This document discusses hypertension and hypertensive emergencies. It begins with an introduction to hypertension, defining it as elevated blood pressure on 3 or more occasions. It notes the high prevalence of hypertension in Malawi.
It then discusses factors that influence the consequences of blood pressure levels, including age, race, glucose levels, and smoking. It also lists potential secondary causes of hypertension like renal disease.
The document goes on to define categories of hypertension from mild to malignant based on blood pressure levels. It distinguishes between hypertensive emergencies, where immediate treatment is needed to prevent end organ damage, hypertensive urgencies with slightly lower blood pressures, and chronic hypertension without symptoms. It provides guidelines for evaluating
2. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 2
Introduction
Hypertension:
The elevation of blood pressure on at least 3 separate
occasions
Asociated w/ high arterial pressure
In malawi, there is a high prevalence of
hypertension in rural and urban areas of malawi, with
low levels of detection, treatment and control.
The need for cost-effective strategies for primary prevention,
detection and treatment of hypertension
The growing public health challenge of non-communicable
diseases in Sub-Saharan Africa.
3. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 3
Introduction
Consequences of the actual blood
pressure will depend:
Measured level
Age / Race / Sex
Glucose intolerance
Cholesterol
Smoking habit
4. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 4
Introduction
Hypertension can be
secondary due to conditions:
Coarctation of the aorta
Renal disease
Endocrine disease
Contraceptive pill.
It is symptomless in the vast
majority of patients
5. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 5
The basics
Mild HTN is considered a diastolic BP of 90-
104mmHg & a systolic BP of 140-159
Moderate HTN is diastolic 105-114 and
systolic of 160-179 mmHg
Severe HTN is diastolic 115 or higher, and
systolic 180-209 mmHg
Malignant HTN demonstrates exudates,
hemorrhages or papilloedema
6. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 6
Key Points
Patients with hypertension can be grouped
into the following categories:
Emergency: Presents with hypertension &
evidence of end organ damage (chest pain,
mental status changes, renal failure, or ocular
findings)
Urgency: Diastolic over 130 and or impending end
organ damage
Chronic: Diastolic under 130 with no specific
symptoms
7. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 7
• Key Points
Diagnosis should not
be based on a single
measurement
If the initial reading
is elevated, it should
be repeated
Wait till the patient
has been resting
quietly on their back
for 5 min. & then
check both arms
8. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 8
• Key Points
When therapy is begun it must continue for
life
Compliance - important determinant of
blood pressure control
Explanation, education & minimizing side
effects are key
10. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 10
Urgent blood pressure reduction may
precipitate stroke or blindness.
Aim of treatment is to bring the diastolic
BP below 90 mmHg w/out unacceptable
side effects
11. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 11
Hypertensive Emergency
Diagnosed not by a specific blood
pressure
Defined as an increased blood pressure
that causes acute end-organ (brain,
heart, kidneys, and eyes) damage
12. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 12
Hypertensive Emergencies
AMI/chest pain
CVA/SAH
Hypertensive
encephalopathy
CHF/Pulmonary
edema
Aortic dissection
13. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 13
Hypertensive Emergencies
Take patients history:
Prior diagnosis of HTN?
Cessation of BP medications?
Cardiovascular/Renal/Cerebrovascular disease
Diabetes
Chronic obstructive pulmonary disease (COPD)
Asthma
14. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 14
Hypertensive Emergencies
Precipitating causes include:
Pregnancy
Illict drug use (e.g. cocaine)
Monoamine oxidase inhibitor or decongestants
15. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 15
Hypertensive Urgencies
Diastolic blood pressure over 115-130 mm
Hg.
Patients may have chronic end organ damage
No evidence of acute, life-threatening
dysfunction
No signs of acute organ dysfunction
↓ The BP over 24-48 hours
Follow-up the next day is recommended.
16. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 16
Acute Hypertensive
Emergency
A systolic BP >180 and DBP > 110
No signs or symptoms
Usually no immediate treatment is
required but the patients should have
follow-up the next day
17. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 17
Transient Hypertension
Normotensive once the precipitating
event is resolved
Examples include:
Pregnancy
Severe anxiety
Alcohol withdrawal
Cocaine/drug use
18. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 18
Clinical Findings
These constitute a
Hypertensive
Emergency:
Papilledema
Retinal exudates
Neurological deficits
Seizures
Meningismus or
encephalopathy
19. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 19
Clinical Findings
Assess for:
Carotid bruits
Heart murmurs
Gallops
Symmetric pulses
Abdominal masses
Pulmonary rales
20. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 20
Diagnosis
Clinical
Don’t wait for lab test to start therapy
Laboratory tests show end organ damage
Electrolytes show kidney damage or
associated electrolyte abnormalities
U/A shows kidney damage
22. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 22
Treatment
Reduce blood pressure rapidly to slightly
above normal level
Don’t reduce blood pressure too quickly in
stroke patients or patients with cerebral
vascular disease
Avoid SL nifedipine to treat HTN urgently
Treat w/ IV medications
23. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 23
Treatment for Specific
Hypertensive Emergencies
Hypertensive encephalopathy
Decrease blood pressure by < 20% in the first
hour
Don’t decrease the BP >30% over the next 48-
72 h
IV Nitroprusside infusion requires blood
pressure checks
24. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 24
Treatment for Specific
Hypertensive Emergencies
CVA, subarachnoid or intra-cerebral
hemorrhage:
If the diastolic BP is persistently >140 mm Hg
then slowly reduced the BP by 20-30% over
12-24 hours
Nitroprusside or labetalol can be use
25. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 25
Treatment for Specific
Hypertensive Emergencies
AMI/Chest pain:
Myocardial infarction is imp
Nitroglycerine SL or preferably IV is the best
drug
Titrate the infusion to reduce the BP to ‘normal’
levels
Beta blockers useful for patients w/ cardiac
ischemia.
26. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 26
Treatment for Specific
Hypertensive Emergencies
CHF/Pulmonary edema
Use a nitroglycerine IV infusion to reduce the
BP to normal
Do not use beta blockers w/ CHF
27. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 27
Treatment for Specific
Hypertensive Emergencies
Chronic Hypertension
Educate patient about the importance of:
Weight loss
Exercise
Salt restriction
Chronic therapy & ongoing care.
28. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 28
Treatment
Chronic Hypertension include:
Drugs
Diuretics
Beta blockers
Calcium channel antagonists
Angiotension-converting enzyme (ACE)
inhibitors
Alpha adrenergic antagonists
29. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 29
Recommended Set up Care
Step One: hydrochlorothiazide (O) 12.5-25 mg
once daily
Step Two: hydrochlorothiazide (O) 25 mg once
daily PLUS
Methyldopa (O) 250 mg two to three times a day
OR
Propranolol (O) 160-320 mg once daily
Step Three: Captopril (O) 12.5-25 mg 3 times
per day
30. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 30
Recommended Hypertensive Medications
Based on Patient Variables
Patient Demographics Diuretic Beta blocker Calcium
channel
blocker
ACE
Inhibitor
Alpha blocker
Elderly ++ +/- + + +
Black Race ++ +/- + + +/-
Patient Medical
Condition
Angina +/- ++ + ++ +
Post AMI + ++ + +/- ++
CHF ++ ? + - ++
CVA + + +/- ++ +
Renal insufficiency ++ +/- + ++ ++
Diabetes - - ++ + ++
Dyslipidemia - - ++ + +
31. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 31
Common Anti-hypertension
Medications
Beta blockers
Atenolol 50mg daily 25 - 100mg
Metoprolol 50mg bid 50 - 450 mg
Propanolol 40mg bid 40 - 240mg
Proponolol LA 80mg daily 60 - 240 mg
Labetalol 100mg bid 200 - 1200 mg
32. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 32
Common Anti-hypertension
Medications
Calcium channel blockers
Diltiazem 5 mg daily 2.5 - 10 mg
Diltiazem SR 60 - 120 mg bid 120 - 360 mg
Diltiazem CD 180 mg bid 180 - 360 mg
Nicardipine 20mg tid 60 - 120 mg
Nicardipine SR 30 mg bid 60 - 120 mg
Nifedipine XL 30 mg daily 30 - 90 mg
Verapamil SR 120 - 140 mg daily 120 - 480 mg
33. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 33
Common Anti-hypertension
Medications
Drug Starting dose Usual dose
Diuretics
Furosemide 20 mg daily 20 - 320 mg
Hydrochlorthiazide 25 mg daily 12.5 - 50 mg
ACE inhibitors
Captopril 25 mg bid 50 - 450 mg
Enalapril 5 mg daily 2.5 - 40 mg
34. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 34
Disposition & Referral
High Blood
Pressure/signs of
end organ damage
Send home
& follow up
Hospitalize
Controlled Blood
Pressure/no signs
of end organ
damage
35. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 35
Case 1
A 48 year old man presents with pitting
edema of the lower extremities which has
slowly developed over the past six months.
He also has chronic(> one year) dyspnea on
exertion which he has attributed to his long-
term cigarette smoking of 1.5 packs per day.
On review of systems, he has vague right
upper quadrant pain of several months'
duration.
36. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 36
Case 1
Dyspneic with moving about the exam room; was
noted to be cyanotic upon arrival to office after
climbing a flight of stairs
Blood Pressure110/60 upright and supine
Pulse100 and regular and Respirations20 at rest
Pursed lip respirations and accessory muscle use
Elevated jugular venous pressure
Apical impulse is not palpable; prominent pulsations
felt in epigastric area. Right ventricular heave present
S3 gallop on auscultation in the epigastric area; I-
II/VI systolic murmur along the left sternal border
which intensifies with inspiration. Loud P2
39. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 39
Case 1
What is the most likely cause of this patient's
illness?
What are the clinical presentations of right
ventricular failure?
What is the most common cause of right
heart failure?
What are other causes of right heart failure?
41. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 41
Case 3
A young man presents with pale, oedematous
face.
He is complaining of headache and dizziness;
is seemed to be a bit confused.
He is speaking slowly and his answers are
simple, short and partly inadequate.
He is saying that he has some visual
disturbances and some slight pressure in his
chest.
42. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 42
Case 3
The relatives are saying that he turned pale and
oedematous several days ago and his condition has
worsened since then.
The present day he has constant nausea and vomited
once.
In the last few hours after an anxious period he
turned somnolent: he did not or hardly reacted and
answered any questions.
He could barely walk and after having been put into
bed by his relatives he fell down from it.
So they decided to bring him to the hospital
43. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 43
Case 3
Have you had fever, shivers or sweating
lately?
Has your urine changed lately?
Has your bowel habit changed lately
(constipation, diarrhoea)?
Have you had some (or more than usual)
alcohol lately?
Have you got any wound on your body?
What have you eaten recently?
Do you feel pain in your back (waist)?
44. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 44
Case 3
The family is showing you a previous medical note about acute
gastro-enteritis. That time his BP was 145/95mmHg.
During a thorough physical examination you are finding pale
skin, periorbital and facial oedema, minimal abdominal
sensitivity and several signs of neurologic abnormalities in
several potential areas referring to different localisation.
These signs are increasing in intensity (but not equally) and
changing their localisation during the prolonged examination.
You are also detecting some uncertain clonus. He’s complaining
of retching without vomiting. His BP is 190/136mmHg,
HR=62/min.
What is your preliminary diagnosis?
45. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 45
Case 3
Would you do some further examination
at the bedside to make a decision about
the need and kind of the therapy?
What acute therapy would be optimal
for the Patient in this situation?
46. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 46
Case 4
A 72 year old black male presents with
chest pain and headache for last two
hours
Vital signs
HR 110
Respiration 14
BP 210/125
Temperature 370C
47. Hypertension
Center for International
Emergency Disaster and Refugee
Studies 47
Case 4
What are some other questions you
want to ask?
What might be some physical exam
findings you may want to look for?
What diagnostic tests would you order?
What is the differential diagnosis?
How would you manage this patient?
What would his disposition be?