HYPERTENSIVE CRISIS

SYED RAZA

OBJECTIVES

• 1. What is Hypertensive Crisis ?• 2. Size of the problem• 3. Clinical presentation• 4. Management

CASE SCENARIO• 69/M• Chest tightness and shortness of breath• Diabetes – 10 years. Chronic smoker• Not known hypertensive• BP 230/120 mmHg HR 110/mt• CVS – S3 gallop, No murmur.• Chest – Bi-basal fine inspiratory crackles• P/A – Kidneys not ballotable. No RA bruit.• Neuro – fully consciouss , No neuro deficits.

Lab

• Hb – 9.4• MCV- 84• Creatinine : 2.1 mg/dl• Urine : 3 + protein• Cardiac markers - Normal

What would you do next?

• 1. 24 hour urinary protein.• 2. 24 hour ambulatory BP• 3. Renal Ultrasound• 4. Fundoscopy

What targets organs are Involved?

• 1. Brain• 2. Heart• 3.Retina• 4. Kidneys

What targets organs are Involved?

• 1. Brain• 2. Heart• 3.Retina• 4. Kidneys

What is the diagnosis?

• 1. Accelerated Hypertension• 2.Malignant Hypertension• 3. Hypertensive Urgency• 4. Hypertensive Emergency

Answer

Hypertensive Emergency Severe Hypertension where BP is > 180/110 mmHg with evidence of target organ damage. 1.Retinopathy / Retinal hemorrhage 2.Encephalopathy/I.C hemorrhage/ IC tension 3.Acute Pulm. Oedema, Myocardial ischaemia/Aortic dissection. 4. Acute Renal Failure

HYPERTENSIVE CRISIS

• Approximately 25% of emergency room visits are due to hypertensive crisis.

• BP > 180/110 mmHg• Emergency : Target organ damage.• Urgency : No target organ damage.

Common precipitating factors

• 1. No regular health checks• 2. Age - elderly• 3.Sub therapeutic treatment• 4. Non adherence to medication.• 5. Lack of family care physician.

Signs and Symptoms

Symptoms specific to target organ damage• Headache• Neck pain• Blurring of vision• Chest tightness• Shortness of breath• Anuria

Lab Work Up

• 1.CBC• 2. KFT• 3.Urine Analysis• 4. CXR – Heart/aorta size/ LVF• 5. ECG• 6.Fundoscopy• 7.CT/MRI Brain

Management : Basic Principle Urgency : Out-patient Oral medication BP reduction 24-48 hours

Emergency : Inpatient Intravenous Immediate BP reduction < 25% within

minutes – 1 Hour 160/100 : 2-6 hours

Intravenous Antihypertensive

• Nitroglycerine (5-100 mic/mt)• Sodium Nitroprusside (0.25-10 mic/kg/mt)• Enalaprilat (only ACEI in I/V form, 1.25-5mg)• Nicardipine (2nd generation) 5-15 mg/hr• Clevidipine (3rd generation)• Esmelol (250-500 mic/kg/mt)• Labetalol (20-80 mg bolus)

Oral Drugs for Hypertensive Urgency

• Amlodipine 5-10 mg OD – 12 hrly• Captopril 12.5 – 25 mg 6 hrly• Nicardipine 20-30 mg 6-8 hrly• Clonidine 0.2 mg 12 hrly• Labetalol 200-400 mg 8-12 hrly• Lasix 20-40 mg 8-12 hrly

Medication of choice

• Myocardial Ischemia/ LVF : NTG, Esmolol• Aortic Dissection : Labetalol• Acute Renal Failure : Fenoldopam /

Nicardipine• Hyper-adrenergic states : due to sympatho-

mimetic drugs : Benzodiazepines. Pheo chromocytoma : Phentolamine

• Eclampsia : Labetalol /Magnesium ACEI and ARB contra-indicated

Intracranial Heamorrhage: Aim MAP 130 mmHg

First : Labetolol Second : Sodium Nitroprusside if no raised ICP If ICP raised : Use Nicardipine.

• Labetalol : Alpha selective, Beta non selective• oral/ intravenous• Nicardipine : second generation

dihydropyridine.Onset of action 5-20 minutes• Nitroglycerine :• More of Venodilator than arterial dilator.• SE: Headache, Flushing, Tachycardia•

• Nitro prussside : Strong veno and arterial vasodilator. rapid onset of action. Risk of thiocyanide toxicity : Hyperreflexia

delerium , psychosis

Fenoldopam

• Selective dopamine 1 receptor Agonist• Onset of action < 1 minute• Useful in patients with acute renal failure.• Fenoldopam improves urinary output, • Creatine clearance , sodium excretion

Use of Captopril

• Short acting ACEI• Hypertensive Urgency• Oral and sublingual : 6.25-50 mg• Effect seen within 5-15 minutes• Max reduction of BP in 30 mins• Duration of effect 2-6 hours• S/E : Hyperkalaemia / Angio-edema/dry cough

Captopril vs Nifedipine

Case

• 72/m• Annual physical check-up• Asymptomatic• BP 210/100-110 mmHg

What would you examine next?

• 1. Fundoscopy• 2. CVS• 3.Neurology examination.• 4. Peripheral pulses

ANSWER

• 1. Fundoscopy• 2. CVS• 3.Neurology examination.• 4. Peripheral pulses

Physical Examination

• Fundoscopy – Normal• Systemic Physical Examination – Normal• Lab- Normal• ECG and CXR - NAD

What is the diagnosis?

• 1. Malignant Hypertension.• 2. Hypertensive Urgency• 3. Hypertensive Emergency• 4. Severe Acute Hypertension.

ANSWER

• 1. Malignant Hypertension.• 2. Hypertensive Urgency• 3. Hypertensive Emergency• 4. Severe Acute Hypertension.

How will you manage the patient?

• 1.Admit and start intravenous antihypertensive medication

• 2. Treat as OP clinic with orally antihypertensive

• 3. Treat if patient is symptomatic• 4. Just Observe

How will you manage the patient?

• 1.Admit and start intravenous antihypertensive medication

• 2. Treat as OP clinic with orally antihypertensive

• 3. Treat if patient is symptomatic• 4. Just Observe

What do the guidelines say?

Joint National Committee •Seventh report on Prevention, Detection, Evaluation and Treatment of Hypertension states ‘’ Initial goal of therapy in hypertensive emergencies is to reduce MAP by no more than 25% - minutes to 1 hour 160/100-110 - 2 to 6 hours <140/90 - 24 to 48 hours

Exceptions

• Patients with ischemic stroke• Patients with Aortic Dissection• Patients requiring urgent thrombolytic

therapy (BP < 180/100 mmHg)

Acute Ischemic Stroke

• If BP < 220/120 mmHg – only observe Unless end organ damage concurrent hemorrhage If SBP > 220 and DBP 120-140 : Labetalol

/Nicardipine If DBP > 140 : Nitroprusside Aim for 10 – 15% reduction over 24 hours

Aortic Dissection

• BP should be lowered quite aggressively• Goal : systolic BP 100-120 mmHg within 20

minutes• Aim a. lower BP b. decrease LV contraction so as to decrease

Aortic shear stress DOC : labetalol or Esmolol