1. COLLAGE OF PHARMACY
SUBJECT :- PHARMACOTHERAPEUTICS -1
SESSION :- 2020 - 21
SUBMITTED BY :-
ABHISHEK PANDEY
PHARM-D 2nd Yr
2. INDEX
Topic Pg.
INTRODUCTION-------------------------03
ETIOLOGY ---------------------------------05
EPIDEMIOLOGY-------------------------07
PATHOPHYSIOLOGY------------------08
HISTORY AND PHYSICAL-------------10
EVALUATION ------------------------------12
TREATMENT/MANAGEMENT-------14
DIFFERENTIAL DIAGNOSIS---------16
PEARLS AND OTHER ISSUES--------17
ENHANCING HEALTHCARE
TEAM OUTCOMES----------------------19
3. HYPERTENSIVE URGENCY
Introduction
Hypertensive urgency is a marked elevation in
blood pressure without evidence of target organ
damage, such as pulmonary edema, cardiac
ischemia, neurologic deficits, or acute renal
failure.
Specific cutoffs have been proposed, such as
systolic blood pressure greater than 180 or
diastolic blood pressure greater than 110 , but
these are arbitrarily derived numbers that have
not been associated with short-term morbidity or
mortality.
4. Given this, some have proposed reserving the term
hypertensive urgency for patients with severely
elevated blood pressure and significant risk
factors for progressive end-organ damage such as
congestive heart failure or chronic kidney disease.
However, hypertensive urgencies are associated
with a higher incidence of adverse cardiovascular
events over the long term and warrant a nuanced
approach focused on ensuring better blood
pressure control, reducing catalysts for marked
elevations of blood pressure, and reliably
following up with primary care.
5. Etiology
The etiology of acute elevations is variable.
Noncompliance with antihypertensive therapy,
use of sympathomimetics, and thyroid
dysfunction are among the many possible causes
of hypertensive urgencies. Even anxiety and pain
may cause acute elevations in blood pressure and
require a different treatment strategy Falsely
elevated blood pressure due to poor equipment or
technique is another potential etiology of
elevated blood pressure readings that should be
evaluated and remedied.
6. NOTE
Pseudohypertension, a falsely elevated blood
pressure reading due to sclerotic or calcified
arteries that do not collapse during inflation of a
blood pressure cuff, is another possible cause of
elevated blood pressure readings.
Pseudohypertension should be considered in
patients presenting without symptoms suggestive
of end-organ dysfunction but with markedly
elevated blood pressure despite seemingly
aggressive management.
7. Epidemiology
About 30% of American adults have hypertension.
Of those, about 1% to 2% will have a hypertensive
crisis, a term that encompasses both hypertensive
urgencies and emergencies. Studies on the
epidemiology of acute hypertensive crises are
limited, possibly due to difficulties in parsing out
when a patient's symptoms are related to their
blood pressure versus some other cause.
Obesity, female gender, history of cardiovascular
disease, diabetes, smoking, and most importantly,
noncompliance with antihypertensive
medications are some of the risk factors
associated with acutely elevated blood pressure.
8. Pathophysiology
The pathophysiology of hypertension is
complicated and not fully understood. At ba
seline, perfusion of cardiac, renal, and brain
tissue is tightly autoregulated by varying
mechanisms. With chronic hypertension, the
cerebral perfusion curve shifts to the right,
accommodating a higher baseline blood
pressure while maintaining a steady cerebral
perfusion pressure.
9. The rapidity of blood pressure elevation is
presumed to be an important factor in causing
end-organ damage. Severe acute elevations are
likely related to an influx of humoral
vasoconstrictors, resulting in elevated systemic
vascular resistance.
The increased vascular wall stress and associated
endothelial injury results in increased vascular
permeability, activation of coagulation factors
and platelets, and fibrin deposition. Continued
endothelial injury and fibrinoid necrosis result in
ischemia, which then leads to further release of
vasoactive mediators and further injury.
10. History and Physical
The history and physical exam for patients with
markedly elevated blood pressure should focus on
determining whether or not the patient has signs
of target organ damage. Symptoms warranting
further evaluation include a headache, dizziness,
shortness of breath, chest pain, vomiting, or
changes in vision.
The physical exam starts with an accurate blood
pressure reading, with a properly-sized cuff placed
on a bare upper arm. If a properly-sized cuff is not
available due to large arm circumference, wrist
measurement may be the most accurate but
should be interpreted with some caution due to
lack of data compared to invasive measurements.
11. Other physical exam signs should be carefully
evaluated. Signs of heart failure such as elevated
jugular venous distention, rales on lung
auscultation, or a gallop on heart auscultation
indicate that the patient may be actively
experiencing a hypertensive emergency rather
than urgency.
A detailed neurologic exam including cerebellar
testing is also important to rule out central
nervous system impairment. Finally, fundoscopy
showing papilledema may be a significant finding
mandating more aggressive therapy.
12. Evaluation
No routine evaluation for hypertensive urgencies
exists. The goal is to rule out target organ
damage. If the history and physical suggest that
this may be present, lab testing or imaging such
as metabolic panels, urinalysis,
electrocardiogram, chest X-ray, and brain
computed tomography may be useful.
Patients at high risk for rapidly evolving target
organ damage warrant particular caution, such
as those with chronic congestive heart failure,
chronic kidney disease, coronary artery disease,
or history of stroke.
13. Pregnant patients with elevated blood pressure
also require extra caution. In these patients,
especially in the absence of preexisting
hypertension, preeclampsia can ensue at blood
pressure levels much lower than commonly seen
in hypertensive emergencies.
In the absence of a history of hypertension,
especially if the patient complains of potentially
worrisome symptoms such as a headache, vision
changes, or abdominal pain, lab testing should be
obtained, including complete blood count,
hepatic function panel, and lactic dehydrogenase.
14. Treatment / Management
The treatment for hypertensive urgency is to ensure
better long-term blood pressure control. Emphasizing
the need for compliance with medications and close
primary care follow up is paramount.
Patients without symptoms or signs of target organ
damage have not been shown to benefit from
aggressive antihypertensive therapy in the acute
setting.
Rapid lowering of blood pressure in these patients
offers no benefit and carries the theoretical risk of
causing relative hypotension and end-organ
hypoperfusion, especially in those individuals who
have longstanding severely elevated blood pressure.
15. If it remains elevated and no treatable secondary
causes are found, the treating hospitalist should
consider altering his chronic antihypertensive
regimen to promote long-term blood pressure
control.
Medication classes such as
calcium channel blockers (sublingual eg, nifedipine in
particular),
beta-blockers (eg, labetolol)
ACE (angiotensin-converting-enzyme inhibitors ) (eg, captopril),
clonidine,
have all been implicated in treatment-related adverse
events.
16.
17. Treating patients with hypertensive urgency is
based on an assumption:
If one does not treat immediately, something bad
(ie, end-organ damage) will occur over the next
few hours.
Although patients with hypertensive urgency are
often treated with medications to acutely lower
their blood pressure, there is no evidence to
support this practice, and a strong
pathophysiologic basis suggests that harm may
result.
The patient in the case described above should be
allowed to rest for at least 30 minutes, with
reevaluation of his blood pressure.
19. Pearls and Other Issues
Hypertensive urgency is an acute, severe elevation
in blood pressure without signs or symptoms of
end-organ damage.
Proposed blood pressure levels indicating
hypertensive urgency are arbitrary and not
associated with short-term morbidity and
mortality.
Focus on symptoms of end-organ damage in the
patient's history, including chest pain, shortness
of breath, headache, neurologic deficits, and
vision changes.
20. Caution is advised in pregnant patients with
hypertension. Preeclampsia can ensue at lower
blood pressure levels than expected in other
hypertensive emergencies.
Treat the patient, not the number. Rapidly
bringing down blood pressure in a patient without
end-organ damage may result in relative
hypoperfusion and harm the patient rather than
help.
21. Enhancing Healthcare Team
Outcomes
Patients with hypertensive urgency are best
managed by an interprofessional team that
includes a cardiologist, internist, nephrologist,
specialty cardiac nurse and an ophthalmologist.
The key is to educate the patient on medication
compliance.
Patients without symptoms or signs of target
organ damage have not been shown to benefit
from aggressive antihypertensive therapy in the
acute setting.
22. Rapid lowering of blood pressure in these patients
offers no benefit and carries the theoretical risk
of causing relative hypotension and end-organ
hypoperfusion, especially in those individuals who
have longstanding severely elevated blood
pressure.
However, it may be beneficial to start these
patients on oral antihypertensives with the goal
of lowering the blood pressure slowly over 24 to 48
hours.
The primary care providers and nurse practitioner
should educate the patient on the importance of a
healthy lifestyle that includes discontinuing
smoking, maintaining a healthy body weight, and
regular exercise.
23. 1 Frei SP, Burmeister DB, Coil JF. Frequency of serious
outcomes in patients with hypertension as a chief
complaint in the emergency department. J Am Osteopath
Assoc. 2013 Sep;113(9):664-8. [PubMed]
2.Levy PD, Mahn JJ, Miller J, Shelby A, Brody A, Davidson
R, Burla MJ, Marinica A, Carroll J, Purakal J, Flack JM,
Welch RD. Blood pressure treatment and outcomes in
hypertensive patients without acute target organ damage: a
retrospective cohort. Am J Emerg Med. 2015 Sep;33(9):1219-
24. [PubMed]
3.Vlcek M, Bur A, Woisetschläger C, Herkner H, Laggner
AN, Hirschl MM. Association between hypertensive
urgencies and subsequent cardiovascular events in patients
with hypertension. J. Hypertens. 2008 Apr;26(4):657-62.
[PubMed]
References
24. 4.Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill
MN, Jones DW, Kurtz T, Sheps SG, Roccella EJ.,
Subcommittee of Professional and Public Education of the
American Heart Association Council on High Blood
Pressure Research. Recommendations for blood pressure
measurement in humans and experimental animals: Part 1:
blood pressure measurement in humans: a statement for
professionals from the Subcommittee of Professional and
Public Education of the American Heart Association
Council on High Blood Pressure Research. Hypertension.
2005 Jan;45(1):142-61. [PubMed]
5.Irving G, Holden J, Stevens R, McManus RJ. Which cuff
should I use? Indirect blood pressure measurement for the
diagnosis of hypertension in patients with obesity: a
diagnostic accuracy review. BMJ Open. 2016 Nov
03;6(11):e012429. [PMC free article] [PubMed]
25. 6.Kleman M, Dhanyamraju S, DiFilippo W. Prevalence and
characteristics of pseudohypertension in patients with
"resistant hypertension". J Am Soc Hypertens. 2013 Nov-
Dec;7(6):467-70. [PubMed]
7.Hajjar I, Kotchen TA. Trends in prevalence, awareness,
treatment, and control of hypertension in the United
States, 1988-2000. JAMA. 2003 Jul 09;290(2):199-206.
[PubMed]
8.Saguner AM, Dür S, Perrig M, Schiemann U, Stuck AE,
Bürgi U, Erne P, Schoenenberger AW. Risk factors
promoting hypertensive crises: evidence from a
longitudinal study. Am. J. Hypertens. 2010 Jul;23(7):775-80.
[PubMed]
9.Kessler CS, Joudeh Y. Evaluation and treatment of severe
asymptomatic hypertension. Am Fam Physician. 2010 Feb
15;81(4):470-6. [PubMed]
26. 10. Marik PE, Varon J. Hypertensive crises: challenges
and management. Chest. 2007 Jun;131(6):1949-62.
[PubMed]
11. Wolf SJ, Lo B, Shih RD, Smith MD, Fesmire FM.,
American College of Emergency Physicians Clinical
Policies Committee. Clinical policy: critical issues in
the evaluation and management of adult patients in
the emergency department with asymptomatic
elevated blood pressure. Ann Emerg Med. 2013
Jul;62(1):59-68. [PubMed]
27. 12. Williams B, Mancia G, Spiering W, Agabiti Rosei E,
Azizi M, Burnier M, Clement D, Coca A, De Simone G,
Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L,
Zanchetti A, Kerins M, Kjeldsen S, Kreutz R, Laurent S, Lip
GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder
R, Shlyakhto E, Tsioufis K, Aboyans V, Desormais I., List of
authors/Task Force members: 2018 Practice Guidelines for
the management of arterial hypertension of the European
Society of Hypertension and the European Society of
Cardiology: ESH/ESC Task Force for the Management of
Arterial Hypertension. J. Hypertens. 2018 Dec;36(12):2284-
2309. [PubMed]
28. 13. Chobanian AV, Bakris GL, Black HR, Cushman
WC, Green LA, Izzo JL, Jones DW, Materson BJ, Oparil
S, Wright JT, Roccella EJ., Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. National Heart, Lung, and Blood
Institute. National High Blood Pressure Education
Program Coordinating Committee. Seventh report of
the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood
Pressure. Hypertension. 2003 Dec;42(6):1206-52.
