الرحيم الرحمن الله بسم
Hypertensive Emergencies and Urgencies
Dr Nahed Sherbini ,Consultant Internist ,Head of Internal Medicine Department
2010 KFH, Medina
Uncontrolled Hypertension: May Occur Throughout the Hospital
ED Medical & Surgical Wards MICU SICU OR
Varon J, Fromm RE. Postgrad Med. 1996;99:189-203.
What I Will Talk About?
Hypertensive Emergencies
Hypertensive Urgencies
An Approach to Drug Treatment of HU and HE
Hypertension — An Epidemic
Affects at least 1 BILLION individuals worldwide.
Most current (2003) evidence basis for chronic management— (JNC 7)—lacks guidance for acute management of patients presenting with severe acute elevations of BP.
JNC 7, JAMA 2003; 289:2560-2572.
Hypertensive Urgenciesand Emergencies
Data are largely lacking.
In a single-center Italian study, HU or HE
HU:HE ratio of 3:1 in that study
Zampaglione et al, Hypertension 1996;27:144.
ED Hypertensive Emergencies
Hypertensive emergencies and urgencies Account for 3% of all ED visits1
An “Internal Medicine” ED N=14,209 1634 had a medical urgency or
emergency2▪ 27.4% of these were hypertensive crises
1. Kitiyakara C, Guzman N. J Am Soc Nephrol. 1998;9:133-142. 2. Zampaglione B, et al. Hypertension. 1996;27:144-147.
Blood Pressure Classification
JNC7
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 Hypertension 140–159 or 90–99
Stage 2 Hypertension >160 or >100
BP Classification SBP mmHg DBP mmHg
JNC 7 Nomenclature
Stage 3 hypertension (JNC 6): Systolic > 180, Diastolic > 110 Functionally, this is “hypertensive
urgency”
What about “crisis,” “emergency,” and “urgency”?
JNC 7, JAMA 2003; 289:2560-2572.
JNC 7 Nomenclature
“hypertensive crisis” is an acute, severe, stage 2 or 3 elevation BP.
Crisis is then differentiated into hypertensive “emergencies” &“urgencies”.
JNC 7, JAMA 2003; 289:2560-2572.
Hypertensive Crisis: JNC-7 definitions
Hypertensive emergency
Severe elevation in BP (>180/120 mmHg) complicated by evidence of impending or progressive target organ dysfunction
Hypertensive urgency
Severe elevation in BP without progressive target organ dysfunction
Chobanian AV et al. Hypertension. 2003;42:1206-1252.
Hypertensive Crisis
Hypertensive
urgency
Hypertensive
emergency
Perioperative
hypertension
Operating roompost-
anesthesia care
Emergencydepartment
Intensive care unit
End-Organ Damage Characterizes Hypertensive Emergencies
BrainHypertensive encephalopathyStroke
RetinaHemorrhagesExudatesPapilledema
Cardiovascular SystemUnstable anginaAcute heart failureAcute myocardial infarctionAcute aortic dissection Dissecting aortic aneurysm
KidneyHematuriaProteinuriaDecreasing renal function
Adapted from Varon J, Marik PE. Chest. 2000;118:214-227 .
Causes of Hypertensive Crises Essential hypertension
Medication noncompliance
Secondary hypertension Aortic coarctation Cushing’s syndrome Elevated ICP Renal dysfunction Pregnancy Hyperparathyroidism Hyperthyroidism Pheochromocytoma Primary aldosteronism
JNC 7, JAMA 2003; 289:2560-2572.
Severe Hypertension: Etiologies
Medical Uncontrolled HTN
▪ Noncompliance Drug-induced HTN
▪ Cocaine, amphetamines
▪ Drug withdrawal▪ Drug-drug
interactions Endocrine disorders
●Surgical– Cardiac surgery
– Major vascular surgery
- Carotid endarterectomy
- Aortic surgery
– Neurosurgery
– Head and neck surgery
– Renal transplantation
– Major trauma – burns or head injury
Varon J, Fromm RE. Postgrad Med. 1996;99:189-203.
Medications That May PrecipitateHypertensive Emergencies / Urgencies
• Oral contraceptives
• Steroids
• NSAIDs
• Nasal decongestants
• Appetite suppressants
Presenting Symptoms
Hypertensive Urgencies Arrhythmia Epistaxis Headache Psychomotor agitation
Usual Primary ED Diagnosis Hypertension
Hypertensive Emergencies Chest pain Dyspnea Neurologic deficits
Usual Primary ED Diagnosis CVA Acute pulmonary edema Hypertensive encephalopathy Acute heart failure
Zampaglione et al, Hypertension 1996;27:144.
Hypertension in presentation
Four Categories of Presentation1. Mild, uncomplicated2. Transient3. Emergencies4. Urgencies
Definitions of Hypertension
Mild, Uncomplicated HTN Diastolic BP <115 mmHg without end
organ symptoms Educate, do not treat, arrange follow up
Transient HTN A reaction to some condition
▪ Pain, fright, epistaxis, drug OD
Treat the condition
SevereHTN
CHF andPulmonary
Edema
Renal
Dysfunction
Myocardial
Infarction
Stroke,Encepha-lopathy
AorticDissectio
n
Severe Hypertension: Clinical Outcomes
Benefits of Lowering BP JNC7
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
Treatment Guidance
Goals of Emergency Therapy of Hypertensive Crises
Goal in hypertensive urgency is to reduce MAP (MAP= ( 2 Diastolic + systolic) / 3) by 10-15% and/or to a DBP of 110 . . . within hours.
HU can generally be managed with oral medications and requires BP lowering over 24-48 h.
JNC 7, JAMA 2003; 289:2560-2572.
Algorithm for Treatment of Hypertension JNC7
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)
as needed .
With Compelling Indications
Lifestyle Modifications
Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg)
Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling Indications
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Compelling Indications for Individual Drug Classes
Compelling Indication Initial Therapy Options Clinical Trial Basis
ACC/AHA Heart Failure Guideline, MERIT-HF, COERNICUS, RALES
ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn,
ALLHAT, HOPE, ANBP2, LIFE, CONVINCE
THIAZ, BB, ACEI, ARB, ALDO ANT
BB, ACEI, ALDO ANT
THIAZ, BB, ACE, CCB
Heart failure
Post MI
High CAD risk
Diabetes
Chronic kidney disease
Recurrent stroke prevention
Compelling Indications for Individual Drug Classes
Compelling Indication Initial Therapy Options Clinical Trial Basis
NKF-ADA Guideline, UKPDS, ALLHAT
NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK
PROGRESS
THIAZ, BB, ACE, ARB, CCB
ACEI, ARB
THIAZ, ACEI
Treatment Goals for Hypertensive Emergency
Reduce MAP by ≤ 25% during the 1st minutes to 1 h.
If stable, reduce BP to 160/100-110 mmHg in next 2-6 h.
Conditions requiring special management Aortic dissection
Stroke eligible for thrombolytic agents Ischemic stroke
Chobanian AV et al. Hypertension. 2003;42:1206-1252.
Cerebral Autoregulation Is Central to Treatment of Hypertensive Crises
100 200
Normotensive
Chronic hypertensive
Increasing risk of hypertensive
encephalopathy
Increasing risk of ischemia
50 150 250
Patients with cerebral ischemia lose their ability to autoregulate
Ischemia
Cerebral Blood Flow
Adapted with permission from Varon J, Marik PE. Chest. 2000;118:214-227.
MAP (mm Hg)
0
Patients with chronic hypertension autoregulate cerebral blood flow
around higher set points
PATHOPHYSIOLOGY
NORMAL AUTOREGULATION
RISE IN BP
ARTERIAL AND ARTERIOLAR CONSTRICTION
Normal flow.(flow=P/r)
RISE IN BP
FAILURE OF VASOCONSTRICTION
ENDOTHELIAL DAMAGE
(due to shear stress on the wall)
AUTOREGULATION FAILURE
JNC 7: Special Considerations in Hypertensive Emergencies
Patients with marked BP elevations and acute target-organ damage
Admitted to an ICU for continuous monitoring of BP.
Should receive parenteral antihypertensive therapy with an agent appropriate for the individual patient.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. US Dept of HHS; NIH publication No. 04-5230; 2004:54.
Ref : CHEST 2007 ; 131 : 1949-1962 : Hypertensive crises : challenges and management
Ref : CHEST 2007 ; 131 : 1949-1962 : Hypertensive crises : challenges and management
47- Year-OldComplains Of Chest Pain
47-Year-Old Complains Of Chest Pain
BP 162/110BP 162/110
Acute Myocardial Infarction
NTG Relieves only chest pain No mortality difference in 77,000 patients
-blockers
Antiplatelets: ASA, clopidogrel
Anticoagulants: LMWH, UFH
GP IIb/IIIa antagonist or DTI w/clopidogrel
NTG Relieves only chest pain No mortality difference in 77,000 patients
-blockers
Antiplatelets: ASA, clopidogrel
Anticoagulants: LMWH, UFH
GP IIb/IIIa antagonist or DTI w/clopidogrel2007 AHA/ACC Guidelines
NitrovasodilatorsNitroprusside versus Nitroglycerin
Drug Nitroprusside NitroglycerinRapid onset of peak effect ++++ +++
Afterload reduction ++++ +
Preload reduction ++ ++++
Coronary steal reported + 0
Coronary dilation – large vessel + ++++
Coronary dilation – small vessel +/- +/-
Tachycardia ++ ++
Potential for symptomatic hypotension ++ +++
Ease of administration ++ +++
Cyanide toxicity ++++ 0
Pepine CJ. Clin Ther. 1988;10:316-325.
54-Year-Old Male, Collapsed At Work
Aortic Dissection — Strategy
Must decrease shear forces Do not use inotropics
Esmolol
Labetolol
Must decrease shear forces Do not use inotropics
Esmolol
Labetolol
Tintinalli, 4th ed.
-Blocker vs Combined - and -Blocker
Esmolol -Blocker
Labetalol
- and -Blocker
Administration BolusContinuous infusion
BolusContinuous infusion
Onset Rapid (60 s)2 Intermediate (peak 5-15 min)2
Offset (Duration of action) Rapid (10-20 min)2 Slower (2-4 h)2
HR Decreased +/-
SVR 0 Decreased
Cardiac output Decreased +/-
Myocardial O2 balance Positive Positive
Contraindications Sinus bradycardiaHeart block >1°
Overt heart failureCardiogenic shock
Severe bradycardiaHeart block >1°
Overt heart failureCardiogenic shock
1. Hoffman BB. In: Hardman JG, Limbird LE, eds. Goodman and Gilman’s Pharmacological Basis of Therapeutics. 10th ed. New York, NY: McGraw-Hill; 1997:215-268.
2. Varon J, Malik PE. Chest. 2000;118:214-227.
Calcium Channel Blockers
Nicardipine(dihydropyridine)
Diltiazem(benzothiazepine)
Verapamil(phenylalkylamine)
Peripheral Vasodilation1 +++++ +++ +++
CoronaryVasodilation2 +++++ +++ ++++
Suppressionof SA Node2 + +++++ +++++
Suppressionof AV Node2 0 ++++ +++++
Suppressionof Cardiac
Contractility20 ++ ++++
.1Frishman WH, et al. Med Clin North Am. 1988;72:523-547 .
.2Adapted from Goodman and Gilman’s: The Pharmacologic Basis of Therapeutics. 9th ed. 2001.
IV Antihypertensive Utilization Trends
1,200,4441,133,717
8,288
139,104
240,785
735,647
502,518
312,432
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
Nitroglycerin Labetalol Hydralazine Enalaprilat Esmolol SNP Nicardipine Fenoldopam
2004 2005 2006
All Patients Treated with Drug
Thomson Patient Level Data. 2006
Finally,
HTN is extremely prevalent & hypertensive crises will become increasingly common in the ED.
So, What is new?
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc8/index.htm
Coming up next year!
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8)
Update of the JNC 7 ReportExpected Availability for Public
Review and Comment: Spring 2011
Expected Release Date: Fall 2011
Thank you for your attention