2. Hypertensive Crises Diagnosis and Treatment

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

4. 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

5. 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

6. 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

7. 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

8. 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

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

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

11. 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

12. Normal

13. Grade 1

15. Grade 3 Retinopathy

17. 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

18. 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

19. 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

20. 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 minutes

21. 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

22. 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
microgm/kg/min

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

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

25. 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

26. 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

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

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

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

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

33. Thank you! Questions?