Hypertensive Emergencies
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Hypertensive Emergencies

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Hypertensive Emergencies Hypertensive Emergencies Presentation Transcript

  • 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.
  • Brain Hypertensive encephalopathy Retina Stroke Hemorrhages Exudates PapilledemaCardiovascular SystemUnstable anginaAcute heart failureAcute myocardial infarction KidneyAcute aortic dissection HematuriaDissecting aortic aneurysm Proteinuria Decreasing renal function Adapted from Varon J, Marik PE. Chest. 2000;118:214-227.
  •  Essential hypertension  Medication noncompliance Secondary hypertension  Aortic coarctation  Cushing’s syndrome  Elevated ICP  Renal dysfunction  Pregnancy  Hyperparathyroidism  Hyperthyroidism  Pheochromocytoma  Primary aldosteronism JNC 7, JAMA 2003; 289:2560-2572.
  •  Medical ● Surgical – Cardiac surgery  Uncontrolled HTN – Major vascular surgery ▪ Noncompliance - Carotid endarterectomy  Drug-induced HTN - Aortic surgery ▪ Cocaine, – Neurosurgery amphetamines – Head and neck surgery ▪ Drug withdrawal – Renal transplantation ▪ Drug-drug interactions – Major trauma – burns or head  Endocrine disorders injuryVaron J, Fromm RE. Postgrad Med. 1996;99:189-203.
  • • Oral contraceptives• Steroids• NSAIDs• Nasal decongestants• Appetite suppressants
  •  Hypertensive  Hypertensive Urgencies Emergencies  Chest pain  Arrhythmia  Dyspnea  Epistaxis  Neurologic deficits  Headache  Psychomotor agitation  Usual Primary ED Diagnosis  CVA  Acute pulmonary edema Usual Primary ED  Hypertensive Diagnosis encephalopathy  Hypertension  Acute heart failure Zampaglione et al, Hypertension 1996;27:144.
  • 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.
  • Compelling Indication Initial Therapy Options Clinical Trial Basis ACC/AHA Heart FailureHeart failure THIAZ, BB, ACEI, ARB, Guideline, MERIT-HF, ALDO ANT COERNICUS, RALESPost MI ACC/AHA Post-MI BB, ACEI, ALDO ANT Guideline, BHAT, SAVE, Capricorn, ALLHAT, HOPE, ANBP2, LIFE,High CAD risk THIAZ, BB, ACE, CCB CONVINCE
  • Compelling Indication Initial Therapy Options Clinical Trial BasisDiabetes THIAZ, BB, ACE, ARB, C NKF-ADA CB Guideline, UKPDS, AL LHATChronic kidney disease ACEI, ARB NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASKRecurrent stroke THIAZ, ACEIprevention PROGRESS
  •  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.
  • Ref : CHEST 2007 ; 131 : 1949-1962 : Hypertensive crises : challenges and management
  • Ref : CHEST 2007 ; 131 : 1949-1962 : Hypertensive crises : challenges and management
  • 47-Year-OldComplains Of Chest Pain BP 162/110
  •  NTG  Relieves only chest pain  No mortality difference in 77,000 patients -blockers Antiplatelets: ASA, clopidogrel Anticoagulants: LMWH, UFH GP IIb/IIIa antagonist or DTI w/clopidogrel 2007 AHA/ACC Guidelines
  • Drug Nitroprusside NitroglycerinRapid onset of peak effect ++++ +++Afterload reduction ++++ +Preload reduction ++ ++++Coronary steal reported + 0Coronary dilation – large vessel + ++++Coronary dilation – small vessel +/- +/-Tachycardia ++ ++Potential for symptomatic hypotension ++ +++Ease of administration ++ +++Cyanide toxicity ++++ 0 Pepine CJ. Clin Ther. 1988;10:316-325.
  •  Must decrease shear forces  Do not use inotropics Esmolol Labetolol Tintinalli, 4th ed.
  • Esmolol Labetalol -Blocker - and -BlockerAdministration Bolus Bolus Continuous infusion Continuous infusionOnset Rapid (60 s)2 Intermediate (peak 5-15 min)2Offset (Duration of action) Rapid (10-20 min)2 Slower (2-4 h)2HR Decreased +/-SVR 0 DecreasedCardiac output Decreased +/-Myocardial O2 balance Positive PositiveContraindications Sinus bradycardia Severe bradycardia Heart block >1° Heart block >1° Overt heart failure Overt heart failure Cardiogenic shock Cardiogenic shock 1. Hoffman BB. In: Hardman JG, Limbird LE, eds. Goodman and Gilman’s Pharmacological Basis of Therapeutics. 10th ed. New York, NY: McGraw-Hill; 1997:215-268. 2. Varon J, Malik PE. Chest. 2000;118:214-227.
  • Nicardipine Diltiazem Verapamil (dihydropyridine) (benzothiazepine) (phenylalkylamine) PeripheralVasodilation1 +++++ +++ +++ CoronaryVasodilation2 +++++ +++ ++++Suppressionof SA Node2 + +++++ +++++Suppressionof AV Node2 0 ++++ +++++Suppression of Cardiac 0 ++ ++++Contractility2 Frishman WH, et al. Med Clin North Am. 1988;72:523-547. .1 Adapted from Goodman and Gilman’s: The Pharmacologic Basis of Therapeutics. 9th ed. 2001. .2
  • All Patients Treated with Drug1,400,000 1,200,4441,200,000 1,133,717 2004 2005 20061,000,000 800,000 735,647 600,000 502,518 400,000 312,432 240,785 200,000 139,104 8,288 0 Nitroglycerin Labetalol Hydralazine Enalaprilat Esmolol SNP Nicardipine Fenoldopam Thomson Patient Level Data. 2006
  •  HTN is extremely prevalent & hypertensive crises will become increasingly common in the ED.
  • So, What is new?
  • http://www.nhlbi.nih.gov/guidelines/hypertension/jnc8/index.htm
  •  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
  • Thank you for your attention