Hypertensive crisis

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It is important to recognize patients with Hypertensive Crisis so that appropriate management is timely initiated.

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Hypertensive crisis

  1. 1. HYPERTENSIVE CRISISSYED RAZA
  2. 2. OBJECTIVES• 1. What is Hypertensive Crisis ?• 2. Size of the problem• 3. Clinical presentation• 4. Management
  3. 3. CASE SCENARIO• 69/M• Chest tightness and shortness of breath• Diabetes – 10 years. Chronic smoker• Not known hypertensive• BP 230/120 mmHg HR 110/mt• CVS – S3 gallop, No murmur.• Chest – Bi-basal fine inspiratory crackles• P/A – Kidneys not ballotable. No RA bruit.• Neuro – fully consciouss , No neuro deficits.
  4. 4. Lab• Hb – 9.4• MCV- 84• Creatinine : 2.1 mg/dl• Urine : 3 + protein• Cardiac markers - Normal
  5. 5. What would you do next?• 1. 24 hour urinary protein.• 2. 24 hour ambulatory BP• 3. Renal Ultrasound• 4. Fundoscopy
  6. 6. What targets organs are Involved?• 1. Brain• 2. Heart• 3.Retina• 4. Kidneys
  7. 7. What targets organs are Involved?• 1. Brain• 2. Heart• 3.Retina• 4. Kidneys
  8. 8. What is the diagnosis?• 1. Accelerated Hypertension• 2.Malignant Hypertension• 3. Hypertensive Urgency• 4. Hypertensive Emergency
  9. 9. AnswerHypertensive EmergencySevere Hypertension where BP is > 180/110mmHg with evidence of target organ damage.1.Retinopathy / Retinal hemorrhage2.Encephalopathy/I.C hemorrhage/ IC tension3.Acute Pulm. Oedema, Myocardialischaemia/Aortic dissection.4. Acute Renal Failure
  10. 10. HYPERTENSIVE CRISIS• Approximately 25% of emergency room visitsare due to hypertensive crisis.• BP > 180/110 mmHg• Emergency : Target organ damage.• Urgency : No target organ damage.
  11. 11. Common precipitating factors• 1. No regular health checks• 2. Age - elderly• 3.Sub therapeutic treatment• 4. Non adherence to medication.• 5. Lack of family care physician.
  12. 12. Signs and SymptomsSymptoms specific to target organ damage• Headache• Neck pain• Blurring of vision• Chest tightness• Shortness of breath• Anuria
  13. 13. Lab Work Up• 1.CBC• 2. KFT• 3.Urine Analysis• 4. CXR – Heart/aorta size/ LVF• 5. ECG• 6.Fundoscopy• 7.CT/MRI Brain
  14. 14. Management : Basic PrincipleUrgency : Out-patientOral medicationBP reduction 24-48 hoursEmergency : InpatientIntravenousImmediate BP reduction < 25% withinminutes – 1 Hour160/100 : 2-6 hours
  15. 15. Intravenous Antihypertensive• Nitroglycerine (5-100 mic/mt)• Sodium Nitroprusside (0.25-10 mic/kg/mt)• Enalaprilat (only ACEI in I/V form, 1.25-5mg)• Nicardipine (2ndgeneration) 5-15 mg/hr• Clevidipine (3rdgeneration)• Esmelol (250-500 mic/kg/mt)• Labetalol (20-80 mg bolus)
  16. 16. Oral Drugs for HypertensiveUrgency• Amlodipine 5-10 mg OD – 12 hrly• Captopril 12.5 – 25 mg 6 hrly• Nicardipine 20-30 mg 6-8 hrly• Clonidine 0.2 mg 12 hrly• Labetalol 200-400 mg 8-12 hrly• Lasix 20-40 mg 8-12 hrly
  17. 17. Medication of choice• Myocardial Ischemia/ LVF : NTG, Esmolol• Aortic Dissection : Labetalol• Acute Renal Failure : Fenoldopam /Nicardipine• Hyper-adrenergic states : due to sympatho-mimetic drugs : Benzodiazepines.Pheo chromocytoma : Phentolamine
  18. 18. • Eclampsia : Labetalol /MagnesiumACEI and ARB contra-indicatedIntracranial Heamorrhage: Aim MAP 130mmHgFirst : LabetololSecond : Sodium Nitroprusside if no raised ICPIf ICP raised : Use Nicardipine.
  19. 19. • Labetalol : Alpha selective, Beta non selective• oral/ intravenous• Nicardipine : second generationdihydropyridine.Onset of action 5-20 minutes• Nitroglycerine :• More of Venodilator than arterial dilator.• SE: Headache, Flushing, Tachycardia•
  20. 20. • Nitro prussside :Strong veno and arterial vasodilator.rapid onset of action.Risk of thiocyanide toxicity : Hyperreflexiadelerium , psychosis
  21. 21. Fenoldopam• Selective dopamine 1 receptor Agonist• Onset of action < 1 minute• Useful in patients with acute renal failure.• Fenoldopam improves urinary output,• Creatine clearance , sodium excretion
  22. 22. Use of Captopril• Short acting ACEI• Hypertensive Urgency• Oral and sublingual : 6.25-50 mg• Effect seen within 5-15 minutes• Max reduction of BP in 30 mins• Duration of effect 2-6 hours• S/E : Hyperkalaemia / Angio-edema/dry cough
  23. 23. Captopril vs Nifedipine
  24. 24. Case• 72/m• Annual physical check-up• Asymptomatic• BP 210/100-110 mmHg
  25. 25. What would you examine next?• 1. Fundoscopy• 2. CVS• 3.Neurology examination.• 4. Peripheral pulses
  26. 26. ANSWER• 1. Fundoscopy• 2. CVS• 3.Neurology examination.• 4. Peripheral pulses
  27. 27. Physical Examination• Fundoscopy – Normal• Systemic Physical Examination – Normal• Lab- Normal• ECG and CXR - NAD
  28. 28. What is the diagnosis?• 1. Malignant Hypertension.• 2. Hypertensive Urgency• 3. Hypertensive Emergency• 4. Severe Acute Hypertension.
  29. 29. ANSWER• 1. Malignant Hypertension.• 2. Hypertensive Urgency• 3. Hypertensive Emergency• 4. Severe Acute Hypertension.
  30. 30. How will you manage the patient?• 1.Admit and start intravenousantihypertensive medication• 2. Treat as OP clinic with orallyantihypertensive• 3. Treat if patient is symptomatic• 4. Just Observe
  31. 31. How will you manage the patient?• 1.Admit and start intravenousantihypertensive medication• 2. Treat as OP clinic with orallyantihypertensive• 3. Treat if patient is symptomatic• 4. Just Observe
  32. 32. What do the guidelines say?Joint National Committee•Seventh report on Prevention, Detection,Evaluation and Treatment of Hypertensionstates ‘’ Initial goal of therapy in hypertensiveemergencies is to reduce MAP by no more than25% - minutes to 1 hour160/100-110 - 2 to 6 hours<140/90 - 24 to 48 hours
  33. 33. Exceptions• Patients with ischemic stroke• Patients with Aortic Dissection• Patients requiring urgent thrombolytictherapy (BP < 180/100 mmHg)
  34. 34. Acute Ischemic Stroke• If BP < 220/120 mmHg – only observeUnless end organ damageconcurrent hemorrhageIf SBP > 220 and DBP 120-140 : Labetalol/NicardipineIf DBP > 140 : NitroprussideAim for 10 – 15% reduction over 24 hours
  35. 35. Aortic Dissection• BP should be lowered quite aggressively• Goal : systolic BP 100-120 mmHg within 20minutes• Aima. lower BPb. decrease LV contraction so as to decreaseAortic shear stressDOC : labetalol or Esmolol

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