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Systemic and Pulmonary Hypertension. Tintinalli Chap. 61. Classification of Hypertension. Systolic BP Normal: < 120 Prehypertension: 120-139 Stage 1: 140-159 Stage 2: >160. Diastolic BP Normal: <80 Prehypertension: 80-89 Stage 1: 90-99 Stage 2: >100. Hypertensive Emergency.

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classification of hypertension
Classification of Hypertension
  • Systolic BP
    • Normal: < 120
    • Prehypertension: 120-139
    • Stage 1: 140-159
    • Stage 2: >160
  • Diastolic BP
    • Normal: <80
    • Prehypertension: 80-89
    • Stage 1: 90-99
    • Stage 2: >100
hypertensive emergency
Hypertensive Emergency
  • Acute elevation of blood pressure associated with end-organ damage (>180/120 mmHg)
    • Acute aortic dissection
    • Acute pulmonary edema
    • Acute myocardial infarction
    • Acute coronary syndrome
    • Acute renal failure
  • Severe preeclampsia, HELLP syndrome, eclampsia
  • Hypertensive retinopathy
  • Hypertensive encephalopathy
  • Subarachnoid hemorrhage
  • Intracranial hemorrhage
  • Acute ischemic stroke
  • Acute postoperative hypertension
  • Sympathetic crisis
hypertensive urgency
Hypertensive Urgency
  • Severe elevation in blood pressure without progressive target organ dysfunction
symptoms
Symptoms
  • Chest pain
    •  Acute Coronary Syndrome
    •  Aortic Dissection
  • Neurologic symptoms (Headache, focal deficit, AMS, seizures, visual disturbance)
    • Hypertensive encephalopathy
    • Intracranial hemorrhage
    •  Stroke
  • Peripheral edema
    • New-onset renal failure
    • Preeclampsia/HELLP syndrome
other common symptoms
Other Common Symptoms
  • Headache
  • Dyspnea
  • Visual changes
  • Dizziness
  • Epistaxis
diagnostics
Diagnostics
  • BMP--Creatinine
  • CXR
  • EKG
  • UA
treatment of hypertensive emergencies
Treatment of Hypertensive Emergencies
  • Labetalol—alpha1, beta adrengeric, much mores BETA
  • Esmolol—beta 1 adrenergic, VERY SHORT, often with nitroprusside to block tachy
  • Metoprolol
  • Nicardipine—CCB, Dec peripheral resistance, dec cerebral vasospasm (good stroke)
  • Clevidipine
  • Nifedipine
  • Nitroglycerin—Venous>>>artery
  • Nitroprusside—vasodilator/arteriolar
  • Phentolamine—Pure Alpha blocker
  • Fenoldopam—dopamine 1 receptor antagonist (acutely improves renal function)
  • Enalaprilat
  • Clonidine
special circumstances
Special Circumstances
  • Acute MI  Nitro, metoprolol
  • Sympathetic crisis  Avoid beta blockers
  • Preeclampsia/Eclampsia No ACE inhibitors
  • Pulmonary edema  Nitro, diuretics
treatment of hypertensive urgencies
Treatment of Hypertensive Urgencies
  • Nitroglycerin
  • Labetalol
  • Clonidine
  • Captopril/Lisinopril
  • Nifedipine
  • Losartan
dispo and follow up
Dispo and Follow-up
  • Arrange follow up for BP check
  • If >180 SBP or >110 DBP
    • Consider initiating therapy
  • If >200 SBP or >120 DBP
    • Begin antihypertensive therapy
      • HCTZ
      • Lisinopril
pulmonary hypertension
Pulmonary Hypertension
  • Elevation of pulmonary vascular pressure which compromises right ventricular function
  • Median pulmonary artery pressure > 25 mmHg at rest or > 30 mmHg during effort
  • Classified into five groups based on cause
incidence
Incidence
  • Sleep apnea – 25-20%
  • CREST syndrome – 60%
  • Hemoglobinopathies – 10-30%
symptoms1
Symptoms
  • Dyspnea
  • Fatigue
  • Syncope
  • Chest pain
  • Peripheral edema
clinical findings
Clinical Findings
  • Increased pulmonary component (P2) of second heart sound
  • Murmur of tricuspid regurgitation
  • Graham Steell murmur of pulmonary insufficiency
  • Prominent sternal impulse
  • JVD
  • Ascites
slide16
EKG
  • Right axis deviation
  • R/S ratio of >1 in V1
  • S wave > 7mm in V5/V6
  • Incomplete RBBB