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Hypertensive Crisis:Hypertensive Emergencies and Urgencies                           6 กพ. 2554                     พญ.เสา...
Definitions and classification of blood pressure levels (mmHg) Category                 ESC 2007                         J...
Acute target organ damageBrain :Hypertensive encephalopathyCerebral infarctionCerebral hemorrhageAdvanced retinopathyHeart...
Triage of Pts with Severe HTHypertensive Urgencies or Emergencies                BP > 180/120 mmHg a) hypertensive emergen...
Hypertensive Emergencies   Severe elevations in BP                        Examples    (>180/120 mmHg)                   ...
Hypertensive Emergencies    Catecholamine excess states      Pheochromocytoma crisis      Overdose with sympathomimetics ...
Initial Evaluation of Patients with a                 Hypertensive EmergencyHistory   Prior diagnosis and treatment of   ...
Initial Evaluation of Patients with a                   Hypertensive EmergencyHistory   Symptoms suggesting an acute    e...
Initial Evaluation of Patients with a                Hypertensive EmergencyPhysical examination   Blood pressure – both u...
Initial Evaluation of Pt with a Hypertensive                      EmergencyLaboratory evaluation   Hematocrit and blood s...
11
Initial Evaluation of Pt with a Hypertensive                     EmergencyLaboratory evaluation   Plasma renin activity a...
Critical Degree of                                     Hypertension     Local effects                                     ...
Clinical Characteristics of Accelerated-             Malignant Hypertension   Blood pressure: usually >140 mm Hg diastoli...
Hypertensive encephalopathy                 Pathophysiology   When mean arterial pressures > 180 mm Hg,    vessels are st...
Hypertensive encephalopathy   A sudden, marked elevation    of BP   Severe headache and    altered mental status,    rev...
MRI hypertensive encephalopathyT 1-weighted images   Posterior reversible    leukoencephalopathy    syndrome    finding :...
Goal of Hypertensive Emergencies Rx               LIMIT ORGAN DAMAGE   Almost all hypertensive emergencies are caused or ...
Treatment of Hypertensive Emergencies   Admitted to an ICU for continuous monitoring of BP and iv    administration of an...
Exceptions   acute aortic dissection   acute stroke in evolution (for which no BP    lowering is generally recommended) ...
Acute aortic dissectionInitial management of thoracic aortic dissection should be    directed at decreasing aortic wall st...
Acute Ischemic StrokeThe American Heart Association recommends   Treatment with intravenous labetalol or nicardipine   S...
Acute STEMIRelative contraindications for thrombolytics   History of chronic, severe, poorly controlled hypertension   S...
Management of ICH   Emergency diagnosis and assessment of ICH    and its cause   Medical RX – correct coagulopathy   In...
HYPERTENSION could contribute to hydrostaticexpansion of the hematoma, peri-hematoma edema, andrebleeding                 ...
Guidelines for Treating Elevated BP in Spontaneous ICH    1. If SBP is 200 mm Hg or MAP is 150 mm Hg    aggressive reducti...
Drug Useful for Hypertensive Emergencies    Agent           Dose            Onset/     Duration of        Precautions     ...
Drug Useful for Hypertensive Emergencies   Agent          Dose         Onset/ of   Duration of action      Precautions    ...
Drug Useful for Hypertensive Emergencies  Agent               Dose               Onset/ of    Duration of      Precautions...
Drug Useful for Hypertensive Emergencies     Agent             Dose           Onset of    Duration       Precautions      ...
Drug Useful for Hypertensive Emergencies    Agent          Dose     Onset/ of   Duration of action      Precautions       ...
Drugs of choice and relative contraindications              for hypertensive emergencies       Condition                  ...
Drugs of choice and relative contraindications           for hypertensive emergencies                                     ...
Hypertensive Urgencies   severe elevations in BP      Examples include    without progressive target   upper levels of st...
Hypertensive Urgencies   Severe uncomplicated essential hypertension   Severe uncomplicated secondary hypertension   Po...
Treatment of Hypertensive Urgencies   Agents that reliably cause an immediate fall in BP    include captopril (25-50 mg),...
Oral Drugs for Hypertensive Urgencies  Drug         Initial dose            Onset            Duration                   Ad...
Treatment of Severe HT (asymptomatic)   immediate normalization of the BP is not necessary   it is usually appropriate t...
ALGORITHM FOR TRIAGE AND                       MANAGEMENT                   Severe hypertension      Hypertensive urgency ...
ALGORITHM FOR TRIAGE AND                    MANAGEMENT                     Severe hypertension      Hypertensive urgency  ...
A 44 –year –old Thai maleChief compliant : Dyspnea, cyanosisPresent illness : Underlying disease HT, CKD, Irregular RX3 hr...
Cardiovascular : heart PMI at 5 th ICS mid clavicular line  normal S1S2 no murmur no gallopLung : rales both lungsAbdomen ...
Problem list1. NSTEMI with CHF2. CKD3. Hypertensive emergency   43
First Rxa. O2 therapyb. IV Furosemidec. IV Morphined. IV NitroglycerineWhich antihypertensive drug ?a. IV Nitroglycerineb....
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Ht emergency 2011 v2003

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  1. 1. Hypertensive Crisis:Hypertensive Emergencies and Urgencies 6 กพ. 2554 พญ.เสาวนินทร์ อินทรภักดี โรงพยาบาลเลิดสิน 1
  2. 2. Definitions and classification of blood pressure levels (mmHg) Category ESC 2007 JNC VII 2003Optimal < 120 and < 80 Normal < 120 and < 80Normal 120–129 and/or 80–84 Pre HT 120-139 or 80-99High normal 130–139 and/or 85–89Grade 1 HT 140–159 and/or 90–99 stage 1 HT 140-159 or 90-99Grade 2 HT 160–179 and/or 100–109 stage 2 HT > 160 or > 100Grade 3 HT > 180 and/or > 110 2
  3. 3. Acute target organ damageBrain :Hypertensive encephalopathyCerebral infarctionCerebral hemorrhageAdvanced retinopathyHeart :Acute coronary syndromesAcute heart failureAorta :Aortic dissectionKidney:Acute renal failurePlacenta :Eclampsia 3
  4. 4. Triage of Pts with Severe HTHypertensive Urgencies or Emergencies BP > 180/120 mmHg a) hypertensive emergencies, often with BP >220/140 life-threatening organ dysfunction. b) hypertensive urgencies symptoms or modest organ damage, c) severe HT without symptoms or acute signs of organ damage 4
  5. 5. Hypertensive Emergencies Severe elevations in BP Examples (>180/120 mmHg)  hypertensive encephalopathy Complicated by evidence of  Intracerebral hemorrhage, impending or progressive  acute MI target organ dysfunction.  acute left ventricular failure Require immediate BP with pulmonary edema reduction (not necessarily to  unstable angina normal) to prevent or limit  dissecting aortic aneurysm, target organ damage.  eclampsia• JNC VII 2003
  6. 6. Hypertensive Emergencies Catecholamine excess states Pheochromocytoma crisis Overdose with sympathomimetics or drugs with similar action (phencyclidine, cocaine, phenylpropanolamine) Hypertension associated with acute renal failure Microangiopathic anemiaManual of Hypertension of the European Society of Hypertension 2008 6
  7. 7. Initial Evaluation of Patients with a Hypertensive EmergencyHistory Prior diagnosis and treatment of hypertension Intake of pressor agents: street drugs, sympathomimetics 7
  8. 8. Initial Evaluation of Patients with a Hypertensive EmergencyHistory 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, stroke 8
  9. 9. Initial Evaluation of Patients with a Hypertensive EmergencyPhysical examination Blood pressure – both upper limbs Funduscopy Cardiopulmonary status AR, MR , signs of CHF Neurologic status level of consciousness, focal sigh of ischemia Body fluid volume assessment Peripheral pulses 9
  10. 10. Initial Evaluation of Pt with a Hypertensive EmergencyLaboratory evaluation Hematocrit and blood smear (microangiopathic hemolysis) Urine analysis Automated chemistry: creatinine, glucose, electrolytes Electrocardiogram Chest radiograph (if heart failure or aortic dissection is suspected) CT brain in patients with neurological symptoms CT chest or MRI in patients with unequal pulses/ an enlarged mediasternum 10
  11. 11. 11
  12. 12. Initial Evaluation of Pt with a Hypertensive EmergencyLaboratory evaluation Plasma renin activity and aldosterone (if primary aldosteronism is suspected) Plasma renin activity before and 1 h after 25 mg captopril (if renovascular hypertension is suspected) Spot urine or plasma for metanephrine (if pheochromocytoma is suspected) 12
  13. 13. Critical Degree of Hypertension Local effects Systemic effects (prostaglandins, free (Renin-angiotensin, radicals) catechol, vasopressin) Endothelial damage Pressure natriuresis initiation and progression Platelet deposit of accelerated-malignant HT HypovolemicMitogenic and migration factors Further increase inMyointimal proliferation vasopressors Further rise in blood pressure and vascular damage Tissue ischemia 13
  14. 14. Clinical Characteristics of Accelerated- Malignant Hypertension Blood pressure: usually >140 mm Hg diastolic Funduscopic findings : accelerated HT - grade 3 retinopathy ( hemorrhages, exudates) malignant HT - grade 4 retinopathy (papilledema) Neurologic status: headache, confusion, somnolence, stupor, vision loss, focal deficits, seizures, coma Renal status: oliguria, azotemia Gastrointestinal status: nausea, vomiting 14
  15. 15. Hypertensive encephalopathy Pathophysiology When mean arterial pressures > 180 mm Hg, vessels are stretched and dilated— producing generalized vasodilation Breakthrough of cerebral blood flow , hyperperfuses the brain under high pressure, with leakage of fluid into the perivascular tissue, leading to cerebral edema 15
  16. 16. Hypertensive encephalopathy A sudden, marked elevation of BP Severe headache and altered mental status, reversible by reduction of BP Encephalopathy is more common in previously normotensive individuals whose pressures rise suddenly 16
  17. 17. MRI hypertensive encephalopathyT 1-weighted images Posterior reversible leukoencephalopathy syndrome finding : edema of the white matter of the parieto-occipital regions hypertensive brainstem encephalopathy finding : pontine abnormalities 17
  18. 18. Goal of Hypertensive Emergencies Rx LIMIT ORGAN DAMAGE Almost all hypertensive emergencies are caused or exacerbated by intense systemic vasoconstriction, often with profound blood volume reduction goal of therapy is to reduce vasoconstriction while maintaining adequate perfusion of target organs 18
  19. 19. Treatment of Hypertensive Emergencies Admitted to an ICU for continuous monitoring of BP and iv administration of an appropriate agent 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. 19 JNC VII 2003
  20. 20. Exceptions acute aortic dissection acute stroke in evolution (for which no BP lowering is generally recommended) JNC VII 2003 20
  21. 21. Acute aortic dissectionInitial management of thoracic aortic dissection should be directed at decreasing aortic wall stress by controlling HR and BP : In the absence of contraindications, Iv beta blockade should be initiated and titrated to a target heart rate < 60 /min If systolic blood pressures > 120 mm Hg after adequate heart rate control has been obtained, then iv angiotensin-converting enzyme inhibitors and/or other vasodilators should be administered . 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With 21 Thoracic Aortic Disease. Circulation. 2010;121:1544-1579.
  22. 22. Acute Ischemic StrokeThe 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 In patients candidates to treatment with intravenous tissue plasminogen activator BP should be maintained below 185/110mmHg. Guidelines for the early management of patients with ischemic stroke. A Scientific Statement from the Stroke Council of the American Stroke Association. 22 Stroke 2003; 34:1056–83.
  23. 23. Acute STEMIRelative contraindications for thrombolytics History of chronic, severe, poorly controlled hypertension Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP >110 mmHg) ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction 2004 23
  24. 24. Management of ICH Emergency diagnosis and assessment of ICH and its cause Medical RX – correct coagulopathy Inpatient management and prevent of secondary brain injury General monitoring Management of glucose Seizures Procedures /surgery – clot removal Prevent of recurrent – Rx hypertension 24
  25. 25. HYPERTENSION could contribute to hydrostaticexpansion of the hematoma, peri-hematoma edema, andrebleeding 25
  26. 26. Guidelines for Treating Elevated BP in Spontaneous ICH 1. If SBP is 200 mm Hg or MAP is 150 mm Hg aggressive reduction of BP with continuous intravenous infusion, with frequent BP monitoring every 5 min. 2. If SBP is 180 mm Hg or MAP is 130 mm Hg and there is the possibility of elevated ICP, then consider monitoring ICP and reducing BP using intermittent or continuous intravenous medications while maintaining a cerebral perfusion pressure 60 mm Hg. 3. If SBP is 180 mm Hg or MAP is 130 mm Hg and there is not evidence of elevated ICP, then consider a modest reduction of BP (MAP of 110 mm Hg or target BP of 160/90 mm Hg) using intermittent or continuous intravenous medications to control BP and clinically reexamine the patient every 15 min Guidelines for the Management of Spontaneous ICH A Guideline for Healthcare Professionals 26 From the American Heart Association/American Stroke Association 2010
  27. 27. Drug Useful for Hypertensive Emergencies Agent Dose Onset/ Duration of Precautions Special indicationvasodilators of action actionSodium 0.25–10.00 Immediate/ 1-2 min Nausea, vomiting, Most hypertensivenitroprusside µg/kg/min as muscle twitching; emergencies , i.v. infusiona; thiocyanate caution with high maximal intoxication, ICP or azotemia dose for 10 methemoglobinemia min only acidosis, cyanide poisoning; bags, bottles, and delivery sets must be light resistantGlyceryl 5–100 µg as 2-5 min 5-10 min Headache, Coronary ischemiatrinitrate i.v. infusion tachycardia, vomiting, flushing, methemoglobinemia; requires special delivery systems due to the drugs binding to polyvinyl chloride 27 tubing
  28. 28. Drug Useful for Hypertensive Emergencies Agent Dose Onset/ of Duration of action Precautions Special indicationvasodilators actionNicardipine 5–15 mg/h 5-10 min/ 15–30 min, but may Tachycardia, Most hypertensiveCalcium i.v. infusion exceed 4h after nausea, vomiting, emergencies ,channel prolonged infusion headache, possible except in acuteblocker protracted heart failure ; hypotension after caution with prolonged infusions coronary ischemia ,Fenoldopam 0.1–0.3 < 5min 30 min Headache, Most hypertensivedopamine mg/kg/min tachycardia, emergencies ,agonist (D1- i.v. infusion flushing, local caution withreceptors) phlebitis glaucoma 28 JNC VII 2003
  29. 29. Drug Useful for Hypertensive Emergencies Agent Dose Onset/ of Duration of Precautions Specialvasodilators action action indicationHydralazine 10–20 mg as i.v. 10 -20 min iv 1-4 h iv Tachycardia, Eclampsia bolus 20-30 min im 4-6 h im headache, 10–40 mg i.m.; vomiting, repeat every 4–6 h aggravation of angina pectorisEnalaprilat 1.25 – 5 mg every 6 15–30 min 6-12 hr Renal failure in Acute LV h i.v. / patients with failure; avoid bilateral artery in acute MI stenosis, hypotension 29 JNC VII 2003
  30. 30. Drug Useful for Hypertensive Emergencies Agent Dose Onset of Duration Precautions Special indication Adrenergic action of action inhibitorsLabetalol 10–80 mg as i.v. 5–10 min 3–6 h Bronchoconstriction Most hypertensiveAlpha1, beta 1 bolus every 10 , heart block, emergencies ,and beta 2 min; up to 2 orthostatic except acute heartreceptor mg/min as i.v. hypotension, failureantggonist infusion vomiting, scalp tinglingEsmolol 500 µg/kg bolus 1-2 min 10–30 min First-degree heart Aortic dissection,Beta 1receptor injection i.v. or block, congestive perioperativeantagonist 50 –100 heart failure, µg/kg/min by asthma infusion ; may repeat bolus after 5 min or increase infusion rate to 300 µg/ kg/minPhentolamine 5–15 mg as i.v. 1–2 min 10-30 min Tachycardia, Catecholamine bolus orthostatic excess hypotension, 30 flushing JNC VII 2003
  31. 31. Drug Useful for Hypertensive Emergencies Agent Dose Onset/ of Duration of action Precautions Special indication vasodilators actionUrapidil 20 -60 3-4 min/ 6-10 h SedationAlpha blocker mg iv,central bolussympatholyticeffect viastimulation ofserotonin5HT(1A)receptorsClevidipine 0.1–0.3 < 5min 30 min Headache, Most hypertensiveCalcium mg/kg/mi tachycardia, emergencies ,channel n i.v. flushing, local caution withclocker infusion phlebitis glaucoma 31 JNC VII 2003
  32. 32. Drugs of choice and relative contraindications for hypertensive emergencies Condition Drug(s) of choice Relative contraindications/cautionsAcute pulmonary Nitroglycerin + loop diuretic Beta-blockers, verapamiledema Nitroprusside + loop diureticAcute coronary Nitroglycerin + beta-blocker Hydralazinesyndromes Nitroprusside + beta-blockerHypertensive Nitroprusside, labetalol, Centrally acting sympatholyticencephalopathy nicardipine agentsDissecting aortic Nitroprusside + beta-blocker Isolated use of pure vasodilatorsaneurysmIntracranial Labetalol, nicardipine Nitroprusside with caution,hemorrhage nifedipine 32 Manual of Hypertension of the European Society of Hypertension 2008
  33. 33. Drugs of choice and relative contraindications for hypertensive emergencies Relative Condition Drug(s) of choice contraindications/cautionsIschemic stroke Nitroprusside, labetalol, Nifedipine nitroglycerinAdrenergic crisis Labetalol, phentolamine + Beta-blocker monotherapy beta-blockerAcute renal Fenoldopam, nicardipine Diuretics with cautionimpairmentEclampsia MgSO4, hydralazine, Nitroprusside methyldopaSubarachnoid Nimodipine Nitroprusside with cautionhemorrhage 33 Manual of Hypertension of the European Society of Hypertension 2008
  34. 34. Hypertensive Urgencies severe elevations in BP Examples include without progressive target upper levels of stage II HT associated with organ dysfunction  severe headache  shortness of breath  Epistaxis  severe anxiety JNC VII 2003 34
  35. 35. Hypertensive Urgencies Severe uncomplicated essential hypertension Severe uncomplicated secondary hypertension Postoperative hypertension Hypertension associated with severe epistaxis Drug-induced hypertension Rebound hypertension (i.e., sudden withdrawal of clonidine) Cessation of prior antihypertensive therapy Severe hypertensive crises related to anxiety, panic attacks or pain Manual of Hypertension of the European Society of Hypertension 2008 35
  36. 36. Treatment of Hypertensive Urgencies Agents that reliably cause an immediate fall in BP include captopril (25-50 mg), central sympatholytics (clonidine 0.1–0.2 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-up within 3 days. 36
  37. 37. Oral Drugs for Hypertensive Urgencies Drug Initial dose Onset Duration Adverse effects Captopril 25–50 mg 15–45 min 6–8 h Renal failure in bilateral artery stenosis Labetalol 200–400 mg 30–120 min 2–12 h Orthostatic hypotension, bronchoconstrictionClonidine 0.150–0.300 mg 30–60 min 8–16 h Hypotension, dry mouth Prazosin 1–2 mg 60–120 min 8–12 h Syncope (first dose), orthostatic hypotension, tachycardiaNicardipine 20–40 mg 30–60 min 8–12 h Headache, tachycardia, flushingAmlodipine 5–10 mg 60–120 min 12–18 h Headache, tachycardia, flushing 37 Manual of Hypertension of the European Society of Hypertension 2008
  38. 38. Treatment of Severe HT (asymptomatic) immediate normalization of the BP is not necessary it is usually appropriate to prescribe a two-drug therapy identify individuals at risk for secondary hypertension counsel the patient on the importance of long-term BP control schedule follow-up within 1 week or less. 38
  39. 39. ALGORITHM FOR TRIAGE AND MANAGEMENT Severe hypertension Hypertensive urgency Hypertensive emergencyBP >180/120 mm Hg >180/120 mm Hg Often >220/140 mm HgSymptoms Often asymptomatic Severe headache Prolonged chest Headache Shortness of breath pain/unstable angina Anxiety Edema Motor impairment/neurologic deficit Altered mental status Uncontrollable bleedingWorkup results No target organ Target organ Pulmonary edema/heart damage/clinical damage/clinical failure cardiovascular disease cardiovascular disease Acute MI may be present Cerebrovascular accident Encephalopathy Renal insufficiency Preeclampsia Renal failure Aneurysm 39
  40. 40. ALGORITHM FOR TRIAGE AND MANAGEMENT Severe hypertension Hypertensive urgency Hypertensive emergencyBP >180/120 mm Hg >180/120 mm Hg Often >220/140 mm HgAcute management Initiate/resume Lower BP with oral or Order baseline laboratories medication(s) parenteral agents as Initiate intravenous line Increase dosage of underlying conditions Monitor vital signs inadequate agent warrant May initiate disease-a Observe for 1–3 h Adjust current therapy appropriate parenteral Observe for 3–6 h therapy in the emergency roomPlan Arrange follow-up >72 h Arrange follow-up Immediate admission to If no prior evaluation, evaluation (24–72 h) intensive care unit schedule appointment Treat to appropriate goal BP Additional diagnostic studies as warranted 40
  41. 41. A 44 –year –old Thai maleChief compliant : Dyspnea, cyanosisPresent illness : Underlying disease HT, CKD, Irregular RX3 hr prior to admission : chest pain with dyspneaPhysical examGeneral appearance : Dyspnea and cyanosisVital sign : BP 220/120 mmHg HR 120/min regular RR 28/min T 37 C O2 sat room air 85%HEENT : UnremarkableNeck : Jugular distension 41
  42. 42. Cardiovascular : heart PMI at 5 th ICS mid clavicular line normal S1S2 no murmur no gallopLung : rales both lungsAbdomen : No hepatosplenomegaly not tenderExtremities : N edemaNeurologic : NormalLab :Hb 14 wbc 3220/mm3 platelet 329,000 /mm3BUN 39.7 ng/dL Creatinine 3.44 ng/mLTroponin I 4.6 42
  43. 43. Problem list1. NSTEMI with CHF2. CKD3. Hypertensive emergency 43
  44. 44. First Rxa. O2 therapyb. IV Furosemidec. IV Morphined. IV NitroglycerineWhich antihypertensive drug ?a. IV Nitroglycerineb. IV Beta blockerc. IV Nicardipined. IV Nitroprusside 44
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