Hypertensive Crises Diagnosis and Treatment

Hypertensive Crises Severely elevated(BP>220/130mmhg) blood pressure with signs and symptoms of acute end organ damage Requires hospitalization Requires parenteral medication

Hypertensive Urgency Severely elevated blood pressure(BP>=220/130 mmhg) without signs and symptoms of acute end organ damage Can be managed as an outpatient Can be managed with short acting oral medications

Severe Hypertension BP 180/110 to 220/130 without symptoms or acute organ damage Almost always occur in chronic HTN patients who stop their medication Treat with long acting oral drugs

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

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

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

Initial Evaluation Neurologic Exam Retinal Exam Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures Lateralizing signs uncommon and suggest cerebrovascular accident Retinal Exam

Retinopathy Grading Grade 1 Grade 2 Mild narrowing of the arterioles “Copper Wire” Grade 2 Moderate narrowing - Copper wire and AV nicking

Retinopathy Grading Grade 3 Grade 4 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

Normal

Grade 1

Grade 3 Retinopathy

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

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

Cerebral Blood Flow Autoregulation Cerebral Blood constant in normotensive individuals over range of MAPs of 60 -120 mm Hg. In chronically hypertensive patients autoregulatory range is higher MAP Range 100-120 to 150-160 mm Hg Autoregulation also impaired in the elderly and those with cerebrovascular disease

Management Hypertensive Crises(elevated BP with target organ damage) Parenteral meds Goal - Reduce diastolic BP by 10-15% or to 110 mm Hg over a period of 30 - 60 minutes

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

Sodium nitroprusside 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 Choice in Aortic Dissection,CHF 0.3-10 microgm/kg/min

Urapidil New central sympatholytic drug Selective alpha -1 receptor blocks Dose12.5-25 mg /kg bolus and 5-40 mg/hr iv infusion Choice in HTN after CABG&After craniotomy

Labetalol Alpha&Beta Blocker(Beta>Alpha) Choice in Hypertensive encephalopathy,Ischemic&Hemorrhagic Stroke,Severe preeclampsia/eclampsia,Aortic Dissection 2-4 mg/min

Management HTN crises with advanced retinopathy without reduction of consciousness(labetalol,nitroprusside,urapidil,nicardipine) HTN crises with encephalopathyBrain edema(posterior region)+ reduce of consciousness(10% reduction of BP in first hour and 15% in next 12 hours to 160/110

Management HTN crises with acute or hemorrhagic stroke With thrombolytic therapyBP <185/110 Without thrombolytic therapy15% reduction in BP In hemorrhagic strokeSBP<180 Urapidil,nicardipine,labetalol Avoid of nitroprusside ,hydralazine

Management Acute coronary syndrome TNG +IV motoral or esmolol Labetalol or urapidil Nitroprusside is cotraindicated Acute heart failure Nitroprusside is choice(+Lasix)

Management Adernergic crisis(pheochromocytomaphentolamine+beta blocker or nitroprusside ,urapidil Clonidine withdrawal clonidine Cocaine or methamphetamine- induced HTN benzodiazepine +phentolamine

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

Management Elevated BP without target organ damage Hypertensive urgency Oral meds Goal - gradual reduction of BP over 24 - 48 hours

Thank you! Questions?