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Emergency DepartmentEvaluation and Treatment
of Hypertension
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What is Hypertension?
Systolic blood pressure >140 mm
Hg or Diastolic blood pressure >90 mm
Hg
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Why is it important to treatHypertension?
Hypertension significantly
increases the risk of cardiovascular disease:
Stroke
CADCHF
Renal insufficiency/failure
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The Framingham Study
Patients 45 74 years oldfollowed for a mean of 18 years
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Results of the FraminghamStudy:
The risk of a cardiovascular event rises
progressively with both systolic anddiastolic blood pressureThe yearly risk of a cardiovascular event is
higher for older patients At all ages and blood pressures, men are ata slightly higher risk than women
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What is the Impact of
treating Hypertension ?In the first few years of treatment :
14% reduction in CAD incidence42% reduction in stroke incidence>50% reduction in CHF incidence
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Classification of BloodPressure for Adults >18
years oldCategory Systolic DiastolicOptimal
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All of these classifications canbe made only after two BP
measurements made duringtwo subsequent visits
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Confounding factors in
Determining the Presence of Chronic Hypertension in the
Emergency Department
Pain
Anxiety Concurrent illness
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Categories of HypertensiveDisease Presenting to
Emergency Departments:
Hypertensive Emergencies Hypertensive Urgencies
Chronic Hypertension
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Hypertensive Emergencies
Severe hypertension plus new or acutely progressive end-organ
dysfunction
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Examples of Hypertensive
Emergencies
Cardiovascular Acute left ventricular failure AMICrescendo angina
Aortic dissection
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Examples of HypertensiveEmergencies
Cerebrovascular EncephalopathyIntracranial hemorrhageSymptomatic papilledema
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Examples of HypertensiveEmergencies
Other Eclampsia/pre-eclampsiaDrug induced
Acute renal failure
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Treatment of Hypertensive
Emergencies Be aggressive
I.V. medications these must beindividualized to the specific situation:- Beta blocker and nitroglycerine for aortic
dissection- Magnesium and Hydralazine for eclamsia-nitroglycerine for severe CHF
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What is the goal of therapy?
Lower the patients blood pressure over 30-60 minutes to the lowest level that willadequately profuse their brain.
Because of cerebral autoregulation, thisshould be no less than 25% - 30% of their mean arterial blood pressure
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mean arterial bloodpressure
MAP = Diastolic BP + ( systolic BP diastolicBP)
3
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For someone with BP = 270/150
MAP = 150 + (270-150) = 150+40 = 1903
Therefore, a reasonable goal would be aMAP of (190) x .75 = 142
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Hypertensive Urgencies
Severe hypertension without significantacute end organ damage
These patients are at risk of complicationsweeks to months in the future notimmediately
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Hypertensive Urgencies
Hypertensive patients:
Awake, alert,with normal neurologicexams, complaining of headache anddizziness, blurred vision (withoutpapilledema),
Proteinuria with normal urea andcreatinine
Epistaxis without coagulopathy
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Hypertensive Urgencies
THE MOST IMPORTANT THING FORTHESE PATIENTS IS TO RULE OUT AHYPERTENSIVE EMERGENCY
Then evaluate their complaint as for anyother patient
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Hypertensive Urgencies
There is no evidence for benefit and thereis anecdotal evidence for harm toasymptomatic patients whose BP istreated hourly until their urgenthypertension responds.
Principles of Ambulatory Medicine, 5 th ed. 1999
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Hypertensive Urgencies
The goal is to control the patientshypertension over the next 24-72 hours
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Hypertensive Urgencies
Evaluation: K+
Urea/creatinineChest X-rayUrinalysis
EKG
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Hypertensive Urgencies
Treatment For uncomplicated hypertension, to date theonly treatments proven in placebo controlled
trials are diuretics (for example,hydrochlorothiazide) and beta blockers (for example metoprolol). Initial monotherapy witheither agent is appropriate.
6 th report of the Joint National Committee onDetection, Evaluation, and Treatment of High BloodPressure, Arch Intern Med, 1997.
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Hypertensive Urgencies
TreatmentOral long-acting calcium channel blockers,ace inhibitors, clonidine, or other diureticsand extended observation can beappropriate
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Hypertensive Urgencies
Treatment Special Cases: Type I diabetes with proteinuria ACE
inhibitors Congestive heart failure ACE inhibitors,
diuretics History of myocardial infarction Beta
blockers
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Hypertensive Urgencies
Treatment There is no need for the patient to have a
normal blood pressure in order to gohome.
The end- point is to solve the patientscomplaint, not the patients blood pressure
Follow-up for repeat BP check in 72 hourswith GP.
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Hypertension - Treatment
Calcium Channel BlockersThe short acting dihydropyridines (this includes
Nifedipine ) are no longer recommended for treatment of hypertension because of asignificant association with myocardial infarction.The long-acting preparations (Adalat Retard) arestill O.K.
The risk of myocardial infarction associated withantihypertensive drug therapies. JAMA 274:620-625,1995
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Hypertension - Treatment
Calcium Channel BlockersThere are many reports of sublingualnifedipine causing harm due to acutehypotension.
Should a moratorium be placed on
sublingual nifedipine capsules given for hypertensive emergencies andpseudoemergencies? JAMA 276:1328-1331,1996
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Chronic Hypertension
No real indication to treat acutely Requires two subsequent visits to truly
diagnose IF you choose to treat, current
recommendations are diuretics or betablockers.