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Hypertensive Emergency

Hypertensive Emergency. Daniel J. McFarlane M.D. Division of Hospital Medicine January 2011. Outline. Epidemiology Definitions Pathophysiology Diagnosis and Recognition Treatment Special Circumstances. Epidemiology. Why should we care about hypertension?

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Hypertensive Emergency

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  1. Hypertensive Emergency Daniel J. McFarlane M.D. Division of Hospital Medicine January 2011

  2. Outline • Epidemiology • Definitions • Pathophysiology • Diagnosis and Recognition • Treatment • Special Circumstances

  3. Epidemiology • Why should we care about hypertension? • One of the most common chronic medical concerns in the US • Affects >30% of the population > age 20 • Risk factor for • Cardiovascular disease and mortality • Cerebrovascular disease and mortality • End stage renal disease • Other end organ damage

  4. Epidemiology • Why should we care about hypertension? • 30% of the population is unaware they have hypertension • Control rates for known cases is about 50% (we don’t do a great job at controlling BP) • Risk Factors • If >50, systolic BP > 140 is a more concerning risk factor for cardiovascular disease than diastolic BP. • The risk of cardiovascular disease doubles for every increase in BP of 20/10 over 115/75.

  5. Epidemiology • Hypertensive Emergency • Estimates are that about 1% of those with hypertension will present with hypertensive emergency each year • That is >500,000 Americans per year • Correct and quick diagnosis and management is critical • Mortality rate of up to 90%

  6. Definitions • Hypertension (according to JNC VII) • Normal BP <120/<80 • Prehypertension 121-139/80-89 • Stage I HTN 140-159/90-99 • Stage II HTN >160/>100 • (Severe HTN >180/>110) • Severe HTN is not a JNC VII defined entity

  7. Definitions • Hypertensive Emergency • Acute, rapidly evolving end-organ damage associated with HTN (usu. DBP > 120) • BP should be controlled within hours and requires admission to a critical care setting • Hypertensive Urgency • DBP > 120 that requires control in BP over 24 to 48 hours • No end organ damage • Malignant Hypertension is no longer used

  8. Definitions • End-Organ Damage (% of cases) • Cerebral infarction…………………………………… 24% • Hypertensive encephalopathy……………………16% • Intracranial hemorrhage……………………………4.5% • Acute aortic dissection………………………………2% • Acute coronary syndrome/myocardial infarction…12% • Pulmonary edema with respiratory failure…………22% • Severe eclampsia/HELLP syndrome………………2% • Acute congestive heart failure……………………14% • Acute renal failure……………………………………9%

  9. Pathophysiology • Hypertensive Emergency • Failure of normal autoregulatory function • Leads to a sharp increase in systemic vascular resistance • Endovascular injury with arteriole necrosis • Ischemia, platelet deposition and release of vasoactive substances • Further loss of autoregulatory mechanism • Exposes organs to increased pressure

  10. Diagnosis and Recognition • Presentation • Always present with a new onset symptom • Take a good history • History of HTN and previous control • Medications with dosage and compliance • Illicit drug use, OTC drugs

  11. Diagnosis and Recognition • Physical • Confirm BP in more than one extremity • Ensure appropriate cuff size • Pulses in all extremities • Lung exam—look for pulmonary edema • Cardiac—murmurs or gallops, angina, EKG • Renal—renal artery bruit, hematuria • Neurologic—focal deficits, HA, altered MS • Fundoscopic exam—retinopathy, hemorrhage

  12. Diagnosis and Recognition • Laboratory/Radiologic evaluations • Basic Metabolic Panel (BUN, Cr) • CBC with smear (hemolytic anemia) • Urinalysis (proteinuria, hematuria) • EKG to look for ischemia • CXR to look for pulmonary edema if dyspnea • Head CT for hemorrhage if HA or altered MS • MRI chest if unequal pulses and wide mediastinum to look for aortic dissection

  13. Treatment • Hypertensive Urgency • No end-organ damage—NOT emergent • Look for reactive HTN and treat this first • Drugs, pain, anxiety, cocaine, withdrawal • Use oral medications to lower BP gradually over 24-48 hours, likely 2 agents needed • May be chronic, decrease BP slowly to avoid hypoperfusion of organs • Avoid sublingual and IM administration due to unpredictable absorption

  14. Treatment • Hypertensive Urgency • Appropriate follow up for asymptomatic patients with no end-organ damage BP range Action Plan • 140-159/90-99 Observe, confirm BP 2mos • 160-179/100-109 Confirm, treat within 1mo • 180-209/110-119 Confirm, treat within 1wk • 210+/120+ Confirm, treat now, close f/u

  15. Medications • Oral drug choices often based on comorbid conditions • Heart failure—TH, BB, ACEI, ARB, ALDO • Post MI—BB, ACEI, ALDO • High CVD risk—TH, BB, ACEI, CCB • Diabetes—TH, BB, ACEI, ARB, CCB • Chronic Renal Failure—ACEI, ARB • Recurrent stroke prevention—TH, ACEI • KEY: ACEI, angiotensin converting enzyme inhibitor; ALDO, aldosterone antagonist; ARB, angiotensin receptor blocker; BB, b blocker; CCB, calcium channel blocker; TH, thiazide.

  16. Treatment • Hypertensive Emergency • Act Quickly • Start IV goal directed pharmacologic therapy • Continuous infusion: short acting titratable meds • Initiate critical care monitoring • Intraortic BP monitoring may be necessary • Start SLOW: Limit initial lowering of BP to 20% below pretreatment level • Due to increased threshold of hypoperfusion of the organs from abnormal autoregulation • Goal: Lower DBP by 10-15% in 30-60 min • Initiate oral therapy and titrate IV medications down

  17. Medications • IV, short acting, titratable. • Arterial Vasodilators • Hydralazine, fenoldepam, nicardipine, enalapril • Venous Vasodilators • Nitroglycerine • Mixed Arterial and Venous Vasodilators • Sodium nitroprusside • Negative Inotrope/Chronotrope • Labetolol (also vasodilates), Esmolol • Alpha blockers (inc. sympathetic activity) • Phentolamine

  18. Medications • Preferred agents by usage • Labetolol>Esmolol>Nicardipine>Fenoldopam (esp in pheochromocytoma) • Preferred agents by end organ damage • Pulmonary Edema (systolic)—Nicardipine • Pulmonary Edema (diastolic)—Esmolol • Acute MI—Labetolol or Esmolol • Hypertensive Encephalopathy—Labetolol • Acute Aortic Dissection—Labetolol • Eclampsia—Labetolol or Nicardipine • Acute Renal Failure—Fenoldopam • Sympathetic Crisis/Cocaine—Verapamil or Diltiazem

  19. Special Circumstances • Acute Aortic Dissection • Start IV meds STAT to lower pulsitile load and aortic stress to lessen the dissection • Vasodilators alone may  reflex tachycardia • Use beta blocker AND vasodilator • Esmolol and Nitroprusside • Surgical evaluation • Type A all go to surgery • Type B only if rupture/leak. Treat with aggressive BP control

  20. Special Circumstances • Stroke • Number one cause of permanent disability • HTN is a protective physiologic effect to maintain blood flow to brain • One study showed better outcome if hypertensive upon presentation of stroke • Treat HTN “rarely and cautiously” • Lower BP 10-15% in first 24 hours (not >20%) • Hemorrhagic stroke • Treat if >200/>110, but still with modest lowering of BP because still worse outcome with low BP

  21. Special Circumstances • Eclampsia • Vasoconstricted and hemoconcentrated • Volume expand, magnesium sulfate, and aggressive BP control. • Delivery is only definitive treatment • Labetolol or Nicardipine are drugs of choice. • Hydralazine was first line but slow onset and unpredictable so may lead to hypotension

  22. Special Circumstances • Sympathetic Crisis • Cocaine use, rarely pheochromocytoma • AVOID beta blockers—leads to uninhibited alpha stimulation and increased BP • Labetolol has alpha and beta blockade, but experimental studies show poor outcomes • Nicardipine, fenoldopam or verapamil (with a benzodiazepine) are drugs of choice

  23. References • Haas, A. and Marik, P. “Current Diagnosis and Management of Hypertensive Emergency.” Seminars in Dialysis. Vol 19, No 6. (2006) pp. 502-512. • Flanigan, J. and Vitberg, D. “Hypertensive Emergency and Severe Hypertension: What to Treat, Who to Treat, and How to Treat.” The Medical Clinics of North America. Vol 90 (2006) pp. 439-451.

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