1. Hypertensive Emergencies
Jason R. Frank MD MA(Ed) FRCPC
Department of Emergency Medicine

2. HTN – What’s the Big Deal?

3. MCC OBJECTIVES – HTN EM KEY objectives:
Differentiate malignant HTN from secondary conditions
Conduct initial HTN lowering treatment
OBJECTIVES:
Differentiate non-localizing neurologic symptoms
Determine presence of other hypertensive emergencies
Interpret clinical & lab findings
Conduct an effective management plan, including specific Rx

4. Case 1
50 woman sent in by community MD & pharmacist for “HTN emergency”
Pharmacy BP = 190/90
Extremely worried, otherwise well
Q: What is the clinical definition of HTN?

5. Case 2
65 male drove in from cottage
Feeling unwell
Flagged at triage with BP 200/100
Forgot BP meds at home…missed 3 days
Q: What is a “hypertensive urgency”?

6. Case 3 72 male with chronic HTN, PAFib, and arthritis.
Referred to CDU with elev BP “for observation”.
180/115 at rest
Progressive SOB over the am.
Q: What is the definition of a “hypertensive emergency”?

7. Case 4
45 CEO of an IT firm
Presents with cp, SOB, intense anxiety
Sweating, tacky, BP 200/120
Admits to cocaine
Q: Management?

8. Case 5
33 F 1 week post-partum
Epigastric pain
Seizure
BP 160/95, P90, T37.2
Q: Dx? Management?

9. Case 6
60 M presents with tearing RSCP
Rad to back
Assoc with L headache and R leg weakness
BP 190/100, P 95
Q. Management?

10. This Session: HTN EM Define HTN Classify HTN
Provide a DDx for the acutely hypertensive patient, including 2ndary causes
Describe the findings of a patient with a HTN emergency
Describe high-utility tests for HTN EM
Describe the management of each of the categories of HTN
Describe at least 2 controversies in the management of HTN EM

11. HYPERTENSION Standard Definition
Based on 3 measurements, each 1 wk apart
> 140 systolic
> 90 diastolic
Most important #: Diastolic
MAP = 1/3 Systolic, 2/3 Diastolic

12. Define HTN?
Joint National
Commission VIVII 2003
“Pre-HTN”

13. HTN Defined:

14. Primary or Secondary Majority (90-95%) essential HTN
Of Secondary: ½ have a potentially curable cause

15. HTN in the Population vs the ED?

16. HTN in the Population vs the ED?
Primary HTN
Chronic
“Essential”
>95%
>25% of NA pop’n
50% adhere to Rx
75% not optimal
More un-Dx
Pre-HTN

17. Thinking about a HTN Definitions:
Pre-HTN……………
Primary chronic………….
Transient ………………..
Secondary……………….
“Tertiary” ...………………
Malignant…………
Also: accelerated, severe, crisis, etc
/80-89
>140/90
white coat, anxiety, pain, etc
Pathologic organ cause
Iatrogenic, ingestion, withdrawal, etc
Bad (enceph & retinal)

18. HTN in the ED – a Taxonomy
Transient HTN
Chronic HTN
HTN Urgency
HTN Emergency
HTN-associated Crisis

19. Transient HTN - Examples
Anxiety
Pain
EtOH-withdrawal
White-coat

20. HTN “Urgency” HTN “threatening” end organ damage “End organs at risk”
Various definitions: DBP>110, DBP>115, DBP>120
Goal: lower BP over hours; rarely requires treatment
Concern: bogus category, may lead to harm (eg CVAs)
-see Gallagher 2003

21. Malignant Hypertension
Severe HTN
&
Evidence of acute end-organ damage
Diastolic BP usually > 130 mm Hg or MAP > 160
Relative rise much more important than #
Affects 1% of hypertensive patients

22. MAP is What Matters:
At normal resting heart rates MAP can be approximated using the more easily measured systolic and diastolic pressures, SP and DP
or equivalently
where PP is the pulse pressure: SP − DP
-Wikipedia

23. “The Delta Diastolic Threatens Death”
The change in DBP accounts for most of the
change in MAP
“∆ DBP is where it is at”
(for the ED setting)

24. Hypertensive Emergency?
Volhard & Fahr, 1914

25. HTN Emergency Acute elevation in MAP causing end organ damage: ARF
CHF, ACS
Encephalopathy (>160 MAP)
CVA, ICH
Hemolysis
Retinal
All have DBP >120
…Mortality ~90% historically

26. HTN Emergency – Organ Incidence?
Acute elevation in MAP causing end organ damage:
CVA (24.5%)
CHF (22.5%)
Encephalopathy (16.3%)
ACS (12%)
ICH (4.5%)
ARF (?)
Hemolysis (?)
Retinal (?)
From Zampaglione, 1996

27. HTN Emergency Pathophysiology: Failure of autoreg Rapid rise in SVR
Endothelial injury
Arteriolar necrosis
Ischemia
…Cascade

28. Secondary HTN DDx

29. Secondary HTN Increased CO RF with fluid overload Acute renal disease
Hyperaldosteronism
Cushing’s syndrome
Coarctation of the Aorta
Increased vascular resistance
Renal Artery Stenosis
Pheochromocytoma
Drugs
Cerebrovascular (CVA, ICH, SAH)

30. Renal Artery Stenosis most common treatable cause (1-5%)
compromised renal perfusion => activation of RAA
2 pt groups:
Elderly with atherosclerotic disease
Young females with fibromuscular dysplasia
Clinical: abdo bruit (40-80%), retinopathy, HTN resistant to Rx, hypoK

31. Aldosteronism Uncommon but treatable
Na retention, volume expansion, increased CO
Hypernatremia & Hypokalemia typical
Primary: Adrenal adenoma, hyperplasia
Secondary: Cushing’s, CAH, exogenous mineralcorticoids

32. Pheochromocytoma Tumour, usually in adrenal medulla
Produces xs catecholamines (epi, NE)
Paroxysmal HTN…difficult to recognize
Episodic HTN, HA, palpitations, diaphoresis, anxiety…not a panic attack!
Easy to diagnose: elevated urinary catecholamines, metanephrines, vandillylmandelic acid

33. Coarctation of the Aorta
Rare but early surgical intervention can improve prognosis
Clinical triad:
upper extremity HTN
systolic murmur over back
delayed femoral pulses

34. Drugs Cocaine, amphetamines ETOH withdrawal
Withdrawal from clonidine, beta blocker
MAOI + tyramine containing foods or certain Rx (meperidine, TCA, ephedrine)
Tyramine causes release of NE
Usually rapidly destroyed by MAO

35. Secondary HTN Neuro: Renal: Endocrine: Vascular: Sleep apnea
Autonomic dysfunction (eg GBS, cord injuries)
CNS insult (HI, ICH)
Renal:
Renovascular stenosis
Renal disease (eg GN, Chronic pyelo)
Endocrine:
Pituitary tumours / ectopic ACTH
Pheochromocytoma; renin tumours; Hyperaldosteronism (egCushings)
Hyper & hypo thyroid & thyroid storm
Vascular:
Coarctation of the Ao
Vasculitis; Collagen-vascular (eg Scleroderma)
Pre-/Eclampsia
Sleep apnea

36. Iatrogenic / Lifestyle HTN (aka “tertiary”)
Too Much:
Too Little:
Tyramine-MAOI
Glucocorticoids
Thyroxine
Fluid overload
NSAIDS
Sympathomimetics
Clonidine withdrawal
Anti-HTN withdrawal
EtOH withdrawal

37. HTN – associated Crisis
HTN is a critical issue relating to an emergency Dx:
Aortic Dissection
Pre/Eclampsia
ICH
CVA
Cocaine

38. HTN in the ED – a Taxonomy 2
Pre-HTN
Chronic HTN
Transient HTN
HTN Emergency
HTN-associated Crisis
1’, 2’, 3’

39. Case 1
50 yo woman sent in by community MD & pharmacist for “HTN emergency”
Pharmacy BP = 190/90
Extremely worried, otherwise well

40. Case 2
65 male drove in from cottage
Feeling unwell
Flagged at triage with BP 200/100
Forgot BP meds at home…missed 3 days

41. Case 3
72 yo male with chronic HTN, PAFib, and arthritis.
Referred to CDU with elev BP “for observation”.
180/115 at rest
Progressive SOB over the am.

42. DDx for the ED Hypertensive Patient
Transient: pain, anxiety, sympathetic outflow
Chronic essential: poorly controlled
Chronic secondary: renovasc, pyelo, GN, pituitary, thyroid
Iatrogenic: fluid overload, pressors
OD/Ingestion: tyramine-MAOI, cocaine, amphetamines,
HTN-associated crises: Ao dissection, PIH, ICH, CVA, etc
HTN emergencies: CNS, ACS, CHF, retinal, RBCs

43. Assessment of the ED Hypertensive Pt?

44. Assessing the HTN Patient in the ED:
Hx HTN & Tx
Rx use
PMHx
Symptoms of end-organ damage
Pain
Confirm BP
Good BP reading
End-organ damage
Heart sounds
Pulses
Fundoscopy

45. ED HTN Testing?

46. Testing for ED HTN:
CBC, 7
EKG
CXR
Urine
CT head prn
r/o HTN emergency

47. ED HTN Management

48. HTN Management by Category:
Pre-HTN………………
Chronic HTN………….
Transient HTN………..
HTN Emergency…......
HTN-associated Crisis.
Advise
Advise, note, po Rx prn
Assess, observe, benzo prn
Assess, lower 20% ~1 hour
Dx-specific tx

49. Anti-HTN agents in ED: Rosen

50. Key Agents for Canadian EM Practice:
Metoprolol
Labetolol
Nitroglycerine
Also:
Nitroprusside
Magnesium
Esmolol
Phentolamine
Ramipril
po; 5 – 20 IV
20 mg bolus IV to max 300 mg
5-100 ug/min
ug/kg/min [Lancet, 1949]
2-6g, then 2g/hr infusion
Load 500ug/kg/ 1min, then 50ug/kg/min, titrate
5-10 mg/min
2.5-5 mg po

51. Therapeutic Goals:
Do no harm!
End cascade
Ensure perfusion
Risk further ischemia when BP dropped below >20% preTx
Maintain CPP

52. Controversies & Issues
Few ED studies for HTN
Accuracy of BP
Missed Dx
HTN “Urgency”
Epistaxis
Should EP’s treat?
Best agents
What benefit?

53. Case 1
50 yo woman sent in by community MD & pharmacist for “HTN emergency”
Pharmacy BP = 190/90
Extremely worried, otherwise well
Q: What is the clinical definition of HTN?

54. Case 2
65 male drove in from cottage
Feeling unwell
Flagged at triage with BP 200/100
Forgot BP meds at home…missed 3 days
Q: What is a “hypertensive urgency”?

55. Case 3 72 yo male with chronic HTN, PAFib, and arthritis.
Referred to CDU with elev BP “for observation”.
180/115 at rest
Progressive SOB over the am.
Q: What is the definition of a “hypertensive emergency”?

56. Case 4
45 yo CEO of an IT firm
Presents with cp, SOB, intense anxiety
Sweating, tacky, BP 200/120
Admits to cocaine
Q: Management?

57. Case 5
33 F 1 week post-partum
Epigastric pain
Seizure
BP 160/95, P90, T37.2
Q: Dx? Management?

58. Case 6
60 M presents with tearing RSCP
Rad to back
Assoc with L headache and R leg weakness
BP 190/100, P 95
Q. Management?

59. This Session: HTN EM Define HTN Classify HTN in the ED setting
Provide a DDx for the acutely hypertensive ED patient, including 2ndary causes
Describe the findings of a patient with a HTN emergency
Describe high-utility tests for HTN in the ED
Describe the management of each of the categories of HTN in the ED
Describe at least 2 controversies in the management of HTN in the ED

60. HTN in the ED – a Taxonomy
Pre-HTN
Chronic HTN
Transient HTN
HTN Emergency
HTN-associated Crisis
1’, 2’, 3’

61. “Treat patients, not numbers”
**DO NO HARM**
“Treat patients, not numbers”

62. HTN – What’s the Big Deal in the ED?

63. Jason R. Frank MD MA(Ed) FRCPC DEM Academic Half Day December, 2009
Hypertension in the ED
Jason R. Frank MD MA(Ed) FRCPC
DEM Academic Half Day
December, 2009