During my junior year. One of the topics need to remember by heart.

1. CME HYPERTENSION
Sharifah Sy.,Aisyah, NurSyahidah, Alia,Diven.
09/12/19

2. CONTENTS
 CASE PRESENTATION
 MANAGEMENT OF HYPERTENSIVE URGENCY
 MANAGEMENT OF HYPERTENSIVE EMERGENCY

3. CASE
 Mr G, 67 years old male, non smoker, ADL independent
 U/L:
 1. Hypertension since last 5 years
 Defaulted medications and follow up since last 2 years
 Gastritis
 p/w
 -blurring of vision x 1/52
 Sudden onset, on and off, lasted few seconds
 No eye pain, no eye injury,no eye discharge
 2-3 times per day

4.  Further hx;
 Slurring of speech last 2/12
 Improved, minimal slurring of speech remained
 o/w;
 No LOC, no headache, no fever
 No limb weakness
 No URTI, no GI symptoms, no chest pain, no abdominal pain

5.  o/e
 Minimal slurred speech, no facial asymmetry
 Lungs clear,
 Cvs s1s2 nm
 Abdomen; soft non tender
 Neuro; UL, LL; power full, normotonia,normoreflexia

6. Progress
 Went to KK, BP; 203/120, given t. captopril 12.5mg-- BP; 217/131
 At ED HSNZ, BP; 228/130, given t captopril 12.5mgx 2 BP; 198/139
 PR; 85 bpm, Temp 37, spo2 98 under RA, CBG: 5.2mmol/L
,

7. In the ward
 BP ranged between 141/105 to 220/110
 Initial dx: HTN urgency TRO CVA, then changed to HTN encephalopathy with LACI
 Still had blurring of vision in ward on and off, but less frequent
 CT brain:
 Multifocal recent and old infarct
 Dx: LACI
 Stroke round :
 CT: multifocal infarct at internal capsule and basal ganglia
 Dx: 1. HTN encephalopathy, 2. LACI

8.  Fundoscopy:
 No cataract, bilateral red reflex equal
 Arteriolar narrowing of both eyes
 No silver wiring
 No cotton wool spot
 Meds given for HTN;
 Initially single therapy: t captopril 25mg tds
 Then 2 meds; changed to T perindopril 8mg od, add T amlodipine 10mg od
 Then 3 meds: T. perindopril 8mg od, T felodipine 10mg od, t metoprolol 50mg bd
 Discharge meds
 T aspirin 150mg od
 T amlodipine 10mg od
 T perindopril 8mg od
 T atorvastatin 40mg on

10. Severe hypertension
 persistent elevated SBP >180 mmHg and/or DBP >110 mmHg.
 Hypertensive urgency
 Hypertensive emergency
 Upon review, hx taking and examination to look signs of TOD/ TOC and causes of
secondary HTN
 Commonest causes of severe HTN: long-standing poorly controlled essential HTN
Hypertensive crisis

11. Secondary
causes of HTN

12. Target Organ Complication/ Target Organ Damage
Organ manifestations
Heart • Left Ventricular Hypertrophy
• Coronary Heart Disease
• Heart Failure
Brain • Transient Ischaemic Attack
• Stroke
• Dementia
Peripheral vasculature • Absence of one or more major pulses in extremities (except
dorsalis pedis) with or without intermittent claudication
• Carotid bruit
• Abdominal aortic aneurysm
Kidney • GFR <60 ml/min/1.73m2
• Proteinuria (1+ or greater)
• Microalbuminuria* (2 out of 3 positive tests over a period of
4-6
months)
Retina • Haemorrhages or exudates
• Papilloedema
TOD = Target organ damage (LVH, retinopathy, proteinuria)
TOC = Target organ complication (heart failure, renal failure)

13. Variable Emergencies Urgencies
Symptoms Yes No / Minimal
Acute target organ
damage/complication
Yes No
BP reduction rate Minutes to hours Hours to days
Evaluation for secondary
hypertension
Yes Yes

14. Hypertensive Urgency
 Persistent BP>180/110 + NO target organ damage/complications
 Aim: 25% reduction within 24 hours, but not less than 160/100mmHg
 Rapid reduction (within minutes to hours) in HTN urgency should be avoided as it
precipitates ischemic events
Drug (tablet) Starting dose
(mg)
Onset of
action (hour)
Duration
(hour)
Frequency
(prn)
Captopril 12.5 0.5 6 1-2 hours
Nifedipine 10 0.5 3-5 1-2 hours
Labetalol 200 2 6 4 hours

16. Hypertensive Urgency Discharge Plan
 Blood pressure monitoring
 Home BP monitoring OR check by healthcare provider at least 3 times per week
 If BP >180/110, repeat after 5 minutes; IF second BP higher or same as the first one OR have
symptoms, seek medical help
 Medications
 Take anti-hypertensive as prescribed
 Follow up care
 Adhere to clinic follow up appointment
 When to call 999
 Symptoms such as chest pain, difficulty in breathing or altered mental status occurs

17. Hypertensive Emergency
 Severe elevation if BP (>180/110mmHg) associated with new or progressive end
organ damage ie:
 Acute heart failure, dissecting aneurysm, ACS, hypertensive encephalopathy,
 ARF
 Subarachnoid haemorrhage and/or intracranial haemorrhage
 Pt should be admitted
 Aim reduction by 10%-25% within certain mins to hours but not lower than
160/90mmHg
 Best achieved with parenteral drugs

18. Common HTN
emergencies
presentation and
treatment goals

19. Common HTN emergencies
presentation and treatment
goals

20. Medications used in
HTN emergencies

21. Medications used
in HTN
emergencies

22. Medications
used in HTN
emergencies