Hypertensive Emergencies: Diagnosis and Treatment

1. Hypertensive Emergencies:Diagnosis and Treatment Jamie Johnston, MD University of Pittsburgh School of Medicine

2. Today’s Road Map • Case Presentations • Definitions • Evaluation • Management • Will not cover pre-eclampsia or pediatric hypertensive emergencies

3. Case 1 • 51 year old man admitted to an outside hospital • CC: Sudden onset of left-sided weakness, severe headache, slurred speech and left facial droop • BP 260/172 • Head CT Scan showed Right basal ganglia hemorrhage with shift • HPI: Transported by air ambulance to PUH. • Intubated en route due to declining mental status

4. Case 1 • PMH - Hypertension - according to wife, patient was non-adherent with prescribed medications • Out patient medications and allergies - not available • Family History +for HTN/CVA • Exam PUH - BP 196/130 • Positive for Left dense hemiparesis

5. Case 1 • Hospital day 2 • Dilated right pupil • Emergent right frontotemporal craniotomy and evacuation of clot • Subsequent Hospital Course • Difficult to control BP • Pneumonia

6. Case 1 • Renal MRI • Right kidney 8.1 cm with three renal arteries • Left kidney 12.2 cm with two renal arteries • Patient transferred to rehab at South Side Hospital on 7/19/07

7. Question 1 • What is the primary reason for hypertensive emergencies in the USA today? • Renovascular Disease • Pheochromocytoma • Non-adherence to anti-hypertensive medication • Hyperaldosteronism • Erythropoeitin

8. 10 What is the primary reason for hypertensive emergencies in the USA today? • Renovascular Disease • Pheochromocytoma • Non-adherence to anti-hypertensive medication • Hyperaldosteronism • Erythropoeitin

9. When you hear hoof beats…

10. Hypertensive Emergency • According to the Joint National Committee on Hypertension Report • Severely elevated blood pressure with signs and symptoms of acute end organ damage • Requires hospitalization • Requires parenteral medication

11. Hypertensive Urgency • Severely elevated blood pressure without signs and symptoms of acute end organ damage • Can be managed as an outpatient • Can be managed with oral medications

12. Hypertensive Emergency CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy Heart - CHF, MI, angina • Damage Kidneys - acute kidney injury, microscopic hematuria Vasculature - aortic dissection, eclampsia Vasculature

13. Epidemiology • Hypertensive emergencies are common • Occur in 1-2% of the hypertensive population • But, 50 million hypertensive Americans • 500,000 hypertensive emergencies/year • Parallels the distribution of primary hypertension • Higher in the elderly and African Americans • Incidence in men 2 times higher than in women

14. Epidemiology • Common associations • Previous history of hypertension • Lack of a primary care physician • Non adherence to antihypertensive regimen • Elicit drug use (cocaine)

15. Pathophysiology Sudden increase in Systemic Vascular Resistance Mechanical Stress with endothelial injury, increased permeability, Coag/Plt activation, fibrin deposition BP Fibrinoid necrosis Ischemia Activation of RAA Proinflammatory cytokines

16. Vaughan and Delanty Lancet 2000; 356:411

18. Underlying Etiology? • Unclear, but some candidates • ACE DD genotype • Absence of the b and g subunit of ENaC • Elevated adrenomedullin levels* • Elevated natriuretic peptide level* • Abnormalities in oxidative stress markers and endothelial dysfunction* • *Correct after effective BP treatment

19. Question 2 • What is the most common complaint in hypertensive emergency? • Neurologic defect • Gross Hematuria • Chest pain • Headache • Epistaxis

20. What is the most common complaint in hypertensive emergency? • Neurologic defect • Gross Hematuria • Chest pain • Headache • Epistaxis

21. Clinical Presentation • Variable • Zampaglione et al (Hypertension 27:144, 1996) • 14, 209 ER visits in one year period • 108 met definition of hypertensive emergency (0.8%) • Mean Systolic BP 210 + 32 • Mean Diastolic BP 130 + 15

22. Clinical Presentation • Frequency of signs and symptoms • Chest Pain 27% • Dyspnea 22% • Neuro defect 21% • Interestingly…. • Headache was only 3% and epistaxis was 0% in this study

23. Question 3 • Hypertensive emergency is associated with a threshold BP of • Systolic > 225 mm Hg • Diastolic > 110 mm Hg • Systolic > 250 mm Hg • Diastolic > 120 mm Hg • All of the above

24. Hypertensive emergency is associated with a threshold BP of • Systolic > 225 mm Hg • Diastolic > 110 mm Hg • Systolic > 250 mm Hg • Diastolic > 120 mm Hg • All of the above

25. Threshold BP • There is no specific BP where hypertensive emergencies occur • But, organ dysfunction is rare with diastolic BPs < 130 mm Hg • Rate of increase may be more important • Hence, encephalopathy will occur at lower BPs in pregnancy and in children

26. Initial Evaluation • Focused history • History of hypertension? • How well is hypertension controlled? • What antihypertensives? • Adherence to antihypertensive regimen? • Last dose of antihypertensive?

27. Initial Evaluation • Social History • Recreational Drugs • Amphetamines • Cocaine • Phencyclidine

28. Initial Evaluation • Confirm BP in both arms • Use appropriate sized BP cuff • Cuff that is too small • BP cuffs that are too small falsely elevate BP measurements in obese patients

30. Initial Evaluation • Assess for end-organ damage • Vascular Disease • Assess pulses in all extremities • Auscultate over renal arteries for bruits • Cardiopulmonary • Listen for rales (CHF) • Murmurs or gallops

31. Initial Evaluation • Neurologic Exam • Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures • Lateralizing signs uncommon and suggest cerebrovascular accident • Retinal Exam • Lost art • Keith-Wagener-Barker Classification

32. Keith-Wagener-Barker Classification • Grade 1 • Mild narrowing of the arterioles • “Copper Wire” • Grade 2 • Moderate narrowing - Copper wire and AV nicking • Changes associated with long standing essential hypertension

33. Normal

34. Grade 1

36. Keith-Wagener-Barker Classification • Grade 3 • Severe Narrowing - Silver wire changes, hemorrhage, cotton wool spots, hard exudates • Grade 4 • Grade 3 + Papilledema • Grade 3 and 4 highly correlated with progression to end organ damage and decreased survival

37. Grade 3 KWB Retinopathy

39. Lab Testing • ECG • LVH, look for signs of ischemia, injury, infarct • Renal Function Tests (urine included) • Elevated BUN, Creatinine, proteinuria, hematuria • CBC • CXR - pulmonary edema, aortic arch, cardiac enlargement

40. Lab Testing • Aortic Dissection? • Suspect with severe tearing chest pain, unequal pulses, widened mediastinum • Contrast Chest CT Scan or MRI • Pulmonary Edema/CHF • Transthoracic Echocardiogram • Differentiate between systolic dysfunction, diastolic dysfunction, mitral regurgitation

41. Management • Elevated BP without target organ damage • Hypertensive urgency • Oral meds • Goal - gradual reduction of BP over 24 - 48 hours

42. Management • Elevated BP with target organ damage • Hypertensive emergency • Parenteral meds • Goal - Reduce diastolic BP by 10-15% or to 110 mm Hg over a period of 30 - 60 minutes

43. How Quickly? • Cerebral Blood Flow Autoregulation • Cerebral Blood constant in normotensive individuals over range of MAPs of 60 -120 mm Hg. • In chronically hypertensive patients autoregulatory range is higher • MAP Range 100-120 to 150-160 mm Hg • Autoregulation also impaired in the elderly and those with cerebrovascular disease

44. How Quickly? • General rule is to lower MAP by 20% in first hour • Should always be done with close clinical observation

45. Management • Where? • ICU with close monitoring • Severe requires intra-arterial BP monitoring • Which Parenteral meds? • Depends on the situation

46. Question 4 • Which of the following drugs should not be used to treat hypertensive emergency? • Sublingual Nifedipine • Labetolol • ACE Inhibitors • Nicardipine • 1 and 3

47. Which of the following drugs should not be used to treat hypertensive emergency? • Sublingual Nifedipine • Labetolol • ACE Inhibitors • Nicardipine • 1 and 3

48. Preferred Agents • Beta blockers • Labetolol • Esmolol • Calcium Entry blocker • Nicardipine • Dopamine-1 receptor agonist • Fenoldapam • Vasodilators - nitroprusside/nitroglucerin

49. Scenarios • Our Case - Acute ischemic stroke/cerebrovascular bleed • Agents • Fenoldopam • Labetolol • Nicardipine

50. CVA or Ischemic Stroke • BP elevation after CVA or ischemic stroke can be protective to preserve cerebral perfusion • Hold on aggressive lowering unless • Thrombolytic therapy anticipated or • BP excessively high ( SBP > 220 mm Hg or DBP >120) • BP Goal for thrombolytic therapy is to lower SBP if > 185 or DBP >110