Case 60 F with PMH HTN, DM, CVA presented to UNC ED CC: seizure. Per the daughter the pt was walking and all of a sudden fell and her whole body started shaking. No bladder or bowel incontinence. Post-ictal in the ambulance. Vitals HR 84 BP 260/180 RR14 100% RA - BP meds Metoprolol 150 mg daily Amlodipine 10 mg daily

What is the diagnosis? A. Primary Seizure Disorder B. Stroke C. Hypertensive Urgency D. Hypertensive Emergency

Doctor? Doctor? A. Head CT B. 12 Lead EKG C. CXR D. IV Labetalol Drip E. Place an arterial line F. Chemistry, UA G. Cardiac Biomarkers

Hypertensive Emergency Intern Conference September 2009

Urgency vs. Emergency Urgency Emergency Any situation in which a rapid decrease in BP is required to limit end-organ damage. Emergency Elevated blood pressure with evidence of end organ damage

Causes Malignant Hypertension Aortic dissection Acute MI Acute glomerulonephritis Scleroderma renal crisis Pheochromocytoma Cocaine Eclampsia

End Organ Damage Unstable angina Acute myocardial infarction Encephalopathy Acute Retinopathy Nephropathy LV failure Dissecting aneurysm

Major Clinical Manifestations Retinal hemorrhages and exudates

Major Clinical Manifestations Papilledema Papilledema is the term reserved for a swollen optic disc caused by increased intracranial pressure. Papilledema is nearly always found in both eyes, although the swelling may be asymmetric.

Major Clinical Manifestations Malignant nephrosclerosis, leading to acute renal failure, hematuria, and proteinuria

Major Clinical Manifestations Neurologic symptoms due to intracerebral or subarachnoid bleeding, lacunar infarcts, or hypertensive encephalopathy PRES (reversible posterior leukoencephalopathy Acutely hypertensive 1 month later normotensive

Management of hypertensive encephalopathy The initial aim of treatment in hypertensive emergency is to rapidly lower the diastolic pressure to about 100 to 105 mmHg; this goal should be achieved within two to six hours, with the maximum initial fall in BP not exceeding 25 percent of the presenting value

Drugs Nitroprusside — an arteriolar and venous dilator, given as an intravenous infusion. Initial dose: 0.25 to 0.5 µg/kg per min; maximum dose: 8 to 10 µg/kg per min. Nitroprusside acts within seconds and has a duration of action of only two to five minutes. Concern for what??? Cyanide toxicity with prolonged use and renal failure Nicardipine — an arteriolar dilator, given as an intravenous infusion. Initial dose: 5 mg/h; maximum dose: 15 mg/h. Labetalol — an alpha- and beta-adrenergic blocker, given as an intravenous bolus or infusion. Bolus: 20 mg initially, followed by 20 to 80 mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg/min. Fenoldopam — a peripheral dopamine-1 receptor agonist, given as an intravenous infusion. Initial dose: 0.1 µg/kg per min; the dose is titrated at 15 min intervals, depending upon the blood pressure response

Oral Therapy Once BP is controlled transition the patient to oral therapy Start orals while drip is still going and allow nurse to wean the drip based on the MAP Be careful not to overshoot and cause hypotension

Prognosis Even with adequate antihypertensive therapy most patients still have moderate to severe vascular damage occurring At higher risk for coronary, cerebrovascular and renal disease

Case Head CT to evaluate for edema MRI to evaluate for stroke Every hypertensive emergency deserves an examination of renal artery stenosis via dopplers or MRA

Take Home Points In hypertensive emergency, control the diastolic blood pressure within the first two to six hours with IV drip and with an arterial line in stepdown or ICU Perform a fundoscopic exam upon admission Transition to oral therapy once goal is achieved Diastolic BP should be reduced to 85-90 over two to three months.