow onset
    • Sublingual NTG is faster route
      • 0.4 mg SL tab or spray q 5 mins
      • easy to control but short acting
    • NTG infusion, 10 - 20 mcg/min
      • seldom used for hypertensive crisis
    • Commonly used prehospital when targeting BP lowering only especially in AMI
drug therapy possibilities2
Drug Therapy Possibilities
  • Nifedipine
    • Calcium channel blocker
      • Peripheral vasodilator
    • 10 mg Sublingual
      • Split capsule longitudinally and place contents under tongue or puncture capsule with needle and have patient chew
    • Used less frequently today! Frequently in past!
      • Concern for rapid reduction of BP resulting in organ ischemia
drug therapy possibilities3
Drug Therapy Possibilities
  • Furosemide
    • Loop Diuretic
      • initially acts as peripheral vasodilator
      • later actions associated with diuresis
    • 40 mg slow IV or 2X daily dose
      • most useful in acute episode with CHF or LVF
    • Often used with other agents such as NTG
drug therapy possibilities4
Drug Therapy Possibilities
  • Hydrazaline
    • Direct smooth muscle relaxant
      • relax arterial smooth muscle > venous
    • 10-20 mg slow IV q 4-6 hrs; initial dose 5 mg for pre-eclampsia/eclampsia
    • Usually combined with other agents such as beta blockers
      • concern for reflex sympathetic tone increase
    • Most useful in pre-eclampsia and eclampsia
drug therapy possibilities5
Drug Therapy Possibilities
  • Metoprolol, orLabetalol
    • decrease in heart rate and contractility
    • Dose
      • Metoprolol: 5 mg slow IV q 5 mins to total ~15 mg
      • Labetalol: 10-20 mg slow IV q 10 mins
    • Metoprolol is selective beta-1
      • minimal concern for use in asthma and obstructive airway disease
    • Labetalol: both alpha & beta blockade
    • Most useful in AMI and Unstable angina
hypertensive emergency1
Hypertensive Emergency
  • Enalapril
    • IV prep of ACE Inhibitor
    • Response is variable (probably b/c these pts have variable plasm renin activity)
    • Contraindicated in pregnancy
    • Start at 1.25 mg iv and up to 5 mg iv q 6 hrs
    • Onset of action: 15 minutes, peak effect 4 hrs
    • Duration of action: 12-24 hours
hypertensive crisis management1

Hypertensive Crisis Management

Avoid crashing BP to hypotensive or normotensive levels!

Ischemia of vital organs may result!

hypertensive crisis management2

Hypertensive Crisis Management

Must assure underlying cause of BP is understood

HTN may be helpful to the patient

Aggressive treatment of HTN may be harmful

What patients may have HTN as a compensatory mechanism?