Evaluation Of Patient’s with HTNEvaluation of hypertensive patients has three objectives:(1) to assess lifestyle and identify other cardiovascular risk factors or associated disorders that may affect prognosis and guide treatment(2) to reveal identifiable causes of high BP(3) to assess the presence or absence of target organ damage
Cardiovascular risk factorsMajor Risk FactorsHypertension*Age (older than 55 years for men, 65 years for women)†Diabetes mellitus*Elevated LDL (or total) cholesterol, or low HDL cholesterol*Estimated GFR <60 mL/minFamily history of premature CVD (men <55 years of age orwomen <65 years of age)MicroalbuminuriaObesity* (BMI >30 kg/m2)Physical inactivityTobacco usage, particularly cigarettes
Identifiable causes of hypertensionChronic kidney diseaseCushing’s syndrome and other glucocorticoid excess statesincluding chronic steroid therapyDrug induced or drug related (see table 18)Obstructive uropathyPheochromocytomaPrimary aldosteronism and other mineralocorticoid excessstatesRenovascular hypertensionSleep apneaThyroid or parathyroid disease
Target Organ DamageHeart LVH Angina/prior MI Prior coronary revascularization Heart failureBrain Stroke or transient ischemic attack DementiaCKDPeripheral arterial diseaseRetinopathyPlacenta Eclampsia
Approach to All Patients With HTN Look for: • LOC and orientation • Respiratory status • For neurological deficits Hemiparesis, slurred speech • Baseline Temperature, HR, RR, BP • Maintain continuous monitoring of BP and HR • BP should not only be measured in both the supine position and the standing position (assess volume depletion), but it should also be measured in both arms (a significant difference may suggest aortic dissection).
•Assess for changes in cardiac rhythm if patient is on a monitor•Monitor I&OSaO2 via pulse oximetry if availableFor associated symptoms Visual disturbance, chest pain, peripheral edema, hematuria
Severe elevations in BP (DBP≥120-130mmhg) without evidenceprogressive target organ dysfunctionExamples:Severe uncomplicated essential hypertensionSevere uncomplicated secondary hypertensionPostoperative hypertensionDrug-induced hypertensionRebound hypertension (i.e., sudden withdrawal of clonidine)Cessation of prior antihypertensive therapySevere hypertensive crises related to anxiety, panic attacks or pain
TREATMENT OF HTN URGENCY:Goals: Lower mean arterial pressure to goal or near goal within several hours.Oral medications can be used.MAP=(2xDP)+SP/3Lower mean arterial pressure by 20- 25% or diastolic pressure to <100 to 110mmHg within 30–60 minutes. excessive falls in pressure that may precipitaterenal, cerebral, or coronary ischemia. Agents that reliably cause an immediate fall in BP include captopril(25-50 mg), central sympatholytics(clonidine0.1–0.2 mg), labetalol(200–400 mg), and amlodipine(2.5–5 mg) •Initiation of therapy with two oral agents is appropriate to lower BP to an intermediate target over 24 to 72 hours •Appropriate follow-upwithin 3 days.
Hypertensive EmergenciesSevere elevations in BP (>180/120 mmHg)Complicated by evidence of impending or progressive targetorgan dysfunction.Require immediate BP reduction (not necessarily to normal) toprevent or limit target organ damage.Exampleshypertensive encephalopathyIntracerebral hemorrhage,acute MIacute left ventricular failure with pulmonary edemaunstable anginadissecting aortic aneurysm,eclampsia
Initial Evaluation of Patients with a HypertensiveEmergencyHistory• Prior diagnosis and treatment of hypertension• Intake of pressor agents: street drugs, sympathomimetics• Symptoms suggesting an acute end-organ involvement• chest pain –myocardial infarction, thoracic aortic dissection• back pain –thoracic aortic dissection• dyspnea–acute pulmonary edema• neurological symptoms-hypertensive encephalopathy
Physical examination• Blood pressure –both upper limbs• Fundoscopy• Cardiopulmonary status AR, MR , signs of CHF• Neurologic status level of consciousness, focal sigh of ischemia• Body fluid volume assessment• Peripheral pulses
Laboratory evaluationHematocrit and blood smear (microangiopathic hemolysis)Urine analysisAutomated chemistry: creatinine, glucose, electrolytesElectrocardiogramChest radiograph (if heart failure or aortic dissection issuspected)CT brain in patients with neurological symptomsCT chest or MRI in patients with unequal pulses/ an enlargedmediasternum
HTN EMERGENCY TREATMENTGOALS:Almost all hypertensive emergencies are caused orexacerbated by intense systemic vasoconstriction,often with profound blood volume reductiongoal of therapy is to reduce vasoconstriction whilemaintaining adequate perfusion of target organs
Treatment: All HTN Emergencies should be admitted and treated in ICU/CCU The initial goal of therapy in hypertensive emergencies is to reduce mean arterial BP by no more than 25 percent (within minutes to 1 hour) If clinical is stable, reduce BP to 160/100–110 mmHg within the next 2–6 hours Further gradual reductions toward a normal BP can be implemented in the next 24–48 hours.
Exceptions• acute stroke in evolution (for which no BP lowering is generally recommended)• The American Heart Association recommends• Treatment with intravenous labetalol or nicardipine Started when BP values are above 220/120mmHg The target BP should be a 10–15% lowering of BP
DRUGS FOR HTN EMERGENCY• Nitroprusside — a rapidly acting arteriolar and venous dilator, given as an intravenous infusion. Initial dose: 0.25 to 0.5 mcg/kg per min; maximum dose: 8 to 10 mcg/kg per min which should be continued for no more than 10 minutes.• Nitroglycerin — a rapidly acting venous and, to a lesser degree, arteriolar dilator, given as an intravenous infusion. Initial dose: 5 mcg/min; maximum dose: 100 mcg/min.• Labetalol — an alpha- and ß-adrenergic blocker, given as an intravenous bolus or infusion. Bolus: 20 mg initially, followed by 20 to 80 mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg/min.• Nicardipine — a calcium channel blocker, given as an intravenous infusion. Initial dose: 5 mg/h; maximum dose: 15 mg/h.• Clevidipine — a calcium channel blocker. Initial dose: 1 mg/hour; maximum dose: 16 mg/hour .
DRUGS FOR HTN EMERGENCY• Fenoldopam — a peripheral dopamine-1 receptor agonist, given as an intravenous infusion. Initial dose: 0.1 mcg/kg per min; the dose is titrated at 15 min intervals, depending upon the blood pressure response.• Hydralazine — an arteriolar dilator, given as an intravenous bolus. Initial dose: 10 mg given every 20 to 30 minutes; maximum dose: 20 mg.• Propranolol — a ß-adrenergic blocker, given as an intravenous infusion and then followed by oral therapy. Dose: 1 to 10 mg load, followed by 3 mg/h.• Phentolamine — an alpha-adrenergic blocker, given as an intravenous bolus. Dose: 5 to 10 mg every 5 to 15 minutes.• Enalaprilat — an angiotensin converting enzyme inhibitor, given as an intravenous bolus. Dose: 1.25 mg every six hours.