Emergenze ipertensive:

quando e come trattare

Lorenzo Ghiadoni, MD, PhD

Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa

UO Medicina d’Urgenza Universitaria, AOUP

European Hypertension Specialist

Physicians in emergency departments (EDs)

frequently triage patients with ‘hypertensive crises’,

as an acute and severe rise in blood pressure (BP)

presenting with highly heterogeneous profiles ranging

from absence of symptoms to life-threatening target

organ damage.

Mancia G, al. Eur Heart J 2013

2013 ESH/ESC guidelines

for the management of arterial hypertension

• The approach in the acute hypertensive setting has not

been well established, in contrast with the evidence-

based recommendations guiding the appropriate

management of chronically elevated BP.

• In addition, a large number of patients in EDs are

affected by chronic hypertension, and do require referral

to outpatient care rather than acute interventions.

• Most importantly, few randomized clinical trials have

addressed the short-term and long-term effects of acute

BP lowering on cardiac and cerebrovascular morbidity

and mortality.

Mancia G, al. Eur Heart J 2013

2013 ESH/ESC guidelines

for the management of arterial hypertension

Acute severe BP rise in the ED

• Few studies have addressed the epidemiology of acute

hypertensive episodes.

• The prevalence of acute hypertensionwas examined in a

retrospective cohort study using administrative data

collected by 114 acute care hospitals from 2005-2007.

• Among 1,290,804 adults, acute hypertension (defined

as SBP ≥180 mmHg in the ED) occurred in 178,131

patients (13.8%).

Shorr AF et al, J Hosp Med. 2012 Mar; 7(3):203-10

Clinical characteristics associated with acute BP rise in

the ED:

• female sex

• obesity,

• coronary artery disease

• somatoform disorder

• high n° of antihypertensive medications

• Non-compliance to treatment

Acute severe BP rise in the ED

Most cases of acute

severe hypertension

in the ED are not life-

threatening and

preventable !!!!

Saguner AM et al. Am J Hypertens. 2010 Jul; 23(7):775-80

Mancia G et al, Lancet 1983

Intra-arterial blood pressure (BP) recording performed in a patient before,

during, and after a 15-minute visit by a physician unknown to the patient.

Maximal changes in intra-arterial

SBP/DBP recorded during the first

4-5 minutes of a physician's visit as

compared with the baseline average

SBP/DBP values of the 5 minutes

preceding the visit

Is the doctor’s visit a hypertensive urgency?

Emergenze ed urgenze ipertensive

L’urgenza di ridurre i valori di PA non è determinata dall’

entità dei valori pressori, ma dal quadro clinico del paziente

ossia dalla probabilità che l’aumento dei valori pressori

possa determinare rapidamente un evento clinico acuto agli

organi bersaglio.

In questo caso l’aumento acuto de valori pressori

rappresenta un’ emergenza o urgenza ipertensiva.

Hypertensive

emergency

Hypertensive

urgency

Acute severe BP rise

Systolic BP > 180 mmHg

and/or

diastolic BP > 120 mmHg

Acute severe BP rise

Systolic BP > 180 mmHg

and/or

diastolic BP > 120 mmHg

Muiesan ML et al. J Cardiovasc Med 2014

Muiesan ML et al. J Cardiovasc Med 2014

Most common presentations of hypertensive emergencies

in the ED are:

• pulmonary oedema and congestive heart failure

• cerebral infarction

• hypertensive encephalopathy

and also include:

intracranial haemorrhage, aortic dissection, myocardial

infarction, malignant hypertension, sympathetic crises

(cocaine toxicity/pheochromocytoma) and eclampsia.

The aim of treatment is to avoid an acute worsening of

organ damage and further long-term complications

Muiesan ML et al. J Cardiovasc Med 2014

• The choice of the best drug(s) with the better benefit–risk ratio

depends on the correct recognition of the clinical picture and the

consideration of comorbidities.

• Several rapid-acting intravenous agents are available for the

treatment of hypertensive emergencies and the choice is mainly

related to the clinical manifestation of end-organ damage

• The effect of these drugs should be carefully monitored in a proper

setting, in order to avoid an excessive velocity of BP reduction

• Sublingual nifedipine is not recommended.

Muiesan ML et al. J Cardiovasc Med 2014

Muiesan ML et al. J Cardiovasc Med 2014

Due to the loss of autoregulation, in the

‘penumbra’ the cerebral perfusion

follows the perfusion pressure and a BP

fall during this critical time may reduce

cerebral perfusion, extend the ischemic

area, induce irreversible damage and

worsen the disabling consequences of

the initial stroke

Unfortunately, an excessive decrease of BP is common among

patients admitted to an ED with hypertensive emergency even in acute

stroke patients, in whom the risk of hypoperfusion is well known

Ischemic stroke

In these patients the rate of change of BP was frequently greater than

recommended, and met American Heart Association recommended

treatment criteria in only one-third of patients.

• The American Stroke Association (ASA) recommend that only BP

values repeatedly > 220/120 mmHg should be treated with either

labetalol or sodium nitroprusside, intravenously, unless there are

other indications for antihypertensive therapy (congestive heart

failure, myocardial infarction, aortic dissection).

• The BP target during the acute phase of an ischemic stroke should

not be a normal BP, but rather:

- 180/105 mmHg diastolic in previously hypertensive patients

- 160–180/90–100 mmHg in previously normotensive patients

Ischemic stroke

AHA/ASA Recommendations for BP Management in Acute Ischemic

Stroke also state that:

• Patients eligible for treatment with intravenous thrombolytics or other

acute reperfusion intervention and SBP 185 mmHg or DBP 110

mmHg should have BP lowered before the intervention.

• A persistent SBP of 185 mmHg or a DBP 110 mmHg is a

contraindication to intravenous thrombolytic therapy.

• After reperfusion therapy, keep SBP below 180 mmHg and DBP

below 105 mmHg for at least 24 h.

Ischemic stroke

AHA/ASA Recommendations for BP Management in Acute Cerebral

Hemorrhages state that:

• if SBP is higher than 200 mmHg or mean arterial pressure (MAP) is

higher than 150 mmHg, consider aggressive reduction of BP

• if SBP is higher than 180 mmHg or MAP is higher than 130 mmHg

and intracerebral pressure (ICP) may be elevated, consider

monitoring ICP and reducing BP to keep cerebral perfusion pressure

between 60 and 80 mmHg.

• if SBP is higher than 180 mmHg or MAP is higher than 130 mmHg

and there is no evidence of or suspicion of elevated ICP, consider

modest BP reduction (e.g. MAP of 110 mmHg or target BP of 160/90

mmHg).

Haemorrhagic stroke

Muiesan ML et al. J Cardiovasc Med 2014

Fundoscopy to detect hypertensive

emergencies/urgencies in ED?

Muiesan, ML et al. J Hypertension 2017, in press

Ocular fundus photography with a smartphone device in acute hypertension

D-Eye, Si14 S.p.A., Padova, Italy

Muiesan ML et al. J Cardiovasc Med 2014

• Retrospective cohort study in patients presenting with hypertensive

urgency (BP>180/110 mmHg, no acute organ damage) to an office in the

Cleveland Clinic Healthcare system (Jan 2008 - Dec 2013).

• No difference in MACE: at 7 days (0 vs 2 [0.5%]; P = 0.11)

from 8 to 30 days (0 vs 2 [0.5%]; P = 0.11)

at 6 months (8 [0.9%] vs 4 [0.9%]; P > 0.99)

• Patients sent home were more likely to have uncontrolled hypertension at

1 month (735 of 852 [86.3%] vs 349 of 426 [81.9%]; P = 0.04) but not at 6

months (393 of 608 [64.6%] vs 213 of 320 [66.6%]; P = 0.56).

• Hypertensive urgency is common, but the rate of MACE in asymptomatic

patients is very low.

• Visits to the ED were associated with more hospitalizations, but not

improved outcomes.

Hypertensive urgencies: home or hospital?

Patel KK et al. JAMA Intern Med 2016

Emergenze

Ipertensive

L’aumento della PA si accompagna a

danno acuto degli organi bersaglio con

pericolo di vita immediata del paziente.

Urgenze

Ipertensive

L’aumento della PA si associa a danno

potenziale (ipertensione peri-operatoria) o

a danno rapidamente evolutivo

(ipertensione accelerata o maligna).

Riduzione della

PA immediata

entro 2-6 ore

Riduzione della

PA entro

24/48 ore

Urgenza dell’intervento terapeutico

PA >

180/110 mmHg

isolata

Non è una condizione d’urgenza, ma il

rischio cardiovascolare è comunque

elevato.

No terapia e

conferma dei

valori di PA entro

una settimana