2. Dr Nahed Sherbini ,Consultant Internist ,Head of Internal Medicine Department
2010 KFH, Medina

3.  ED
 Medical & Surgical Wards
 MICU
 SICU
 OR
Varon J, Fromm RE. Postgrad Med. 1996;99:189-203.

4.  Hypertensive Emergencies
 Hypertensive Urgencies
 An Approach to Drug Treatment of HU and HE

6.  Affects at least 1 BILLION individuals
worldwide.
 Most current (2003) evidence basis for
chronic management— (JNC 7)—lacks
guidance for acute management of patients
presenting with severe acute elevations of BP.
JNC 7, JAMA 2003; 289:2560-2572.

7.  Data are largely lacking.
 In a single-center Italian study, HU or HE
 HU:HE ratio of 3:1 in that study
Zampaglione et al, Hypertension 1996;27:144.

8.  Hypertensive emergencies and urgencies
 Account for 3% of all ED visits1
 An “Internal Medicine” ED
 N=14,209
 1634 had a medical urgency or emergency2
▪ 27.4% of these were hypertensive crises
1. Kitiyakara C, Guzman N. J Am Soc Nephrol. 1998;9:133-142.
2. Zampaglione B, et al. Hypertension. 1996;27:144-147.

10. JNC7
BP Classification SBP mmHg DBP mmHg
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 Hypertension 140–159 or 90–99
Stage 2 Hypertension >160 or >100

11.  Stage 3 hypertension (JNC 6):
 Systolic > 180, Diastolic > 110
 Functionally, this is “hypertensive urgency”
 What about “crisis,” “emergency,” and
“urgency”?
JNC 7, JAMA 2003; 289:2560-2572.

12.  “hypertensive crisis” is an acute, severe, stage
2 or 3 elevation BP.
 Crisis is then differentiated into hypertensive
“emergencies” &“urgencies”.
JNC 7, JAMA 2003; 289:2560-2572.

13. Hypertensive Severe elevation in BP
emergency (>180/120 mmHg) Hypertensive Crisis
complicated by evidence of
impending or progressive
target organ dysfunction
Hypertensive Hypertensive Perioperative
Hypertensive Severe elevation in BP urgency emergency hypertension
urgency without progressive
target organ dysfunction
Emergency Intensive care Operating room
department unit post-anesthesia
care
Chobanian AV et al. Hypertension. 2003;42:1206-1252.

14. Brain
Hypertensive encephalopathy Retina
Stroke Hemorrhages
Exudates
Papilledema
Cardiovascular System
Unstable angina
Acute heart failure
Acute myocardial infarction Kidney
Acute aortic dissection Hematuria
Dissecting aortic aneurysm Proteinuria
Decreasing renal function
Adapted from Varon J, Marik PE. Chest. 2000;118:214-227.

15.  Essential hypertension
 Medication noncompliance
 Secondary hypertension
 Aortic coarctation
 Cushing’s syndrome
 Elevated ICP
 Renal dysfunction
 Pregnancy
 Hyperparathyroidism
 Hyperthyroidism
 Pheochromocytoma
 Primary aldosteronism
JNC 7, JAMA 2003; 289:2560-2572.

16.  Medical ● Surgical
– Cardiac surgery
 Uncontrolled HTN
– Major vascular surgery
▪ Noncompliance
- Carotid endarterectomy
 Drug-induced HTN
- Aortic surgery
▪ Cocaine,
– Neurosurgery
amphetamines
– Head and neck surgery
▪ Drug withdrawal
– Renal transplantation
▪ Drug-drug interactions
– Major trauma – burns or head
 Endocrine disorders injury
Varon J, Fromm RE. Postgrad Med. 1996;99:189-203.

17. • Oral contraceptives
• Steroids
• NSAIDs
• Nasal decongestants
• Appetite suppressants

18.  Hypertensive  Hypertensive
Urgencies Emergencies
 Chest pain
 Arrhythmia  Dyspnea
 Epistaxis  Neurologic deficits
 Headache
 Psychomotor agitation  Usual Primary ED
Diagnosis
 CVA
 Acute pulmonary edema
 Usual Primary ED  Hypertensive
Diagnosis encephalopathy
 Hypertension  Acute heart failure
Zampaglione et al, Hypertension 1996;27:144.

19. Four Categories of Presentation
1. Mild, uncomplicated
2. Transient
3. Emergencies
4. Urgencies

20.  Mild, Uncomplicated HTN
 Diastolic BP <115 mmHg without end organ
symptoms
 Educate, do not treat, arrange follow up
 Transient HTN
 A reaction to some condition
▪ Pain, fright, epistaxis,
drug OD
 Treat the condition

22. Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%

24.  Goal in hypertensive urgency is to reduce
MAP (MAP= ( 2 Diastolic + systolic) / 3) by
10-15% and/or to a DBP of 110 . . . within
hours.
 HU can generally be managed with oral
medications and requires BP lowering over
24-48 h.
JNC 7, JAMA 2003; 289:2560-2572.

25. Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling With Compelling
Indications Indications
Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling
(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications
Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs
May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB)
or combination. ACEI, or ARB, or BB, or CCB) as needed.
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.

26. Compelling Indication Initial Therapy Options Clinical Trial Basis
ACC/AHA Heart Failure
Heart failure THIAZ, BB, ACEI, ARB, Guideline, MERIT-HF,
ALDO ANT COERNICUS, RALES
Post MI ACC/AHA Post-MI
BB, ACEI, ALDO ANT Guideline, BHAT,
SAVE, Capricorn,
ALLHAT, HOPE,
ANBP2, LIFE,
High CAD risk THIAZ, BB, ACE, CCB CONVINCE

27. Compelling Indication Initial Therapy Options Clinical Trial Basis
Diabetes THIAZ, BB, ACE, ARB, C NKF-ADA
CB Guideline, UKPDS, AL
LHAT
Chronic kidney disease ACEI, ARB
NKF Guideline,
Captopril Trial,
RENAAL, IDNT, REIN,
AASK
Recurrent stroke THIAZ, ACEI
prevention PROGRESS

28.  Reduce MAP by ≤ 25% during the 1st minutes
to 1 h.
 If stable, reduce BP to 160/100-110 mmHg in
next 2-6 h.
 Conditions requiring special management
 Aortic dissection
 Stroke eligible for thrombolytic agents
 Ischemic stroke
Chobanian AV et al. Hypertension. 2003;42:1206-1252.

29. Patients with chronic hypertension
Cerebral Blood Flow autoregulate cerebral blood flow
around higher set points
Patients with cerebral ischemia
Increasing risk of lose their ability to autoregulate
hypertensive Ischemia
encephalopathy Normotensive
Chronic hypertensive
Increasing risk
of ischemia
0 50 100 150 200 250
MAP (mm Hg)
Adapted with permission from Varon J, Marik PE. Chest. 2000;118:214-227.

30. NORMAL AUTOREGULATION AUTOREGULATION FAILURE
RISE IN BP RISE IN BP
ARTERIAL AND FAILURE OF
ARTERIOLAR VASOCONSTRICTION
CONSTRICTION
Normal flow.(flow=P/r) ENDOTHELIAL DAMAGE
(due to shear stress on the wall)

31.  Patients with marked BP elevations and acute
target-organ damage
 Admitted to an ICU for continuous monitoring of BP.
 Should receive parenteral antihypertensive therapy with
an agent appropriate for the individual patient.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure. US Dept of HHS; NIH publication No. 04-5230; 2004:54.

32. Ref : CHEST 2007 ; 131 : 1949-1962 : Hypertensive crises : challenges and management

33. Ref : CHEST 2007 ; 131 : 1949-1962 : Hypertensive crises : challenges and management

34. 47-Year-Old
Complains Of Chest Pain
BP 162/110

35.  NTG
 Relieves only chest pain
 No mortality difference in 77,000 patients
 -blockers
 Antiplatelets: ASA, clopidogrel
 Anticoagulants: LMWH, UFH
 GP IIb/IIIa antagonist or DTI w/clopidogrel
2007 AHA/ACC Guidelines

36. Drug Nitroprusside Nitroglycerin
Rapid onset of peak effect ++++ +++
Afterload reduction ++++ +
Preload reduction ++ ++++
Coronary steal reported + 0
Coronary dilation – large vessel + ++++
Coronary dilation – small vessel +/- +/-
Tachycardia ++ ++
Potential for symptomatic hypotension ++ +++
Ease of administration ++ +++
Cyanide toxicity ++++ 0
Pepine CJ. Clin Ther. 1988;10:316-325.

38.  Must decrease shear forces
 Do not use inotropics
 Esmolol
 Labetolol
Tintinalli, 4th ed.

39. Esmolol Labetalol
-Blocker - and -Blocker
Administration Bolus Bolus
Continuous infusion Continuous infusion
Onset Rapid (60 s)2 Intermediate (peak 5-15 min)2
Offset (Duration of action) Rapid (10-20 min)2 Slower (2-4 h)2
HR Decreased +/-
SVR 0 Decreased
Cardiac output Decreased +/-
Myocardial O2 balance Positive Positive
Contraindications Sinus bradycardia Severe bradycardia
Heart block >1° Heart block >1°
Overt heart failure Overt heart failure
Cardiogenic shock Cardiogenic shock
1. Hoffman BB. In: Hardman JG, Limbird LE, eds. Goodman and Gilman’s Pharmacological Basis of
Therapeutics. 10th ed. New York, NY: McGraw-Hill; 1997:215-268.
2. Varon J, Malik PE. Chest. 2000;118:214-227.

40. Nicardipine Diltiazem Verapamil
(dihydropyridine) (benzothiazepine) (phenylalkylamine)
Peripheral
Vasodilation1
+++++ +++ +++
Coronary
Vasodilation2
+++++ +++ ++++
Suppression
of SA Node2 + +++++ +++++
Suppression
of AV Node2 0 ++++ +++++
Suppression
of Cardiac 0 ++ ++++
Contractility2
Frishman WH, et al. Med Clin North Am. 1988;72:523-547. .1
Adapted from Goodman and Gilman’s: The Pharmacologic Basis of Therapeutics. 9th ed. 2001. .2

41. All Patients Treated with Drug
1,400,000
1,200,444
1,200,000 1,133,717
2004 2005 2006
1,000,000
800,000 735,647
600,000
502,518
400,000
312,432
240,785
200,000 139,104
8,288
0
Nitroglycerin Labetalol Hydralazine Enalaprilat Esmolol SNP Nicardipine Fenoldopam
Thomson Patient Level Data. 2006

42.  HTN is extremely prevalent &
hypertensive crises will become
increasingly common in the ED.

43. So, What is new?

44. http://www.nhlbi.nih.gov/guidelines/hypertension/jnc8/index.htm

45.  The Eighth Report of the Joint National
Committee on
Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 8)
 Update of the JNC 7 Report
 Expected Availability for Public Review and
Comment: Spring 2011
 Expected Release Date: Fall 2011

46. Thank you for your attention