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HYPERTENSIVE
EMERGENCY &
URGENCY
DR.ABHINAV KUMAR
MEDICINE RESIDENT
M.S RAMAIAH MEDICAL COLLEGE
HYPERTENSIVE EMERGENCY
BP elevation is associated with ongoing
neurological, myocardial, hematological or renal TARGET
ORGAN DISEASE (TOD)
HYPERTENSIVE URGENCY
- potential for TOD is great & likely to occur if BP is not
controlled.
- occurs on chronic stable complication
ACCELERATED
HYPERTENSION
keith wagener barker retinopathy grade 3
(constriction,sclerosis+hemorrhages,exudates)
- may be urgency or emergency
MANIFESTATIONS OF TARGET ORGAN DISEASE
LARGE VESSELS Aneurysmal dilations ,
atherosclerosis
Aortic dissection
CARDIAC Acute - pulm edema , MI
Chronic - LVH , CAD
CEREBROVASCULAR Intracerebral bleed, TIA, seizures,
mental
status change, stroke
RENAL Hematuria, azotemia, Cr>1.5,
proteinuria
INITIAL EVALUATION
Cardinal points in history-
- TOD symptoms (most imp)
- prior Htn
- Medical Renal Disease
- medicine with compliance
- cocaine, amphetamine
-Usually occurs on background of essential hypertn.
Imp secondary causes- renovascular(fibromuscular
dysplasia/atheresclerosis)
-chronic GN/reflux nephropathy/analgesic
nephropathy
SYMPTOMS OF HYPERTENSIVE
CRISIS
 MC is - headache (usually worse in morning)
- visual (scotoma, diplopia, hemianopia, blindness)
- neuro (focal deficits, stroke, TIA, somnolence)
- ischemic chest pain
- renal (polyuria, nocturia, hematuria)
- back pain (aortic aneurysm)
- nausea ,vomiting
- wt loss.
Threshold BP
There is no specific BP where hypertensive emergencies
occur
But, organ dysfunction is rare with diastolic BPs < 130 mm
Hg
Rate of increase may be more important
Hence, encephalopathy will occur at lower BPs in pregnancy
and in children
Initial Evaluation
Focused history
History of hypertension?
How well is hypertension controlled?
What antihypertensives?
Adherence to antihypertensive regimen?
Last dose of antihypertensive?
Initial Evaluation
Social History
Recreational Drugs
Amphetamines
Cocaine
Phencyclidine
Initial Evaluation
Confirm BP in both arms
Use appropriate sized BP cuff
Cuff that is too small
Falsely elevate BP measurements in obese patients
Initial Evaluation
Assess for end-organ damage
Vascular Disease
Assess pulses in all extremities
Auscultate over renal arteries for bruits
Cardiopulmonary
Listen for rales
Murmurs or gallops
Initial Evaluation
Neurologic Exam
Hypertensive Encephalopathy - mental status changes, nausea,
vomiting, seizures
Lateralizing signs uncommon and suggest cerebrovascular
accident
Retinal Exam
Lost art
Keith-Wagener-Barker Classification
Keith-Wagener-Barker Classification
Grade 1
Mild narrowing of the arterioles
“Copper Wire”
Grade 2
Moderate narrowing - Copper wire and AV nicking
Changes associated with long standing essential hypertension
Normal
Grade 1
Keith-Wagener-Barker Classification
Grade 3
Severe Narrowing - Silver wire changes, hemorrhage, cotton
wool spots, hard exudates
Grade 4
Grade 3 + Papilledema
Grade 3 and 4 highly correlated with progression to end organ
damage and decreased survival
Grade 3 KWB Retinopathy
Lab Testing
ECG
LVH, look for signs of ischemia, injury, infarct
Renal Function Tests (urine included)
Elevated BUN, Creatinine, proteinuria, hematuria
CBC
CXR - pulmonary edema, aortic arch, cardiac
enlargement
Lab Testing
Aortic Dissection?
Suspect with severe tearing chest pain, unequal pulses, widened
mediastinum
Contrast Chest CT Scan or MRI
Pulmonary Edema/CHF
Transthoracic Echocardiogram
Management
ED considerations
- Many HPT pts – only small number will require emergent treatment
- Primary goal of EP?
The pts – syptoms of EOD and require immediate iv parenteral therapy.
VS
The pt with acutely elev BP(SBP>200 or DBP>120) without EOD
symptoms, who require initiation of medical therapy and close follow
up as outpatient /inpatient
Remember - “treat the patient and not the number”
Treatment
ED Care - general principles
1. Consider context of elevated BP (pain, anxiety)
2. Screen for EOD (Hx/workup)
- Pts without evidence of EOD – d/c + f/up
- Pts with EOD – require ICU admission and rapid but gradual
lowering of BP - using IV meds.
BP should not be lowered to normal levels
- Rapid reduction in BP – below the autoregulatory range results
in reduction in organ blood flow – risk of ischemia and infarction
- General rule – the MAP should be lowered by no more than
20% - 1st hour
remains stable - BP lowered to 160/110 in next 2-6hrs
- BP goals best achieved by a continuous infusion of a short-
acting, titratable,
- parenteral anti-HPT agent, along with constant intensive
patient monitoring
Date of download: 3/24/2015
Copyright © 2015 American Medical
Association. All rights reserved.
Guideline Comparisons of Goal BP and
Initial Drug Therapy for Adults With
Hypertension
Date of download: 3/24/2015
Copyright © 2015 American Medical
Association. All rights reserved.
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
Treatment
Medication options
1. Oral antihypertensives
• Chronic hypertensive
• Hypertensive urgency
2. IV antihypertensives
• Hypertensive emergency
Pharmacology – IV anti-
HPT
1. Vasodilators
• Sodium nitroprusside
• Nitroglycerin
• Nicardipine
• Fenoldapam
• Hydralazine
• Enalapril
2. Adrenergic inhibitors
• Labetalol
• Esmolol
• Phentolamine
“IDEAL IV ANTI-
HYPERTENSIVE”
Lower the BP without compromising blood flow to critical
organs
Vasodilators generally considered 1st , because they
preserve organ blood flow in the face of reduced perfusion
and also tend to increase CO.
Profile of an ideal IV
antihypertensive
Preserves GFR and renal blood flow
Few or no drug reactions
Little or no potential for exacerbation of co-morbid conditions
Rapid onset and offset of action
Minimal hypotension “overshoot”
Minimal need for continuous BP monitoring and frequent dose
titration
No acute tolerance
Ease of use and convenience
Safe and no toxic metabolites
Multiple formulations for short and long term use
Minimal symphathetic activation
Sodium Nitroprusside
MoA:
Direct smooth muscle dilator (art + ven)
Nitric oxide compound
Potent preload and afterload reducer
Causes cerebral vasodilation
Ultra short acting
Immediate onset - DoA : 10min
Dose:
0.1-0.5mcg/kg/min IV infusion
titrate to desired effect
rates>10mcg/kg/min – cyanide toxicity
Adverse affects/Precautions:
Cyanide and thiocyanate toxicity (pts with liver/renal
dysfunction)
Can cause precipitous drop in BP (hypotensive effects
unpredictable)
Ideally Art.line with continuous BP monitoring
Causes significant reflex tachycardia ( incr Oxygen demand)
(angina/aortic dissection/cerebral oedema)
Nausea and vomiting
Increased ICP
Drug of choice:
Perioperative HPT
Cocaine toxicity
Aortic dissection(combination)
Neurologic syndromes
Nitroglycerin
MoA:
Potent vasodilator (nitric oxide compound)
Primary affects the venous system, decrease preload
Decreases coronary vasospasm
Dose: cont infusion
start 5mcg/min, incr by 5mcg/min
every 3-5min to 20mcg/min
If NO Response
increase by 10mcg/min every 3-5min,up
200mcg/min
Onset : 2-5min/DoA : 5-10min
Adverse effects/precautions:
Constant monitoring is essential
Tolerance from uninterrupted use (12hr withdrawal)
Headache, tachycardia, flushing
Contra ind:
Concurrent use with PDE-5 inhibitors - causes significant
hypotension
Head trauma/cerebral haemorrhage
Severe anaemia
Drug of choice:
Acute HF
ACS
Nicardipine
Ca channel blocker – selective arterial vasodilator
Onset: 1-5min
DoA: 15-30min
Dose: start 5mg/hr IV infusion, titrate every 15min to max 15mg/hr.
Advantages:
Cause cerebral and coronary vasodilatation
Precautions: can worsen/cause HF
liver failure
can exacerbate renal insuff.
Ideal for CNS emergencies
Fenoldapam
MoA:
Peripheral dopamine agonist
(high vs low doses)
causes selective neuro
vasodilatation
mesenteric vasodilatation
increases renal blood flow and
sodium excretion
Onset – <5min, but more gentle,
lasts for 30min (titratable, predictable
and stable)
Standard BP monitoring is sufficient,
no toxic metabolites
Dosing:
Start at 0.1-0.3mcg/kg/min IV
infusion
May be increased in
increments of 0.05-
0.1mcg/kg/min every 15min,
until target BP reached
Precautions:
Pts with glaucoma or intraocular
hypertension
Dose related tachycardia can
occur – angina
Close BP monitoring
Close K monitoring
Caution with raised ICP
Drug of choice
Renal insuffiency
Strokes ( combination with
nicardipine)
Hydralazine
MoA:
Decreases systemic resistance by direct vasodilation of
arterioles
Dose:
5-20mg IV bolus or 10-40mg IM repeat every 4-6hrs
“old school”
used too much
boluses takes 20min to work
not titratable
Adverse effects/Precautions
tachycardia, flushing, headache
sodium and water retention
increased ICP
adjust dose in severe renal dysfunction
response may be delayed and unpredictable
Still drug of choice in pregnancy(Eclampsia), but B-blocker/Labetalol
Enalaprilat
The active component of Enalapril (hydrolyzed in liver and kidney)
MoA:
ACE inhibitor
Dose:
0.625-2.5mg every 6hr IV
Not titratable
Onset – within 30 min + long half life
Adverse effects/Precautions
Contra-indicated – volume depletion, renal vascular disease
Prolonged ½ life
Labetalol
MoA:
selective alpha blocker – will reduce vascular smooth m. resistance
non-selective Beta blocker – decrease cardiac inotropic and
myocardial O2 consumption, will prevent reflex tachycardia
Dose:
Bolus: effect in 5-10min,max effect at 20min. (DoA: 2-6hrs)
1st dose 20mg then every 10-20min
2nd dose 40mg, 3rd dose 80mg.
Cont. infusion: 0.5 – 2mg/min – titrate to response,max 300mg total
dose
Difficult to titrate due to very wide dose range
Advantages:
smooth onset
Transition to oral Rx easy (dose equivalent)
Improve cerebral blood flow – stroke pt
No need for ICU/Arterial line
Adverse effects/precautions
Relative CI – Heart failure, heart block, Asthma (bronchoconstriction)
Vomiting, scalp tingling
Impaired hepatic function
Elderly patients
Contraindicated in HPT secondary to Cocaine
use/Phaeochromocytoma
(B-blocker effect outway the alpha effect, thus unapposed alpha
constriction)
Drug of choice:
Aortic dissection
Hypertensive emergencies
Esmolol
MoA:
highly selective beta
blocker
Dose: (titratable)
bolus: 250-500mcg/kg IV
over 1-3min
infusion: 50-
100mcg/kg/min
may repeat bolus after
5min or increase
infusion rate to
300mcg/kg/min
Onset 1-2min / short acting
Adverse effect/Precautions
Hypotension common
nausea
Asthma
1st degree AV block
heart failure
Contraindications
Sinus bradycardia
Heart block
Cardiogenic shock
Bronchial asthma
Uncompensated CF
Pregnancy
Drug of choice:
Aortic dissection ( with
nitrate)
Phentolamine
MoA:
alpha adrenergic
receptor blocker
Dose:
load 5-20mg IV every
5min or
infusion 0.2-0.5mg/min
Onset 1-2min
Adverse
effect/precautions
tachycardia
flushing/headache
MI
cerebrovascular spasm
Contra-indications
renal impairment
Concurrent use with PDE-5 inhibito
coronary or cerebral arterioscleros
Drug of choice
Cocaine associated HPT crisis
Pheochromocytoma HPT crisis
Neurological
emergencies
Hypertensive encephalopathy
reduce MAP by 25% or diastole to 100mmHg
over 8 hrs
Drug of choice:
Sodium nitroprusside
Labetalol
Neurological
emergencies
Acute Ischemic stroke
often loss of cerebral auto-regulation
ischemic region more prone to hypoperfusion
thus BP reduction not recommended
unless SBP>220 or DBP>120
UNLESS planning fibrinolysis – SBP<185 & DBP< 110
Drug of choice:
Labetalol
Nicardipine
Sodium Nitroprusside
Neurological
emergencies
Acute ICH/SAH
Treatment based on clinical/radiographic evidence of raised ICP
Raised ICP – MAP<130 (1st 24hrs)
No raised ICP – MAP<110
Drug of choice:
Sodium Nitroprusside
Labetalol
Nicardipine
Cardiovascular
emergencies
ACS
treat if SBP>160 and/or DBP>100
Reduce MAP by 20 -30% of baseline
nitrates should be given till symptoms subside or until
DBP<100
Drug of choice:
Nitroglycerine
Labetalol
Nicardipine
CVS emergencies
Acute HF (pulmonary edema)
treat with vasodilator (additional to diuretics)
Sodium Nitroprusside in conjunction with morphine,
oxygen and loop diuretic
Enalaprilat also an option
CVS emergencies
Aortic dissection
anti-hypertensive Rx is aimed at reducing the shear
stress on aortic wall (BP and Pulse)
immediate lowering of BP – lifesaving
maintain SBP<110, unless signs of end organ
hypoperfusion
preferred Rx is combination of Morphine, B-blocker and
vasodilator
Nitroprusside + Labetalol
Other disorders
Cocaine toxicity/pheochromocytoma
Hpt and tachycardia rarely require specific Rx
Alpha adrenergic blockers – preferred
B – blockers can be added, but only after alpha
blockade.
Drug of choice
Phentolamine
Labetalol
Diazepam
Other disorders
Pre-eclampsia/Eclampsia
Goal SBP<160 and DBP<110 in pre-and- intrapartum
periods.
Platelets < 100 000, BP should be maintained < 150/100
IV Magnesium to prevent seizures
Drug of choice:
Methyldopa
Hydralazine
Other disorders
Perioperative hypertension
target BP to within 20% of baseline, except if potential for
life threatening arterial bleeding
typically related to catecholamine surge post-op.
Drug of choice :
B-blocker
Labetalol
THANKYOU

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HYPERTENSION EMERGENCY & URGENCY

  • 1. HYPERTENSIVE EMERGENCY & URGENCY DR.ABHINAV KUMAR MEDICINE RESIDENT M.S RAMAIAH MEDICAL COLLEGE
  • 2. HYPERTENSIVE EMERGENCY BP elevation is associated with ongoing neurological, myocardial, hematological or renal TARGET ORGAN DISEASE (TOD) HYPERTENSIVE URGENCY - potential for TOD is great & likely to occur if BP is not controlled. - occurs on chronic stable complication
  • 3. ACCELERATED HYPERTENSION keith wagener barker retinopathy grade 3 (constriction,sclerosis+hemorrhages,exudates) - may be urgency or emergency
  • 4.
  • 5.
  • 6.
  • 7. MANIFESTATIONS OF TARGET ORGAN DISEASE LARGE VESSELS Aneurysmal dilations , atherosclerosis Aortic dissection CARDIAC Acute - pulm edema , MI Chronic - LVH , CAD CEREBROVASCULAR Intracerebral bleed, TIA, seizures, mental status change, stroke RENAL Hematuria, azotemia, Cr>1.5, proteinuria
  • 8. INITIAL EVALUATION Cardinal points in history- - TOD symptoms (most imp) - prior Htn - Medical Renal Disease - medicine with compliance - cocaine, amphetamine -Usually occurs on background of essential hypertn. Imp secondary causes- renovascular(fibromuscular dysplasia/atheresclerosis) -chronic GN/reflux nephropathy/analgesic nephropathy
  • 9. SYMPTOMS OF HYPERTENSIVE CRISIS  MC is - headache (usually worse in morning) - visual (scotoma, diplopia, hemianopia, blindness) - neuro (focal deficits, stroke, TIA, somnolence) - ischemic chest pain - renal (polyuria, nocturia, hematuria) - back pain (aortic aneurysm) - nausea ,vomiting - wt loss.
  • 10. Threshold BP There is no specific BP where hypertensive emergencies occur But, organ dysfunction is rare with diastolic BPs < 130 mm Hg Rate of increase may be more important Hence, encephalopathy will occur at lower BPs in pregnancy and in children
  • 11. Initial Evaluation Focused history History of hypertension? How well is hypertension controlled? What antihypertensives? Adherence to antihypertensive regimen? Last dose of antihypertensive?
  • 12. Initial Evaluation Social History Recreational Drugs Amphetamines Cocaine Phencyclidine
  • 13. Initial Evaluation Confirm BP in both arms Use appropriate sized BP cuff Cuff that is too small Falsely elevate BP measurements in obese patients
  • 14. Initial Evaluation Assess for end-organ damage Vascular Disease Assess pulses in all extremities Auscultate over renal arteries for bruits Cardiopulmonary Listen for rales Murmurs or gallops
  • 15. Initial Evaluation Neurologic Exam Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures Lateralizing signs uncommon and suggest cerebrovascular accident Retinal Exam Lost art Keith-Wagener-Barker Classification
  • 16. Keith-Wagener-Barker Classification Grade 1 Mild narrowing of the arterioles “Copper Wire” Grade 2 Moderate narrowing - Copper wire and AV nicking Changes associated with long standing essential hypertension
  • 19.
  • 20. Keith-Wagener-Barker Classification Grade 3 Severe Narrowing - Silver wire changes, hemorrhage, cotton wool spots, hard exudates Grade 4 Grade 3 + Papilledema Grade 3 and 4 highly correlated with progression to end organ damage and decreased survival
  • 21. Grade 3 KWB Retinopathy
  • 22.
  • 23. Lab Testing ECG LVH, look for signs of ischemia, injury, infarct Renal Function Tests (urine included) Elevated BUN, Creatinine, proteinuria, hematuria CBC CXR - pulmonary edema, aortic arch, cardiac enlargement
  • 24. Lab Testing Aortic Dissection? Suspect with severe tearing chest pain, unequal pulses, widened mediastinum Contrast Chest CT Scan or MRI Pulmonary Edema/CHF Transthoracic Echocardiogram
  • 25. Management ED considerations - Many HPT pts – only small number will require emergent treatment - Primary goal of EP? The pts – syptoms of EOD and require immediate iv parenteral therapy. VS The pt with acutely elev BP(SBP>200 or DBP>120) without EOD symptoms, who require initiation of medical therapy and close follow up as outpatient /inpatient Remember - “treat the patient and not the number”
  • 26. Treatment ED Care - general principles 1. Consider context of elevated BP (pain, anxiety) 2. Screen for EOD (Hx/workup) - Pts without evidence of EOD – d/c + f/up - Pts with EOD – require ICU admission and rapid but gradual lowering of BP - using IV meds.
  • 27. BP should not be lowered to normal levels - Rapid reduction in BP – below the autoregulatory range results in reduction in organ blood flow – risk of ischemia and infarction - General rule – the MAP should be lowered by no more than 20% - 1st hour remains stable - BP lowered to 160/110 in next 2-6hrs - BP goals best achieved by a continuous infusion of a short- acting, titratable, - parenteral anti-HPT agent, along with constant intensive patient monitoring
  • 28. Date of download: 3/24/2015 Copyright © 2015 American Medical Association. All rights reserved. Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With Hypertension
  • 29. Date of download: 3/24/2015 Copyright © 2015 American Medical Association. All rights reserved. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
  • 30.
  • 31. Treatment Medication options 1. Oral antihypertensives • Chronic hypertensive • Hypertensive urgency 2. IV antihypertensives • Hypertensive emergency
  • 32. Pharmacology – IV anti- HPT 1. Vasodilators • Sodium nitroprusside • Nitroglycerin • Nicardipine • Fenoldapam • Hydralazine • Enalapril 2. Adrenergic inhibitors • Labetalol • Esmolol • Phentolamine
  • 33. “IDEAL IV ANTI- HYPERTENSIVE” Lower the BP without compromising blood flow to critical organs Vasodilators generally considered 1st , because they preserve organ blood flow in the face of reduced perfusion and also tend to increase CO.
  • 34. Profile of an ideal IV antihypertensive Preserves GFR and renal blood flow Few or no drug reactions Little or no potential for exacerbation of co-morbid conditions Rapid onset and offset of action Minimal hypotension “overshoot” Minimal need for continuous BP monitoring and frequent dose titration No acute tolerance Ease of use and convenience Safe and no toxic metabolites Multiple formulations for short and long term use Minimal symphathetic activation
  • 35. Sodium Nitroprusside MoA: Direct smooth muscle dilator (art + ven) Nitric oxide compound Potent preload and afterload reducer Causes cerebral vasodilation Ultra short acting Immediate onset - DoA : 10min Dose: 0.1-0.5mcg/kg/min IV infusion titrate to desired effect rates>10mcg/kg/min – cyanide toxicity
  • 36. Adverse affects/Precautions: Cyanide and thiocyanate toxicity (pts with liver/renal dysfunction) Can cause precipitous drop in BP (hypotensive effects unpredictable) Ideally Art.line with continuous BP monitoring Causes significant reflex tachycardia ( incr Oxygen demand) (angina/aortic dissection/cerebral oedema) Nausea and vomiting Increased ICP Drug of choice: Perioperative HPT Cocaine toxicity Aortic dissection(combination) Neurologic syndromes
  • 37. Nitroglycerin MoA: Potent vasodilator (nitric oxide compound) Primary affects the venous system, decrease preload Decreases coronary vasospasm Dose: cont infusion start 5mcg/min, incr by 5mcg/min every 3-5min to 20mcg/min If NO Response increase by 10mcg/min every 3-5min,up 200mcg/min Onset : 2-5min/DoA : 5-10min
  • 38. Adverse effects/precautions: Constant monitoring is essential Tolerance from uninterrupted use (12hr withdrawal) Headache, tachycardia, flushing Contra ind: Concurrent use with PDE-5 inhibitors - causes significant hypotension Head trauma/cerebral haemorrhage Severe anaemia Drug of choice: Acute HF ACS
  • 39. Nicardipine Ca channel blocker – selective arterial vasodilator Onset: 1-5min DoA: 15-30min Dose: start 5mg/hr IV infusion, titrate every 15min to max 15mg/hr. Advantages: Cause cerebral and coronary vasodilatation Precautions: can worsen/cause HF liver failure can exacerbate renal insuff. Ideal for CNS emergencies
  • 40. Fenoldapam MoA: Peripheral dopamine agonist (high vs low doses) causes selective neuro vasodilatation mesenteric vasodilatation increases renal blood flow and sodium excretion Onset – <5min, but more gentle, lasts for 30min (titratable, predictable and stable) Standard BP monitoring is sufficient, no toxic metabolites Dosing: Start at 0.1-0.3mcg/kg/min IV infusion May be increased in increments of 0.05- 0.1mcg/kg/min every 15min, until target BP reached Precautions: Pts with glaucoma or intraocular hypertension Dose related tachycardia can occur – angina Close BP monitoring Close K monitoring Caution with raised ICP Drug of choice Renal insuffiency Strokes ( combination with nicardipine)
  • 41. Hydralazine MoA: Decreases systemic resistance by direct vasodilation of arterioles Dose: 5-20mg IV bolus or 10-40mg IM repeat every 4-6hrs “old school” used too much boluses takes 20min to work not titratable Adverse effects/Precautions tachycardia, flushing, headache sodium and water retention increased ICP adjust dose in severe renal dysfunction response may be delayed and unpredictable Still drug of choice in pregnancy(Eclampsia), but B-blocker/Labetalol
  • 42. Enalaprilat The active component of Enalapril (hydrolyzed in liver and kidney) MoA: ACE inhibitor Dose: 0.625-2.5mg every 6hr IV Not titratable Onset – within 30 min + long half life Adverse effects/Precautions Contra-indicated – volume depletion, renal vascular disease Prolonged ½ life
  • 43. Labetalol MoA: selective alpha blocker – will reduce vascular smooth m. resistance non-selective Beta blocker – decrease cardiac inotropic and myocardial O2 consumption, will prevent reflex tachycardia Dose: Bolus: effect in 5-10min,max effect at 20min. (DoA: 2-6hrs) 1st dose 20mg then every 10-20min 2nd dose 40mg, 3rd dose 80mg. Cont. infusion: 0.5 – 2mg/min – titrate to response,max 300mg total dose Difficult to titrate due to very wide dose range Advantages: smooth onset Transition to oral Rx easy (dose equivalent) Improve cerebral blood flow – stroke pt No need for ICU/Arterial line
  • 44. Adverse effects/precautions Relative CI – Heart failure, heart block, Asthma (bronchoconstriction) Vomiting, scalp tingling Impaired hepatic function Elderly patients Contraindicated in HPT secondary to Cocaine use/Phaeochromocytoma (B-blocker effect outway the alpha effect, thus unapposed alpha constriction) Drug of choice: Aortic dissection Hypertensive emergencies
  • 45. Esmolol MoA: highly selective beta blocker Dose: (titratable) bolus: 250-500mcg/kg IV over 1-3min infusion: 50- 100mcg/kg/min may repeat bolus after 5min or increase infusion rate to 300mcg/kg/min Onset 1-2min / short acting Adverse effect/Precautions Hypotension common nausea Asthma 1st degree AV block heart failure Contraindications Sinus bradycardia Heart block Cardiogenic shock Bronchial asthma Uncompensated CF Pregnancy Drug of choice: Aortic dissection ( with nitrate)
  • 46. Phentolamine MoA: alpha adrenergic receptor blocker Dose: load 5-20mg IV every 5min or infusion 0.2-0.5mg/min Onset 1-2min Adverse effect/precautions tachycardia flushing/headache MI cerebrovascular spasm Contra-indications renal impairment Concurrent use with PDE-5 inhibito coronary or cerebral arterioscleros Drug of choice Cocaine associated HPT crisis Pheochromocytoma HPT crisis
  • 47. Neurological emergencies Hypertensive encephalopathy reduce MAP by 25% or diastole to 100mmHg over 8 hrs Drug of choice: Sodium nitroprusside Labetalol
  • 48. Neurological emergencies Acute Ischemic stroke often loss of cerebral auto-regulation ischemic region more prone to hypoperfusion thus BP reduction not recommended unless SBP>220 or DBP>120 UNLESS planning fibrinolysis – SBP<185 & DBP< 110 Drug of choice: Labetalol Nicardipine Sodium Nitroprusside
  • 49. Neurological emergencies Acute ICH/SAH Treatment based on clinical/radiographic evidence of raised ICP Raised ICP – MAP<130 (1st 24hrs) No raised ICP – MAP<110 Drug of choice: Sodium Nitroprusside Labetalol Nicardipine
  • 50. Cardiovascular emergencies ACS treat if SBP>160 and/or DBP>100 Reduce MAP by 20 -30% of baseline nitrates should be given till symptoms subside or until DBP<100 Drug of choice: Nitroglycerine Labetalol Nicardipine
  • 51. CVS emergencies Acute HF (pulmonary edema) treat with vasodilator (additional to diuretics) Sodium Nitroprusside in conjunction with morphine, oxygen and loop diuretic Enalaprilat also an option
  • 52. CVS emergencies Aortic dissection anti-hypertensive Rx is aimed at reducing the shear stress on aortic wall (BP and Pulse) immediate lowering of BP – lifesaving maintain SBP<110, unless signs of end organ hypoperfusion preferred Rx is combination of Morphine, B-blocker and vasodilator Nitroprusside + Labetalol
  • 53. Other disorders Cocaine toxicity/pheochromocytoma Hpt and tachycardia rarely require specific Rx Alpha adrenergic blockers – preferred B – blockers can be added, but only after alpha blockade. Drug of choice Phentolamine Labetalol Diazepam
  • 54. Other disorders Pre-eclampsia/Eclampsia Goal SBP<160 and DBP<110 in pre-and- intrapartum periods. Platelets < 100 000, BP should be maintained < 150/100 IV Magnesium to prevent seizures Drug of choice: Methyldopa Hydralazine
  • 55. Other disorders Perioperative hypertension target BP to within 20% of baseline, except if potential for life threatening arterial bleeding typically related to catecholamine surge post-op. Drug of choice : B-blocker Labetalol