Management of Hypertensive Crisis(diskusi RSUD).ppt

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Management ofManagement ofHypertensive CrisisHypertensive Crisis

Bernard V.S. ManansangInternal Medicine Departement of Bitung District Hospital



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Definition

Hypertensive crisis :• Severe elevation of blood pressure, which must be

reduced immediately

• Hypertensive emergency :– accompanied by acute target organ damage– BP must be reduced within minutes

• Hypertensive urgency :– no acute organ damage– BP must be reduced within hours

Clinical Hypertension, Kaplan !!"



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Definition

• #ot determined by BP level, but rather theimminent compromise vital organ function

• $ormerly when :

– systolic ≥ %&! mm Hg– diastolic ' %%! mm Hg

(stage )))* +H !!"-

.he Kidney and Hypertension, Ba/ris, !!0



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High blood pressure in asymptomaticchronic hypertension

)S #. 1 H2P34.3#S)53 C4)S3S



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Precipitating factors in hypertensive crisis

1. Accelerated sudden rise in blood pressure inpatient wit pree!isting essential "pertension

#. $eno%ascular "pertension

&. 'lomerulonepritis(acute). *clampsia+. ,eocromoc"toma-. Anti"pertensi%e witdrawl s"ndromes

. Head in/uries0. $enin secreting tumors. Ingestion of catecolamine precursor in patients

ta2ing MA3 inibitors



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H"pertensi%e emergenc"

• Accelerated(malignant "pertension wit papilledema• 4erebro%ascular conditions

H"pertensi%e brain infarction wit se%ere "pertensionIntracerebral 5 Subaracnoid

• 4ardiac conditionsAcute aortic dissectionAcute or impending m"ocardial infarction

• $enal conditions$enal crises from collagen(%ascular diseasesSe%ere "pertension after 2idne" transplantation

• *clampsia• Surgical conditions

Se%ere "pertension in patients re6uiring immediate surge"• Se%ere epista!is



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Sign and symptom in various types of hypertensive emergency

.ype ofhypertensive emergency

.ypical symptoms .ypical signs Comment

1cute stro/e in evolution

(thrombotic or embolic-

+ea/ness, altered

motor s/ill(s-

$ocal neruological

deficit(s-

Hypertension not

usually treated

Suibarachnoid hemorrhage Headache,

delerium

1ltered mental

status, meningeal

signs

6umbar puncture

typically shows

7anthochromia or redblood cells

1cute head in8ury9trauma Headache, altered

sensorium or

motor s/ills

6acerations,

ecchymoses,

altered mental

status

Computed

tomographic (C.-

scan is helpful to

determine e7tent of

intracranial in8uryHypertensiveencephalopathy

Headache, alteredmental status

papilledema sually a diagnosisof e7clusion

Cardiac

ischemia9infraction

Chest discomfort,

nausea, vomiting

1bnormal 3K;

(esp< .=wave

elevations-



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.ype ofhypertensive emergency

.ypical symptoms .ypical signs Comment

1cute left ventricular

failure9pulmonary edema

Shortness of

breath

4ales auscultated

in chest

1ortic dissection Chest discomfort +idened aortic

/nob on chest 7=

ray

3chocardiogram,

chest C., or

angiogram usuallyneeded to confirm

4ecent vascular surgery Bleeding,

tenderness at

suture lines

Bleeding at suture

lines

ften re>uire

surgical revision of

vascular anastamosis

Pheochromocytoma Headache,sweating,

palpitations

Pallor, flushing,rare s/in signs

(pha/omatoses-

Phentolamine is veryuseful

?rug related

catecholamine e7cess

state

Headache,

palpilations

tachycardia History regarding

drug e7posure is /ey

Preeclampsia 9 eclampsia Headache, uterine

irritability

3dema,

hyperrefle7ia

#ew treatment

guidelines e7ist

Sign and symptom in various types of hypertensive emergency



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Management of H"pertensi%e emergenc"

'eneral principle 7

• te goal is8 inibit te progression of organdamage

• parenteral drugs must be used• balance te benefit and te organ perfusion8

particularl" brain8 m"ocardium and 2idne"

M)MS Cardiovascular ;uide, !!@



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9erapeutic guidelines

• do not lower B, more tan #+: o%er te first 1 ourunless necessar" to protect oter organs

• reduce te SB, of 1-; mmHg8 DB, of 1;; mmHg8 orMA, of 1#; mmHg8 in te first #) ours

• begin te concomitant long(term terap" soon afterte initial emergenc" treatment

• attempt te establised normotension witin a fewda"s

MIMS Cardiovascular Guide, 2005



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,arenteral drugs for treatment of "pertensi%e emergenc"

Drug Dose Onset ofactions Durationof action Special indications

Diuretics

Furosemide

20-40 mg in 1-2 min,repeated and higherdoses with renalinsufficiency

5-15 min 2- h !ssually needed tomaintain efficacy ofother drugs

"asodilators#itropruside

0$25-10$00µg%min%&g%min as i$'$

infusion

(mmediate 1-2 min )ost hypertensi'eemergencies* cautionwith high intracranialpressure or a+otemia

#itroglycerin

#itro-id (".

5-100 µg%min as i$'$

infusion

2-5 min 5-10 min /oronary ischemia

#icardipine 5-15 mg%h i$'$ 5-10 min 1-4 h )ost hypertensi'eemergencies* cautionwith acute heart failure



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Drug Dose Onset ofactions

Durationof action

Special indications

ydrala+ine 10-20 mg i$'$ 10-20 min - h clampsia* caution withhigh intracranialpressure

nalaprilat 1$25-5$00 mg e'ery 3 h 15 min 3 h cute left 'entricularfailure

drenergicinhiitors

hentolamine

smolol

6aetalol

5-15 mg i$'$

200-500 µg%&g%min for 4

min, then 50-00

µg%&g%min i$'$

20-0 mg i$'$ olus

e'ery 10 min2 mg%min i$'$ infusion

1-2 min

1-2 min

5-10 min

-10 min

10-20 min

-3 h

/atecholamine e7cess

ortic dissection, afteroperation

)ost hypertensi'e

emergencies e7ceptacute heart failure

/lonidin 85-100 µg%unit 5-10 min -3 h )ost hypertensi'eemergency, highcaution with reoundeffect

,arenteral drugs for treatment of "pertensi%e emergenc"



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Condition Preerred anti!"#ertensive a$ent

%cute #ul&onar" ede&a 'enoldo#a& or nitro#russide in co&(ination )it!

nitro$l"cerin *u# to 60 µ$+&in and a loo# diuretic

%cute &"ocardial isc!e&ia -a(etalol or es&olol in co&(ination )it!

nuitro$l"cerin *u# to 60 µ$+&in

."#ertensive ence#!alo#at!" -a(etalol, nicardi#ine, or enoldo#a&

%cute aortic dissection -a(etalol or co&(ination o nicardi#ine orenoldo#a& and es&olol or co&(ination onitro#russide )it! eit!er es&ool or intravenous&eto#rolol

/cla&#sia -a(etalol or nicardi#ine ."dralaine &a" (e used

in a nonIC settin$

%cute renal ailure+ &icroan$io#at!icane&ia

'enoldo#a& or nicardi#ine

S"&#at!etic crisis+cocaine overdose era#a&il, diltiae&, or nicardi#inein co&(ination)it! a (enodiae#ine

9able $ecommended anti"pertensi%e agents for "pertensi%ecrisis



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H"pertensi%e <rgenc"

• ,otentiall" dangerous B, ele%ation8 witoutacute5life(treatening end organ damage

• Blood pressure formerl" S ≥10; mmHg8 D ≥11; mmHg

• Some of te circumstance 7

– Hig B, wit retinal canges => II

– ,reoperati%e8 perioperati%e or post operati%e

condition– ,ain(induced or stress induced "pertension

– H"pertensi%e rebound



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Management of H"pertensi%e urgenc"

• 'oal 7 pre%ent to te target organ damage

• 9erapeutic consideration 7

– <se oral drugs

– Sub lingual drug ?@• $eac te B, 1-;51;; mmHg in #) ours8 normal

after #)()0 ours



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Sublingual drug• Still contro%ersial 5 begin to a%oid• Subse6uent studies sowed tat te bioa%ailabilit" of

sublingual nifedipione was negligible• DA recommendations 1- 7

Cifedipine sublingual sould be used wit greatcaution8 if at al A

Ba/ris, Kidney and Hypertension !!0



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.able ral drugs for hypertensive urgencies

Drug /lass Dose Onset Duration h.

/aptopril /apoten. ngiotensin-con'ertingen+yme inhi$

25-50$0 mg 15 min 4-3

/lonidine /atapres. /entral -

agonist

0$2 mg initially,

then 0$1 mg%h,up to 0$ mg

total

0$2-2$0 h 3-

Furosemide 6asi7. Diuretic 20-40 mg 0$5-1$0 h 3-

6aetalol #ormodyne,

9randate.

- and -

:loc&er

100-200 mg 0$5-2$0 h -12

#ifedipine procardia,dalat.

/alciumchannelloc&er

5-10 mg 5-15 min -5

ropanolol (nderal. -:loc&er 20-40 mg 15-0 min -3



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athways for management of patients with se'ere hypertension, defined as

lood pressure :. in e7cess of 10%110 mmg$

Se'ere ypertension

: ; 10 % 110

ncephalopathy

rogressing target organ damage

<es

9 mergency.

#o

#ew onset

9 !rgency.

rior similar e7perience*

#egati'e wor&up

!ncontrolled 9.

dmit to (/!

:aseline la

:aseline la

Oral =7

=einstitute oral =7

Follow closely

arenteral =7

>or&up for

identifiale causes?=eno'ascular 9

9he @idney and ypertension, :a&ris, 2004



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.H3 4);H. $4

%<4ight medicine

<4ight indication

"<4ight dose

0<4ight patient

C143 . .H3 1?534S3 3$$3C.



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Management of Hypertensive Crisis(diskusi RSUD).ppt