HYPERTENSIVE CRISES Mini-Lecture

Objectives: Define the various types of hypertensive crises Recognize signs and symptoms associated with hypertensive crises Treatment options

Clinical Vignette 65 y/o M with past medical history of Type II DM (on oral hypoglycemics), presenting with headache, chest pain and shortness of breath that developed after lunch the day of admission; non-exertional; no alleviating factors. Physical Exam: Vitals: 37.3, 195/125, 92, 24, 93% on RA HEENT: Decreased A:V on retinal exam (<25%) Heart: S4 heard on exam, no m/r/g Lungs: mild resp distress, otherwise clear to auscultation What’s the diagnosis and next best step in management? TELL THEM TO THINK ABOUT IT, COME BACK TO IT LATER ON. This patient is having chest pain and shortness of breath. Patient has diabetes which is a risk factor for CAD, therefore looking at the clinic picture (EKG, h/o smoking etc), ACS should be ruled out. CXR should be obtained. Patient should be started on an IV antihypertensive and admitted to ICU for closer monitoring.

Definitions: Hypertension: Hypertensive Urgency: Stage I: 140-159/90-99 Stage II: >160/100 Hypertensive Urgency: Systolic BP >180 or Diastolic BP >120 in the absence of end-organ damage

Definitions Continued: Hypertensive Emergencies: SBP >180 OR DBP>120 in the presence of end-organ damage Malignant Hypertension: End-organ damage--eyes, kidneys, brain (hemorrhage/infarct) affected Hypertensive encephalopathy: Cerebral edema leading to neurological symptoms End-organ damage is important to differentiate Emergency from Urgency, as treatment options can be very different.

Signs and Symptoms: Hypertensive Urgency: Can be completely asymptomatic Some symptoms include: Severe headache Shortness of breath Nosebleeds Severe anxiety Signs: Elevated BP on consecutive readings Blood pressure should be repeated whenever a high value is obtained on the initial reading; consecutive elevated BP readings should lead the physician to titrate medications for optimal BP control

S&S Continued Hypertensive Emergencies Symptoms: nausea, vomiting (cerebral edema) Chest Pain SOB Blurry vision Confusion Loss of consciousness

Signs: Retinal hemorrhages, exudates, or papilledema Renal involvement (malignant nephrosclerosis) with AKI, proteinuria, hematuria Cerebral edema  seizures and coma Pulmonary Edema Myocardial Infarction Hemorrhagic Stroke, lacunar infarcts

Treatment Options Hypertensive Urgency: Goal: Reduce BP to <160/100 over several hours to day Elderly at high risk of ischemia from rapid reduction of BP, therefore slower reduction in BP in this patient population Previously treated hypertension: Increase dose of existing med or add another med Reinstitution of med in non-compliant patients Patients coming to the ED with hypertensive urgency can be given po antihypertensives, monitored for reduction in BP, and sent home after their medication dosage has been titrated.

Treatment continued Hypertensive Urgency continued: Previously untreated hypertension: Slow reduction of BP (one to two days): Amlodipine, Metoprolol XL, lisinopril (po anti-hypertensives usually enough) Experts recommend: Initiate two agents or a combination agent (one being a thiazide diuretic) Rationale: Most patients with BP >20/10 above goal will require two agents to control their BP -Rapid vs slow reduction depends on patient’s risk factors (elderly, h/o stroke, h/o CAD etc)—in such patients BP should be reduced slowly to avoid ischemia -These patients should be started on po antihypertensive agents for better BP control once they leave the hospital; close follow-up with a PCP is necessary.

Treatment Continued Hypertensive Emergency: Goal: Lower Diastolic BP to approximately 100-105 over 2-6 hours; max initial fall not to exceed 25% More aggressive decrease can lead to ischemic stroke and myocardial ischemia If focal neurological sx presentobtain MRI to r/o acute stroke (rapid BP correction contraindicated) Parenteral antihypertensives (IV Drip) recommended over oral agents in hypertensive emergency

Treatment Recommended parenteral antihypertensive agents (IV drip) for Hypertensive Emergencies and admission to ICU Nitroprusside (cautious about cyanide toxicity), Nicardipine, and Labetalol. Once BP controlled, switch to oral anti-hypertensives and follow-up closely Nitroprusside, Nicardipine, and labetalol are commonly used medications in an ICU setting. Nicardipine and Labetalol are contraindicated in acute heart failure. Nitroprusside can cause cyanide toxicity.

Clinical Vignette Revisited 65 y/o M with past medical history of Type II DM (on oral hypoglycemics), presenting with headache, chest pain and shortness of breath that developed after lunch the day of admission; non-exertional; no alleviating factors. Physical Exam: Vitals: 37.3, 195/125, 92, 24, 93% on RA HEENT: Decreased A:V on retinal exam (<25%) Heart: S4 heard on exam, no m/r/g Lungs: mild resp distress, otherwise clear to auscultation What’s the diagnosis and next best step in management? This patient is having chest pain and shortness of breath. Patient has diabetes which is a risk factor for CAD, therefore looking at the clinic picture (EKG, h/o smoking etc), ACS should be ruled out. CXR should be obtained. Patient should be started on an IV antihypertensive and admitted to ICU for closer monitoring.

Summary Hypertensive Crises are common Differentiate Hypertensive Urgency from Emergency on the basis of end-organ damage Can treat hypertensive urgency with oral antihypertensives, but parenteral medications required for hypertensive emergencies 25% reduction in diastolic BP over 2-6 hours for hypertensive emergencies Don’t forget to start Oral antihypertensives and follow-up closely!