management of hypertensive urgency and emergency

1. Hypertensive urgencies and
emergencies
Dr G.Venkata ramana
HOD family medicine
RDT hospital Bathalapalli

2. Hypertensive urgency/severe
asymptomatic HTN
• systolic pressure ≥180 mmHg and/or
• diastolic pressure ≥120 mmHg
• without acute end organ injury

3. Hypertensive emergency
• systolic pressure ≥180 mmHg and/or
• diastolic pressure ≥120 mmHg
• with acute end organ injury
• develop in patients with or without known
pre existing HTN

4. Malignant hypertension
• entered the medical lexicon in 1928
• because, at that time, patients with this
condition had a prognosis that was similar
to patients with many cancers

5. Hypertensive emergencies
• Neurologic emergencies
• Cardiac emergencies
• Vascular emergencies
• Renal emergencies
• Sympathetic over activity resulting HTN
emergencies
• HTN emergencies during pregnancy

6. Approach to therapy
• For most hypertensive emergencies,MAP
should be reduced gradually by approx 10-
20% in the first hour and by a further 5-15%
over the next 23 hours
• Target BP of <180/<120 for the first hour and
<160/<110mmhg for the next 23 hrs

7. Neurologic emergencies
• Ischemic stroke
• Hemorrhagic stroke
• Head trauma
• Hypertensive encephalopathy

8. Ischemic stroke
• BP not lowered unless it is ≥185/110
mmHg in patients who are candidates for
reperfusion therapy
• or ≥220/120 mmHg in patients who are not
candidates for reperfusion (thrombolytic)
therapy

9. Ischemic stroke
cautious lowering of BP by approximately 15
percent during the first 24 hours after stroke
onset is suggested
BP should be stabilized and maintained at or
below 180/105 mmHg for at least 24 hours
after thrombolytic treatment

10. Ischemic stroke
Drugs:IV
1.Labetalol
2.Nicardipine
3.Clevidipine

11. Hemorrhagic stroke
• systolic blood pressure (SBP) between
150 and 220 mmHg, lowering of SBP to a
target of 140 mmHg, ideally within the first
one hour of presentation, provided the
patient remains clinically stable

12. Hemorrhagic stroke
• SBP >220 mmHg, rapid lowering of SBP
to <220 mmHg.
• Thereafter, the blood pressure is gradually
reduced (over a period of hours) to a
target range of 140 to 160 mmHg,
provided the patient remains clinically
stable.

13. Hemorrhagic stoke
• DRUGS:IV
• Labetalol
• Nicardipine
• Clevidipine
• Esmolol
• Enalaprilat
• Fenoldopam

14. Head trauma
• Hypertension is usually treated in this
setting only if the cerebral perfusion
pressure (mean arterial pressure minus
intracranial pressure) is >120 mmHg and
the intracranial pressure is >20 mmHg.

15. Hypertensive encephalopathy
• signs and symptoms of hypertensive
encephalopathy (eg, headache, confusion,
nausea, vomiting) usually abate after the
blood pressure is lowered
• diagnosis of exclusion
• blood pressure lowered by approximately
10 to 20 percent during the first hour of
treatment.

16. • pressure is reduced by no more than 25
percent at the end of the first day of
treatment.
• DRUGS:IV
• Clevidipine
• Nicardipine
• Fenoldopam
• Nitroprusside.

17. Cardiac emergencies
• Acute heart failure
• Acute coronary syndrome

18. Acute heart failure
• Loop diuretics
• Vasodilator(eg,sodium nitroprusside,
nitroglycerin) to reduce afterload
• Drugs that increase cardiac work
(eg, hydralazine) or acutely decrease cardiac
contractility (eg, labetalol or other beta
blocker) should be avoided

19. Acute coronary syndrome
• DRUGS:IV
• Nitroglycerin
• Clevidipine
• Nicardipine
• Intravenous metoprolol or esmolol (to
reduce myocardial oxygen consumption,
reduce the underlying coronary ischemia,
and improve prognosis)

20. Acute aortic dissection
• goal systolic of 100 to 120 mmHg within
approximately 20 minutes of diagnosis
• An intravenous beta blocker is given first
(usually esmolol, but labetalol, propranolol,
and metoprolol can also be used) to reduce the
heart rate below 60 beats per minute and the shear
stress on the aortic wall .
• In addition, a vasodilator (often nitroprusside
or clevidipine) is typically required to quickly achieve
the goal blood pressure.

21. Severe hypertension in patients with
recent vascular surgery
• Severe elevations of blood pressure can
threaten suture lines, and therefore, such
patients are often treated with rapidly
acting intravenous antihypertensive agents
in an intensive care unit setting.

22. Renal emergencies
• Severe hypertension may occasionally
cause acute injury to the kidneys (acute
hypertensive nephrosclerosis, formerly
called "malignant nephrosclerosis").
• This condition is characterized by
hematuria (usually microscopic hematuria,
which is found in approximately 75 percent
of patients with hypertensive emergencies)
and an elevated serum creatinine.

23. • fenoldopam is associated with a
temporary improvement in kidney function
and is therefore a useful antihypertensive
agent in patients with renal hypertensive
emergencies

24. Withdrawal of short-acting
antihypertensive agents
• especially clonidine, propranolol, or other
beta blockers can be associated with
severe hypertension and may mimic the
signs and symptoms of
pheochromocytoma.
• Typically, reinstitution of the recently
discontinued drug will lower the blood
pressure.

25. • Oral clonidine will begin to lower blood pressure
within an hour; however, some beta blockers take
much longer to lower the blood pressure and,
therefore, short-acting intravenous medications
are often required while waiting for the reinstituted
beta blocker to achieve an effect

26. Ingestion of
sympathomimetic agents
• eg, tyramine-containing foods in patients
who take chronic monoamine oxidase
inhibitors , amphetamine-like compounds,
cocaine, etc can precipitate severe
hypertension and end-organ damage.
• DRUGS:IV
• phentolamine
• Nitroprusside.

27. Severe autonomic dysfunction
• eg, Guillain-Barré and multiple system
atrophy syndromes or acute spinal cord injury
is occasionally associated with hypertensive
emergency.
• DRUGS:IV
• Phentolamine
• Nitroprusside
• Labetalol

28. • Unless a beta blocker was recently
withdrawn, administration of a beta blocker
alone is contraindicated in these settings
since inhibition of beta receptor-induced
vasodilation can result in unopposed
alpha-adrenergic vasoconstriction and a
further rise in blood pressure

29. Hypertensive emergencies
during pregnancy
• Hydralazine and labetalol have been
widely used in pregnant people with
severe hypertension, which is usually due
to preeclampsia or exacerbation of
preexistent hypertension.
• Fenoldopam and nicardipine have also
been used.

30. EVALUATION AND DIAGNOSIS
• History:Acute head injury or trauma
• Generalized neurologic symptoms, such
as agitation, delirium, stupor, seizures, or
visual disturbances
• Focal neurologic symptoms that could be
due to an ischemic or hemorrhagic stroke

31. • Fresh flame hemorrhages, exudates
(cotton-wool spots), or papilledema when
direct funduscopy is performed, as these
are consistent with grade III or IV
hypertensive retinopathy and can rarely be
associated with hypertensive
encephalopathy
• Nausea and vomiting, which may be a
sign of increased intracranial pressure

32. • Chest discomfort or pain, which may be
due to myocardial ischemia or aortic
dissection
• Acute, severe back pain, which might be
due to aortic dissection
• Dyspnea, which may be due to pulmonary
edema

33. • Use of drugs that can produce a
hyperadrenergic state, such as cocaine,
amphetamine(s), phencyclidine, or
monoamine oxidase inhibitors, or recent
discontinuation of clonidine or, less
commonly, other antihypertensive agents
• Pregnancy, as such patients with severe
hypertension could have preeclampsia or
develop eclampsia

34. Investigations
• Electrocardiography
• Conventional chest radiography
• Urinalysis, urine pregnancy test (if
appropriate)
• Serum electrolytes and serum creatinine
• Cardiac biomarkers (if an acute coronary
syndrome is suspected)

35. • Computed tomography (CT) or magnetic
resonance imaging (MRI) of the brain (if
head injury, neurologic symptoms,
hypertensive retinopathy, nausea, or
vomiting are present)
• CT OR MRI Angiography or
transesophageal echocardiography (if
aortic dissection is suspected

36. DRUGS
ADRENERGIC BLOCKING AGENTS
Labetalol is a combined beta-adrenergic
and alpha-adrenergic blocker. rapid onset of
action (five minutes or less)
• Labetalol is safe in patients with active
coronary disease since it does not
increase heart rate.
• avoided in patients with asthma, chronic
obstructive lung disease, heart failure,
bradycardia, or greater than first-degree
heart block.
..

37. • labetalol should not be used without prior
adequate alpha blockade in patients with
hyperadrenergic states, such as
pheochromocytoma or cocaine or
methamphetamine overdose, since
unopposed, inadequately blocked alpha-
adrenergic activity can increase blood
pressure if beta blockade is not complete

38. Labetalol can be given as intravenous bolus
injections or as a constant-dose infusion.
• The bolus dose is 20 mg initially, followed
by 20 to 80 mg every 10 minutes to a total
dose of 300 mg.
• The infusion rate is 0.5 to 2 mg/min.
Higher total doses and higher infusion
rates are used, particularly in patients who
are overweight or who have obesity

39. ADRENERGIC BLOCKING AGENTS
• Esmolol, a cardioselective beta blocker, is
rapidly metabolized by blood esterases.
• Its effects begin immediately, and it has
both a short half-life (approx 9 minutes)
and a short total duration of action (approx
30 minutes), permitting rapid titration.
• Esmolol is often used during anesthesia to
prevent postintubation hemodynamic
perturbations

40. Nitrates
• Sodium nitroprusside , begins to act
within one minute or less, and once
discontinued, its effects disappear within
10 minutes or less.
• Frequent monitoring is required since this
drug can produce a sudden and drastic
drop in blood pressure

41. • The recommended starting dose
of nitroprusside is 0.25 to 0.5 mcg/kg per
minute.
• This can be increased as necessary to a
maximum dose of 8 to 10 mcg/kg per minute,
although use of these higher doses should
generally be avoided or limited to a maximum
duration of 10 minutes .

42. • Toxicities:Nitroprusside is metabolized to
cyanide, possibly leading to the
development of cyanide (or, rarely,
thiocyanate) toxicity that may be fatal .
• This problem, which can manifest in as
little as four hours, presents with altered
mental status and lactic acidosis.

43. • Risk factors for nitroprusside-induced
cyanide poisoning include a prolonged
treatment period (>24 to 48 hours),
underlying kidney function impairment,
and the use of doses that exceed the
capacity of the body to detoxify cyanide
(ie, more than 2 mcg/kg per minute).

44. • The risk of toxicity can be minimized by using the
lowest possible dose, avoiding prolonged use (ie,
no more than two or three days), and by careful
patient monitoring (with special attention to
unexplained acidemia or decreasing serum
bicarbonate concentrations).
• doses of 10 mcg/kg per minute should never be
given for more than 10 minutes.
• An infusion of sodium thiosulfate can be used in
affected patients to provide a sulfur donor to
detoxify cyanide into thiocyanate

45. • can result in dose-related declines in
coronary, kidney, and cerebral perfusion.
• Nitroprusside should not be given to
pregnant women, patients with Leber optic
atrophy, or patients with tobacco
amblyopia.should be avoided, if possible,
in patients with impaired kidney function.
• The high cost of nitroprusside may limit its
availability in some setting

46. Nitrates
• Nitroglycerin similar in action and
pharmacokinetics to nitroprusside except
that it produces relatively greater
venodilation than arteriolar dilation.
• useful in patients with symptomatic
coronary disease and in those with
hypertension following coronary bypass.
Prolonged infusions are generally avoided
to prevent tachyphylaxis.

47. • The initial dose of nitroglycerin is 5
mcg/min, which can be increased as
necessary to a maximum of 100 mcg/min.
The onset of action is 2 to 5 minutes, while
the duration of action is 5 to 10 minutes.

48. • Headache (due to direct vasodilation) and
tachycardia (resulting from reflex
sympathetic activation) are the primary
adverse effects.
• Cyanide accumulation does not occur.
• Methemoglobinemia has been reported in
patients receiving this agent for more than
24 hours

49. Clevidipine
• Clevidipine ultra-short-acting
dihydropyridine calcium channel blocker that
is approved for intravenous use to treat
severe hypertension.
• The drug is hydrolyzed by serum esterases
and has a serum elimination half-life of 5 to
15 minutes.
• It reduces blood pressure without affecting
cardiac filling pressures but can cause reflex
tachycardia
• ..

50. • Clevidipine is contraindicated in patients
with severe aortic stenosis (because it
increases the risk of severe hypotension),
disordered lipid metabolism (because it is
administered in a lipid-laden emulsion), or
known allergies to soy or eggs (because
these are used to produce the emulsion).

51. • The initial dose is 1 mg/hour, which can be
increased as necessary to a maximum of
21 mg/hour

52. Nicardipine
• Nicardipine dihydropyridine calcium
channel blocker (like nifedipine) that can
be given as an intravenous infusion.
• The initial dose is 5 mg/hour and can be
increased to a maximum of 15 mg/hour.
• The major limitations are a longer onset of
action, which precludes rapid titration, and
a longer serum elimination half-life (three
to six hours).

53. Dopamine-1 agonist
• Fenoldopam is a peripheral dopamine-1
receptor agonist , maintains or increases
kidney perfusion while it lowers blood pressure
.
• Fenoldopam may be particularly beneficial in
patients with kidney function impairment.
• starting at 0.1 mcg/kg per minute, the dose
can be titrated at 15-minute intervals to 1.6
mcg/kg per minute, depending upon the blood
pressure response. Some experts have used
doses as high as 2.0 mcg/kg per minute or
higher without inducing toxicity.

54. Fenoldopam
• Fenoldopam should be used cautiously or
not at all in patients with glaucoma
• In addition, because this agent is
premixed in a solution containing sodium
metabisulfite, caution is recommended for
patients with sulfite sensitivity

55. Hydralazine
• is a direct arteriolar vasodilator with little or no
effect on the venous circulation.
• precautions are needed in patients with
underlying coronary disease or aortic dissection,
and a beta blocker should be given concurrently to
minimize reflex sympathetic stimulation.
• Hydralazine can be given as an intravenous
bolus. The initial dose is 10 mg, with the maximum
dose being 20 mg. The fall in blood pressure can
be sudden and begins within 10 to 30 minutes and
lasts two to four hours.

56. Enalaprilat
• Intravenously active, des-ethyl ester of the
angiotensin-converting enzyme (ACE)
inhibitor, enalapril
• The hypotensive response to enalaprilat is
unpredictable and depends upon the plasma
volume and plasma renin activity in individual
patients with a hypertensive emergency
• Typically, hypovolemic patients with a high
plasma renin activity are most likely to have
an excessive hypotensive response.

57. • contraindicated in pregnancy, severe
renal artery stenosis with kidney ischemia,
and severe hyperkalemia
• The usual initial dose is 1.25 mg. As much
as 5 mg may be given every six hrs .
• The onset of action begins in 15 min, but
the peak effect may not be seen for four
hours. The duration of action ranges from
12 to 24 hours.

58. Phentolamine
• Nonselective alpha-adrenergic blocker,
the use of which is limited to the treatment
of severe hypertension due to increased
catecholamine activity.
• Examples include pheochromocytoma or
tyramine ingestion in a patient being
treated with a monoamine oxidase
inhibitor.

59. • Phentolamine is given as an intravenous
bolus.
• The usual dose is 5 to 15 mg every 5 to 15
minutes as necessary.
• Patients receiving this agent who do not
require intravenous therapy can be
converted to oral phenoxybenzamine

60. HYPERTENSIVE URGENCY
• Initial goal blood pressure –
• Lowering the BP over a period of hour to days
• Lowering the blood pressure to <160/<100 mmHg or
to a level that is no more than 25 to 30 percent lower
than the baseline blood pressure.
• The short-term blood pressure target may need to be
above 160/100 mmHg in patients who present with
very high pressures
• cerebral or myocardial ischemia or infarction, or acute
kidney injury, can be induced by rapid and aggressive
antihypertensive therapy if the blood pressure falls
below the range at which tissue perfusion can be
maintained by autoregulation.

61. HYPERTENSIVE URGENCY
• Therapeutic options
• Rest in quiet room
• This may produce a fall in blood pressure ≥20/10 mmHg
in approximately one-third of adults.
• If this is not effective, antihypertensive drugs may be
given.
• oral clonidine (but should not be maintained as long-
term therapy) or oral captopril(if the patient is not volume
overloaded).
• sublingual nifedipine is contraindicated in this setting
and should not be used.

62. HYPERTENSIVE URGENCY
• Treatment is resumption of
antihypertensive therapy (in nonadherent
patients), initiation of antihypertensive
therapy (if patients are treatment naïve), or
the addition of another antihypertensive
drug (in patients who are currently
treated).