1 Hypertensive Crises Diagnosis and Treatment Hypertensive Crises

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Hypertensive Crises Diagnosis and Treatment

Hypertensive Crises • Severely elevated(BP>220/130 mmhg) 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 CNS - encephalopathy, • Damage intracranial hemorrhage, Grade 3 -4 retinopathy Kidneys - acute kidney injury, microscopic hematuria Vasculature Vasculatur e aortic dissection, eclampsia Heart - CHF, MI, angina

Epidemiology • Hypertensive emergencies are common – 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 – Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures – Lateralizing signs uncommon and suggest cerebrovascular accident • Retinal Exam

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

Retinopathy Grading • Grade 3 – 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 – 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? – 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 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? – 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, ur apidil, 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 phentolamin e+beta blocker or nitroprusside , urapidil • Clonidine withdrawal clonidine • Cocaine or methamphetamine- induced HTN benzodiazepine +phentolamine

Aortic Dissection • Standard therapy – 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?