Dr Nahed Sherbini ,Consultant Internist ,Head of Internal Medicine Department2010 KFH, Medina
ED Medical & Surgical Wards MICU SICU OR Varon J, Fromm RE. Postgrad Med. 1996;99:189-203.
Hypertensive Emergencies Hypertensive Urgencies An Approach to Drug Treatment of HU and HE
Affects at least 1 BILLION individuals worldwide. Most current (2003) evidence basis for chronic management— (JNC 7)—lacks guidance for acute management of patients presenting with severe acute elevations of BP. JNC 7, JAMA 2003; 289:2560-2572.
Data are largely lacking. In a single-center Italian study, HU or HE HU:HE ratio of 3:1 in that study Zampaglione et al, Hypertension 1996;27:144.
Hypertensive emergencies and urgencies Account for 3% of all ED visits1 An “Internal Medicine” ED N=14,209 1634 had a medical urgency or emergency2 ▪ 27.4% of these were hypertensive crises 1. Kitiyakara C, Guzman N. J Am Soc Nephrol. 1998;9:133-142. 2. Zampaglione B, et al. Hypertension. 1996;27:144-147.
JNC7BP Classification SBP mmHg DBP mmHgNormal <120 and <80Prehypertension 120–139 or 80–89Stage 1 Hypertension 140–159 or 90–99Stage 2 Hypertension >160 or >100
Stage 3 hypertension (JNC 6): Systolic > 180, Diastolic > 110 Functionally, this is “hypertensive urgency” What about “crisis,” “emergency,” and “urgency”? JNC 7, JAMA 2003; 289:2560-2572.
“hypertensive crisis” is an acute, severe, stage 2 or 3 elevation BP. Crisis is then differentiated into hypertensive “emergencies” &“urgencies”. JNC 7, JAMA 2003; 289:2560-2572.
Hypertensive Severe elevation in BPemergency (>180/120 mmHg) Hypertensive Crisis complicated by evidence of impending or progressive target organ dysfunction Hypertensive Hypertensive PerioperativeHypertensive Severe elevation in BP urgency emergency hypertensionurgency without progressive target organ dysfunction Emergency Intensive care Operating room department unit post-anesthesia care Chobanian AV et al. Hypertension. 2003;42:1206-1252.
Four Categories of Presentation1. Mild, uncomplicated2. Transient3. Emergencies4. Urgencies
Mild, Uncomplicated HTN Diastolic BP <115 mmHg without end organ symptoms Educate, do not treat, arrange follow up Transient HTN A reaction to some condition ▪ Pain, fright, epistaxis, drug OD Treat the condition
Average Percent ReductionStroke incidence 35–40%Myocardial infarction 20–25%Heart failure 50%
Goal in hypertensive urgency is to reduce MAP (MAP= ( 2 Diastolic + systolic) / 3) by 10-15% and/or to a DBP of 110 . . . within hours. HU can generally be managed with oral medications and requires BP lowering over 24-48 h. JNC 7, JAMA 2003; 289:2560-2572.
Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Without Compelling With Compelling Indications Indications Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB) or combination. ACEI, or ARB, or BB, or CCB) as needed. Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
Reduce MAP by ≤ 25% during the 1st minutes to 1 h. If stable, reduce BP to 160/100-110 mmHg in next 2-6 h. Conditions requiring special management Aortic dissection Stroke eligible for thrombolytic agents Ischemic stroke Chobanian AV et al. Hypertension. 2003;42:1206-1252.
Patients with chronic hypertensionCerebral Blood Flow autoregulate cerebral blood flow around higher set points Patients with cerebral ischemia Increasing risk of lose their ability to autoregulate hypertensive Ischemia encephalopathy Normotensive Chronic hypertensive Increasing risk of ischemia 0 50 100 150 200 250 MAP (mm Hg) Adapted with permission from Varon J, Marik PE. Chest. 2000;118:214-227.
NORMAL AUTOREGULATION AUTOREGULATION FAILURE RISE IN BP RISE IN BP ARTERIAL AND FAILURE OF ARTERIOLAR VASOCONSTRICTION CONSTRICTION Normal flow.(flow=P/r) ENDOTHELIAL DAMAGE (due to shear stress on the wall)
Patients with marked BP elevations and acute target-organ damage Admitted to an ICU for continuous monitoring of BP. Should receive parenteral antihypertensive therapy with an agent appropriate for the individual patient.The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. US Dept of HHS; NIH publication No. 04-5230; 2004:54.
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) Update of the JNC 7 Report Expected Availability for Public Review and Comment: Spring 2011 Expected Release Date: Fall 2011