1. Optimal Management of Hypertensive Emergency Patients: Clinical Scenarios and Panel Discussion

2. Ponte Vedra Beach, FL June 24, 2010 2010 Clinical Decision Making in Emergency Medicine Ponte Vedra Beach, FL June 24, 2010 Clinical Decision Making in Emergency Medicine – A N E V I D EN C E - B A S E D C O N F E R E N C E

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4. Edward P. Sloan, MD, MPH FACEP Professor Department of Emergency Medicine University of Illinois College of Medicine Chicago, IL

5. Attending Physician Emergency Medicine University of Illinois Hospital Swedish American Belvidere Hospital Chicago, IL

6. Panelists Dr. Bradshaw Bunney: Dr. Bradshaw Bunney: Associate Professor University of Illinois Associate Professor University of Illinois Department of Emergency Medicine Department of Emergency Medicine FERNE Executive Board FERNE Executive Board Genentech Speakers’ Bureau Genentech Speakers’ Bureau Dr. Heather Prendergast: Dr. Heather Prendergast: Associate Professor University of Illinois Associate Professor University of Illinois Department of Emergency Medicine Department of Emergency Medicine FERNE Executive Board FERNE Executive Board No individual financial disclosures No individual financial disclosures

7. Panelists Dr. Andy Jagoda: Dr. Andy Jagoda: Professor and Chair Professor and Chair Mt Sinai Department of Emergency Medicine, NY Mt Sinai Department of Emergency Medicine, NY FERNE Executive Board FERNE Executive Board Dr. Scott Silvers: Dr. Scott Silvers: Chair, Emergency Department Chair, Emergency Department Mayo Clinic Jacksonville, FL Mayo Clinic Jacksonville, FL FERNE Executive Board FERNE Executive Board

8. Disclosures FERNE Chairman and President FERNE Chairman and President FERNE advisory board for The Medicine Company in May 2007 FERNE advisory board for The Medicine Company in May 2007 FERNE grant by The Medicines Company to support this program FERNE grant by The Medicines Company to support this program No individual financial disclosures No individual financial disclosures

9. Disclosures Jagoda: Past work with The Medicines Company in 2007 Jagoda: Past work with The Medicines Company in 2007 Bunney: Genentech Bunney: Genentech Prendergast: None Prendergast: None Silvers: None Silvers: None No other individual financial disclosures No other individual financial disclosures

10. Thank You Clinical Decisions in EM Consortium Clinical Decisions in EM Consortium Well assembled staff Well assembled staff EB Medicine EB Medicine The Medicines Company The Medicines Company FERNE staff FERNE staff Panelists Panelists All of you All of you

11. Hypertensive Crisis Hypertensive urgency: Hypertensive urgency: elevation of blood pressure without acute end organ damage elevation of blood pressure without acute end organ damage Hypertensive emergency Hypertensive emergency elevation of blood pressure with acute end organ damage elevation of blood pressure with acute end organ damage Diastolic BP usually >120 in both instances Diastolic BP usually >120 in both instances

12. Q: Who/what do you treat? Do you treat the pt or the number? Do you treat the pt or the number? 1. Patient 1. Patient 2. Number 2. Number 3. Patient, but if pressed, I will treat the number regardless 3. Patient, but if pressed, I will treat the number regardless

13. Q: What number do you treat? Do you treat SBP, DBP, or MAP? Do you treat SBP, DBP, or MAP? 1. SBP 1. SBP 2. DBP 2. DBP 3. MAP 3. MAP

14. Q: Mean Arterial Pressure Do you know how to calculate MAP? Do you know how to calculate MAP? 1. Yes 1. Yes 2. No 2. No

15. Q: Mean Arterial Pressure 1/3 systolic + 2/3 diastolic 1/3 systolic + 2/3 diastolic 180/120 = 60 + 80 = 140 MAP 180/120 = 60 + 80 = 140 MAP 120/90 = 40 + 60 = 100 MAP 120/90 = 40 + 60 = 100 MAP

16. Q: Diastolic BP Above what diastolic BP will you treat a patient, regardless if the pt is asymptomatic and the BP elevation in chronic? Above what diastolic BP will you treat a patient, regardless if the pt is asymptomatic and the BP elevation in chronic? 1. 100 1. 100 2. 110 2. 110 3. 120 3. 120 4. 130 4. 130 5. 140 5. 140

17. Q: Treatment Endpoint What is your successful treatment endpoint? What is your successful treatment endpoint? 1. Absolute drop in endpoint BP 1. Absolute drop in endpoint BP 2. % Drop in endpoint BP 2. % Drop in endpoint BP 3. Depends on how high BP is 3. Depends on how high BP is 4. Depends on clinical situation 4. Depends on clinical situation 5. Varies, not consistent 5. Varies, not consistent

18. Case 1: Ischemic Stroke A 64 year old male patient with a history of hypertension and diabetes presents to the Emergency Department with a new onset of ipsilateral right-sided facial droop, arm and leg weakness, aphasia, and gaze to the left. A 64 year old male patient with a history of hypertension and diabetes presents to the Emergency Department with a new onset of ipsilateral right-sided facial droop, arm and leg weakness, aphasia, and gaze to the left. His vital signs are BP 230/135, HR110, RR 16, and Temp 98.4. His vital signs are BP 230/135, HR110, RR 16, and Temp 98.4.

20. Q: How would you Rx this pt? What type of anti-hypertensive agent would you use? What type of anti-hypertensive agent would you use? 1. Oral 1. Oral 2. IV bolus 2. IV bolus 3. Continuous infusion 3. Continuous infusion 4. Other 4. Other

21. Q: What IV anti-hypertensive? What IV bolus agent might you use? What IV bolus agent might you use? 1. Hydralazine 1. Hydralazine 2. Labetalol 2. Labetalol 3. Enalaprilat 3. Enalaprilat 4. Phentolamine 4. Phentolamine 5. Other 5. Other

22. Q: What IV anti-hypertensive? What IV infusion Rx might you use? What IV infusion Rx might you use? 1. Sodium nitroprusside 1. Sodium nitroprusside 2. Nicardipine 2. Nicardipine 3. Fenoldopam 3. Fenoldopam 4. NTG 4. NTG 5. Esmolol 5. Esmolol 6. Clevidipine 6. Clevidipine

23. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? To what clinical endpoint would you treat this patient? How? How? Why? Why?

24. Case 2: Chest Pain A 68 year old male presents with chest pain, sub-sternal described as severe. Onset less than one hour prior to arrival. Associated with nausea, diaphoresis. No known cardiac history. Patient is a Smoker, ?cholesterol. A 68 year old male presents with chest pain, sub-sternal described as severe. Onset less than one hour prior to arrival. Associated with nausea, diaphoresis. No known cardiac history. Patient is a Smoker, ?cholesterol. His vital signs are BP 198/118, HR100, RR 20, and Temp 98.8. His vital signs are BP 198/118, HR100, RR 20, and Temp 98.8.

26. Q: How would you Rx this pt? What type of anti-hypertensive agent would you use? What type of anti-hypertensive agent would you use? 1. Oral 1. Oral 2. IV bolus 2. IV bolus 3. Continuous infusion 3. Continuous infusion 4. Other 4. Other

27. Q: What IV anti-hypertensive? What IV bolus agent might you use? What IV bolus agent might you use? 1. Hydralazine 1. Hydralazine 2. Labetalol 2. Labetalol 3. Enalaprilat 3. Enalaprilat 4. Phentolamine 4. Phentolamine 5. Other 5. Other

28. Q: What IV anti-hypertensive? What IV infusion Rx might you use? What IV infusion Rx might you use? 1. Sodium nitroprusside 1. Sodium nitroprusside 2. Nicardipine 2. Nicardipine 3. Fenoldopam 3. Fenoldopam 4. NTG 4. NTG 5. Esmolol 5. Esmolol 6. Clevidipine 6. Clevidipine

29. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? To what clinical endpoint would you treat this patient? How? How? Why? Why?

30. Case 3: Dyspnea A 58 year old female patient with a history of ESRD on dialysis, hypertension, pacemaker and diabetes brought to the Emergency Department by EMS for vomiting and mild frontal headache. Per family, pt missed her last dialysis session. A 58 year old female patient with a history of ESRD on dialysis, hypertension, pacemaker and diabetes brought to the Emergency Department by EMS for vomiting and mild frontal headache. Per family, pt missed her last dialysis session. Her vital signs are BP 225/142, HR125, RR 30, and Temp 98.4. Her vital signs are BP 225/142, HR125, RR 30, and Temp 98.4.

32. Q: How would you Rx this pt? What type of anti-hypertensive agent would you use? What type of anti-hypertensive agent would you use? 1. Oral 1. Oral 2. IV bolus 2. IV bolus 3. Continuous infusion 3. Continuous infusion 4. Other 4. Other

33. Q: What IV anti-hypertensive? What IV bolus agent might you use? What IV bolus agent might you use? 1. Hydralazine 1. Hydralazine 2. Labetalol 2. Labetalol 3. Enalaprilat 3. Enalaprilat 4. Phentolamine 4. Phentolamine 5. Other 5. Other

34. Q: What IV anti-hypertensive? What IV infusion Rx might you use? What IV infusion Rx might you use? 1. Sodium nitroprusside 1. Sodium nitroprusside 2. Nicardipine 2. Nicardipine 3. Fenoldopam 3. Fenoldopam 4. NTG 4. NTG 5. Esmolol 5. Esmolol 6. Clevidipine 6. Clevidipine

35. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? To what clinical endpoint would you treat this patient? How? How? Why? Why?

36. Case 4: AMS/Coma A 49 year old male patient with a history of hypertension presents to the Emergency Department with a thunderclap headache, vomiting, and altered mental status. Upon arrival to the ED, he becomes unresponsive. A 49 year old male patient with a history of hypertension presents to the Emergency Department with a thunderclap headache, vomiting, and altered mental status. Upon arrival to the ED, he becomes unresponsive. His vital signs are BP 264/142, HR 90, RR 12, and Temp 98.4. His vital signs are BP 264/142, HR 90, RR 12, and Temp 98.4.

38. Q: How would you Rx this pt? What type of anti-hypertensive agent would you use? What type of anti-hypertensive agent would you use? 1. Oral 1. Oral 2. IV bolus 2. IV bolus 3. Continuous infusion 3. Continuous infusion 4. Other 4. Other

39. Q: What IV anti-hypertensive? What IV bolus agent might you use? What IV bolus agent might you use? 1. Hydralazine 1. Hydralazine 2. Labetalol 2. Labetalol 3. Enalaprilat 3. Enalaprilat 4. Phentolamine 4. Phentolamine 5. Other 5. Other

40. Q: What IV anti-hypertensive? What IV infusion Rx might you use? What IV infusion Rx might you use? 1. Sodium nitroprusside 1. Sodium nitroprusside 2. Nicardipine 2. Nicardipine 3. Fenoldopam 3. Fenoldopam 4. NTG 4. NTG 5. Esmolol 5. Esmolol 6. Clevidipine 6. Clevidipine

41. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? To what clinical endpoint would you treat this patient? How? How? Why? Why?

42. Case 5: Ankle Pain A 44 year old male patient with no significant past medical history presents to the Emergency Department with acute ankle injury while getting off the bus. Exam shows significant soft tissue swelling to lateral malleolus. A 44 year old male patient with no significant past medical history presents to the Emergency Department with acute ankle injury while getting off the bus. Exam shows significant soft tissue swelling to lateral malleolus. His vital signs are BP 197/126, HR 89, RR 16, and Temp 98.4. His vital signs are BP 197/126, HR 89, RR 16, and Temp 98.4.

44. Q: How would you Rx this pt? What type of anti-hypertensive agent would you use? What type of anti-hypertensive agent would you use? 1. Oral 1. Oral 2. IV bolus 2. IV bolus 3. Continuous infusion 3. Continuous infusion 4. Other 4. Other

45. Q: What IV anti-hypertensive? What IV bolus agent might you use? What IV bolus agent might you use? 1. Hydralazine 1. Hydralazine 2. Labetalol 2. Labetalol 3. Enalaprilat 3. Enalaprilat 4. Phentolamine 4. Phentolamine 5. Other 5. Other

46. Q: What IV anti-hypertensive? What IV infusion Rx might you use? What IV infusion Rx might you use? 1. Sodium nitroprusside 1. Sodium nitroprusside 2. Nicardipine 2. Nicardipine 3. Fenoldopam 3. Fenoldopam 4. NTG 4. NTG 5. Esmolol 5. Esmolol 6. Clevidipine 6. Clevidipine

47. Q: Clinical Rx Endpoint To what clinical endpoint would you treat this patient? To what clinical endpoint would you treat this patient? How? How? Why? Why?

48. Q: Start on HTN Rx Would you start them on an anti- hypertensive medication? Would you start them on an anti- hypertensive medication? 1. Yes 1. Yes 2. No 2. No

49. Q: Disposition What special instruction would you give for follow-up? What special instruction would you give for follow-up? Where? Where? When? When?

50. Q: ACEP Guideline Have you read the ACEP HTN guideline ? Have you read the ACEP HTN guideline ? 1. Yes 1. Yes 2. No 2. No

51. Q: Any HTN Guideline Have you read any HTN guideline ? Have you read any HTN guideline ? 1. Yes 1. Yes 2. No 2. No

52. Conclusions There are good Rx options Treatment options must be individualized for each patient Guidelines, clinical studies, and literature do provide guidance Treat the patient, be careful A reasonable standard of care Pt outcomes can be optimized

53. Questions? edsloan@uic.edu 312 317 4996 www.ferne.org ferne_clindec_2010_htn_emerg_panel_questions_062410_final 5/11/2015 6:34 PM

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