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

HTN – What’s the Big Deal?

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

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?

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”?

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”?

Case 4 45 CEO of an IT firm Presents with cp, SOB, intense anxiety Sweating, tacky, BP 200/120 Admits to cocaine Q: Management?

Case 5 33 F 1 week post-partum Epigastric pain Seizure BP 160/95, P90, T37.2 Q: Dx? Management?

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?

This Session: HTN EM Define HTN Classify HTN Provide a DDx for the acutely hypertensive patient, including 2ndary causes Describe the findings of a patient with a HTN emergency Describe high-utility tests for HTN EM Describe the management of each of the categories of HTN Describe at least 2 controversies in the management of HTN EM

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

Define HTN? Joint National Commission VIVII 2003 “Pre-HTN”

HTN Defined:

Primary or Secondary Majority (90-95%) essential HTN Of Secondary: ½ have a potentially curable cause

HTN in the Population vs the ED?

HTN in the Population vs the ED? Primary HTN Chronic “Essential” >95% >25% of NA pop’n 50% adhere to Rx 75% not optimal More un-Dx Pre-HTN

Thinking about a HTN Definitions: Pre-HTN……………........ Primary chronic…………. Transient ……………….. Secondary………………. “Tertiary” ...……………… Malignant…………......... Also: accelerated, severe, crisis, etc 130-139/80-89 >140/90 white coat, anxiety, pain, etc Pathologic organ cause Iatrogenic, ingestion, withdrawal, etc Bad (enceph & retinal)

HTN in the ED – a Taxonomy Transient HTN Chronic HTN HTN Urgency HTN Emergency HTN-associated Crisis

Transient HTN - Examples Anxiety Pain EtOH-withdrawal White-coat

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

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

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

“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)

Hypertensive Emergency? Volhard & Fahr, 1914

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

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

HTN Emergency Pathophysiology: Failure of autoreg Rapid rise in SVR Endothelial injury Arteriolar necrosis Ischemia …Cascade

Secondary HTN DDx

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)

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

Aldosteronism Uncommon but treatable Na retention, volume expansion, increased CO Hypernatremia & Hypokalemia typical Primary: Adrenal adenoma, hyperplasia Secondary: Cushing’s, CAH, exogenous mineralcorticoids

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

Coarctation of the Aorta Rare but early surgical intervention can improve prognosis Clinical triad: upper extremity HTN systolic murmur over back delayed femoral pulses

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

Secondary HTN Neuro: Renal: Endocrine: Vascular: Sleep apnea 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

Iatrogenic / Lifestyle HTN (aka “tertiary”) Too Much: Too Little: Tyramine-MAOI Glucocorticoids Thyroxine Fluid overload NSAIDS Sympathomimetics Clonidine withdrawal Anti-HTN withdrawal EtOH withdrawal

HTN – associated Crisis HTN is a critical issue relating to an emergency Dx: Aortic Dissection Pre/Eclampsia ICH CVA Cocaine

HTN in the ED – a Taxonomy 2 Pre-HTN Chronic HTN Transient HTN HTN Emergency HTN-associated Crisis 1’, 2’, 3’

Case 1 50 yo woman sent in by community MD & pharmacist for “HTN emergency” Pharmacy BP = 190/90 Extremely worried, otherwise well

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

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.

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

Assessment of the ED Hypertensive Pt?

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

ED HTN Testing?

Testing for ED HTN: CBC, 7 EKG CXR Urine CT head prn r/o HTN emergency

ED HTN Management

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

Anti-HTN agents in ED: Rosen

Key Agents for Canadian EM Practice: Metoprolol Labetolol Nitroglycerine Also: Nitroprusside Magnesium Esmolol Phentolamine Ramipril 25-100 po; 5 – 20 IV 20 mg bolus IV to max 300 mg 5-100 ug/min 0.25-10 ug/kg/min [Lancet, 1949] 2-6g, then 2g/hr infusion Load 500ug/kg/ 1min, then 50ug/kg/min, titrate 5-10 mg/min 2.5-5 mg po

Therapeutic Goals: Do no harm! End cascade Ensure perfusion Risk further ischemia when BP dropped below >20% preTx Maintain CPP

Controversies & Issues Few ED studies for HTN Accuracy of BP Missed Dx HTN “Urgency” Epistaxis Should EP’s treat? Best agents What benefit?

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?

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”?

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”?

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?

Case 5 33 F 1 week post-partum Epigastric pain Seizure BP 160/95, P90, T37.2 Q: Dx? Management?

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?

This Session: HTN EM Define HTN Classify HTN in the ED setting Provide a DDx for the acutely hypertensive ED patient, including 2ndary causes Describe the findings of a patient with a HTN emergency Describe high-utility tests for HTN in the ED Describe the management of each of the categories of HTN in the ED Describe at least 2 controversies in the management of HTN in the ED

HTN in the ED – a Taxonomy Pre-HTN Chronic HTN Transient HTN HTN Emergency HTN-associated Crisis 1’, 2’, 3’

“Treat patients, not numbers” **DO NO HARM** “Treat patients, not numbers”

HTN – What’s the Big Deal in the ED?

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