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

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Presentation on theme: "Hypertensive Emergencies Jason R. Frank MD MA(Ed) FRCPC Department of Emergency Medicine."— Presentation transcript:

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 1.Define HTN 2.Classify HTN 3.Provide a DDx for the acutely hypertensive patient, including 2ndary causes 4.Describe the findings of a patient with a HTN emergency 5.Describe high-utility tests for HTN EM 6.Describe the management of each of the categories of HTN 7.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 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: 1)upper extremity HTN 2)systolic murmur over back 3)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: –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: Tyramine-MAOI Glucocorticoids Thyroxine Fluid overload NSAIDS Sympathomimetics Too Little: 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 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 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 1.Few ED studies for HTN 2.Accuracy of BP 3.Missed Dx 4.HTN “Urgency” 5.Epistaxis 6.Should EP’s treat? 7.Best agents 8.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 1.Define HTN 2.Classify HTN in the ED setting 3.Provide a DDx for the acutely hypertensive ED patient, including 2ndary causes 4.Describe the findings of a patient with a HTN emergency 5.Describe high-utility tests for HTN in the ED 6.Describe the management of each of the categories of HTN in the ED 7.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 **DO NO HARM** “Treat patients, not numbers”

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

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


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