1. Hypertensive Emergencies: Diagnosis and Treatment
Jamie Johnston, MD
University of Pittsburgh
School of Medicine

2. Today’s Road Map Case Presentations Definitions Evaluation Management
Will not cover pre-eclampsia or pediatric hypertensive emergencies

3. Case 1 51 year old man admitted to an outside hospital
CC: Sudden onset of left-sided weakness, severe headache, slurred speech and left facial droop
BP 260/172
Head CT Scan showed Right basal ganglia hemorrhage with shift
HPI: Transported by air ambulance to PUH.
Intubated en route due to declining mental status

4. Case 1
PMH - Hypertension - according to wife, patient was non-adherent with prescribed medications
Out patient medications and allergies - not available
Family History +for HTN/CVA
Exam PUH - BP 196/130
Positive for Left dense hemiparesis

5. Case 1 Hospital day 2 Subsequent Hospital Course Dilated right pupil
Emergent right frontotemporal craniotomy and evacuation of clot
Subsequent Hospital Course
Difficult to control BP
Pneumonia

6. Case 1
Renal MRI
Right kidney 8.1 cm with three renal arteries
Left kidney 12.2 cm with two renal arteries
Patient transferred to rehab at South Side Hospital on 7/19/07

7. Question 1
What is the primary reason for hypertensive emergencies in the USA today?
Renovascular Disease
Pheochromocytoma
Non-adherence to anti-hypertensive medication
Hyperaldosteronism
Erythropoeitin

8. What is the primary reason for hypertensive emergencies in the USA today?
Renovascular Disease
Pheochromocytoma
Non-adherence to anti-hypertensive medication
Hyperaldosteronism
Erythropoeitin 10

9. When you hear hoof beats…

10. Hypertensive Emergency
According to the Joint National Committee on Hypertension Report
Severely elevated blood pressure with signs and symptoms of acute end organ damage
Requires hospitalization
Requires parenteral medication

11. Hypertensive Urgency
Severely elevated blood pressure without signs and symptoms of acute end organ damage
Can be managed as an outpatient
Can be managed with oral medications

12. Hypertensive Emergency
CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy
Damage
Heart - CHF, MI, angina
Kidneys - acute kidney injury, microscopic hematuria
Vasculature - aortic dissection, eclampsia
Vasculature

13. Epidemiology Hypertensive emergencies are common
Occur in 1-2% of the hypertensive population
But, 50 million hypertensive Americans
500,000 hypertensive emergencies/year
Parallels the distribution of primary hypertension
Higher in the elderly and African Americans
Incidence in men 2 times higher than in women

14. Epidemiology Common associations Previous history of hypertension
Lack of a primary care physician
Non adherence to antihypertensive regimen
Elicit drug use (cocaine)

15. Pathophysiology Sudden increase in Systemic Vascular Resistance
Mechanical Stress with endothelial injury, increased permeability, Coag/Plt activation, fibrin deposition BP
Fibrinoid necrosis
Ischemia
Activation of RAA
Proinflammatory cytokines

16. Vaughan and Delanty Lancet 2000; 356:411

18. Underlying Etiology? Unclear, but some candidates ACE DD genotype
Absence of the b and g subunit of ENaC
Elevated adrenomedullin levels*
Elevated natriuretic peptide level*
Abnormalities in oxidative stress markers and endothelial dysfunction*
*Correct after effective BP treatment
Underlying Etiology?

19. Question 2
What is the most common complaint in hypertensive emergency?
Neurologic defect
Gross Hematuria
Chest pain
Headache
Epistaxis

20. What is the most common complaint in hypertensive emergency?
Neurologic defect
Gross Hematuria
Chest pain
Headache
Epistaxis

21. Clinical Presentation
Variable
Zampaglione et al (Hypertension 27:144, 1996)
14, 209 ER visits in one year period
108 met definition of hypertensive emergency (0.8%)
Mean Systolic BP
Mean Diastolic BP

22. Clinical Presentation
Frequency of signs and symptoms
Chest Pain 27%
Dyspnea 22%
Neuro defect 21%
Interestingly….
Headache was only 3% and epistaxis was 0% in this study

23. Question 3 Hypertensive emergency is associated with a threshold BP of
Systolic > 225 mm Hg
Diastolic > 110 mm Hg
Systolic > 250 mm Hg
Diastolic > 120 mm Hg
All of the above

24. Hypertensive emergency is associated with a threshold BP of
Systolic > 225 mm Hg
Diastolic > 110 mm Hg
Systolic > 250 mm Hg
Diastolic > 120 mm Hg
All of the above

25. Threshold BP
There is no specific BP where hypertensive emergencies occur
But, organ dysfunction is rare with diastolic BPs < 130 mm Hg
Rate of increase may be more important
Hence, encephalopathy will occur at lower BPs in pregnancy and in children

26. Initial Evaluation Focused history History of hypertension?
How well is hypertension controlled?
What antihypertensives?
Adherence to antihypertensive regimen?
Last dose of antihypertensive?

27. Initial Evaluation Social History Recreational Drugs Amphetamines
Cocaine
Phencyclidine

28. Initial Evaluation Confirm BP in both arms
Use appropriate sized BP cuff
Cuff that is too small
BP cuffs that are too small falsely elevate BP measurements in obese patients

30. Initial Evaluation Assess for end-organ damage Vascular Disease
Assess pulses in all extremities
Auscultate over renal arteries for bruits
Cardiopulmonary
Listen for rales (CHF)
Murmurs or gallops

31. Initial Evaluation Neurologic Exam Retinal Exam
Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures
Lateralizing signs uncommon and suggest cerebrovascular accident
Retinal Exam
Lost art
Keith-Wagener-Barker Classification

32. Keith-Wagener-Barker Classification
Grade 1
Mild narrowing of the arterioles
“Copper Wire”
Grade 2
Moderate narrowing Copper wire and AV nicking
Changes associated with long standing essential hypertension

33. Normal

34. Grade 1

36. Keith-Wagener-Barker Classification
Grade 3
Severe Narrowing Silver wire changes, hemorrhage, cotton wool spots, hard exudates
Grade 4
Grade 3 + Papilledema
Grade 3 and 4 highly correlated with progression to end organ damage and decreased survival

37. Grade 3 KWB Retinopathy

39. Lab Testing ECG Renal Function Tests (urine included) CBC
LVH, look for signs of ischemia, injury, infarct
Renal Function Tests (urine included)
Elevated BUN, Creatinine, proteinuria, hematuria
CBC
CXR - pulmonary edema, aortic arch, cardiac enlargement

40. Lab Testing Aortic Dissection? Pulmonary Edema/CHF
Suspect with severe tearing chest pain, unequal pulses, widened mediastinum
Contrast Chest CT Scan or MRI
Pulmonary Edema/CHF
Transthoracic Echocardiogram
Differentiate between systolic dysfunction, diastolic dysfunction, mitral regurgitation

41. Management Elevated BP without target organ damage
Hypertensive urgency
Oral meds
Goal - gradual reduction of BP over hours

42. Management Elevated BP with target organ damage Hypertensive emergency
Parenteral meds
Goal - Reduce diastolic BP by 10-15% or to 110 mm Hg over a period of minutes

43. How Quickly? Cerebral Blood Flow Autoregulation
Cerebral Blood constant in normotensive individuals over range of MAPs of mm Hg.
In chronically hypertensive patients autoregulatory range is higher
MAP Range to mm Hg
Autoregulation also impaired in the elderly and those with cerebrovascular disease

44. How Quickly? General rule is to lower MAP by 20% in first hour
Should always be done with close clinical observation

45. Management Where? Which Parenteral meds? Depends on the situation
ICU with close monitoring
Severe requires intra-arterial BP monitoring
Which Parenteral meds?
Depends on the situation

46. Question 4
Which of the following drugs should not be used to treat hypertensive emergency?
Sublingual Nifedipine
Labetolol
ACE Inhibitors
Nicardipine
1 and 3

47. Which of the following drugs should not be used to treat hypertensive emergency?
Sublingual Nifedipine
Labetolol
ACE Inhibitors
Nicardipine
1 and 3

48. Preferred Agents Beta blockers Calcium Entry blocker
Labetolol
Esmolol
Calcium Entry blocker
Nicardipine
Dopamine-1 receptor agonist
Fenoldapam
Vasodilators - nitroprusside/nitroglucerin

49. Scenarios Our Case - Acute ischemic stroke/cerebrovascular bleed
Agents
Fenoldopam
Labetolol
Nicardipine

50. CVA or Ischemic Stroke
BP elevation after CVA or ischemic stroke can be protective to preserve cerebral perfusion
Hold on aggressive lowering unless
Thrombolytic therapy anticipated or
BP excessively high ( SBP > 220 mm Hg or DBP >120)
BP Goal for thrombolytic therapy is to lower SBP if > 185 or DBP >110

51. Cardiac Conditions Acute Pulmonary Edema with systolic dysfunction
Nicardipine
Fenoldopam
Sodium nitroprusside
Nitroglycerin
Loop diuretic

52. Cardiac Conditions Acute Pulmonary Edema with diastolic dysfunction
Esmolol, metoprolol, labetolol
verapamil
Nitroglycerin
Loop diuretic

53. Cardiac Conditions Acute myocardial ischemia Esmolol, labetolol
Nitroglycerin

54. Sympathetic Crisis
Generally in association with recreational drugs such as cocaine, amphetamine or phencyclidine
Sudden cessation of clonidine or Beta-adrenergic antagonist
Pheochromocytoma - rare

55. Question 5
Which of the following drugs should be avoided in sympathetic crises with hypertensive emergency?
Phentolamine
Benzodiazepine
Labetolol
Nicardipine
Fenoldopam

56. Which of the following drugs should be avoided in sympathetic crises with hypertensive emergency?
Phentolamine
Benzodiazepine
Labetolol
Nicardipine
Fenoldopam

57. Sympathetic Crisis
Beta-adrenergic antagonists will result in unopposed alpha-adrenergic stimulation
In cocaine use, Beta blockers can
Increase blood pressure
Worsen coronary artery vasoconstriction
Decrease survival
Avoid beta blockade (including non selective agents such as labetolol)

58. Sympathetic Crisis Recommended Drugs Nicardipine Fenoldopam Verapamil
Benzodiazepine
If pheo suspected use phentolamine

59. Aortic Dissection Treatment is paramount
75% of patients with ascending aortic dissection die in 2 weeks of the acute episode without successful therapy
5 year survival is 75% with successful intervention
Khan et al. Chest 2002, 122:311
Kouchoukos New Engl J Med 1997; 336:1876

60. Aortic Dissection Vasodilator alone? Causes reflex tachycardia
Increases cardiac ejection velocity
Increases aortic shear forces
Extends the dissection

61. Aortic Dissection Standard therapy Nitroprusside can be used as well
Beta-adrenergic blocker plus vasodilator
Esmolol + Nicardipine or fenoldopam
Nitroprusside can be used as well

62. Acute Post Operative Hypertension
Frequent in post-operative state (20-75%)
Hyper-responsiveness to surgical trauma
Increased stress hormones?
Activation of RAA?
Also hypothermia, hypoxia, carbon dioxide retention, bladder distention

63. Acute Post Operative Hypertension
Prevention
Safe to give antihypertensives pre-op
Hold diuretics
Treatment - BP thresholds vary
Control pain and anxiety
While NPO use nicardipine, esmolol or labetolol
Resume oral medications when possible

64. What happened to sodium nitroprusside?
Mansoor and Friedman. Heart Disease 2002; 4:358
Sodium nitroprusside recommended for all hypertensive emergencies except eclampsia
Marik and Varon. Chest 2007; 131:1949
Sodium nitroprusside recommended for
acute aortic dissection
acute pulmonary edema with systolic dysfunction

65. “riding the pride” Disadvantages of sodium nitroprusside
Decrease cerebral blood flow and increases intracranial pressure
Can reduce regional blood flow in coronary artery disease
Risk of cyanide toxicity
Use when other agents not effective
Monitor thiocyanate levels
Avoid in renal or hepatic dysfunction

66. Have we made progress? First described by Volhard and Fahr
Die Brightsche Nierenkrankenheit: Klinik Patholgie und Atlas. Berlin, Germany, Springer 1914:247
Keith, Wagener, Barker Am J Med Sci, 1939;197:332
Mean survival of patients with htn and grade 4 retinopathy was 10.5 mo with none living beyond 5 years

67. We have made progress Development of antihypertensive drugs
Increased diagnosis of hypertension
Increased ICU settings
Survival of patients with hypertensive urgency and emergency is 18 years compared to 21 years in those with uncomplicated hypertension

68. Thank you! Questions?

69. Messerli N Engl J Med 1995;

70. Messerli N Engl J Med 1995;