Hypertensive Crises


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Hypertensive Crises

  2. 2. HYPERTENSION BP of 140/90 recorded on at least two separate occasions CLASSIFICATION SBP mm Hg DBP mm Hg Normal < 120 and < 80 Prehypertension 120-139 or 80-89 Stage 1 HPN 140-159 or 90-99 Stage 2 HPN ≥ 160 or ≥ 100
  3. 3. Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Lifestyle Modifications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Stage 2 Hypertension (SBP > 160 or DBP > 100 m mHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140 –159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
  4. 4. Classification and Management of BP for adults *Treatment determined by highest BP category. † Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡ Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. BP classification SBP* mmHg DBP* mmHg Lifestyle modification Initial drug therapy Without compelling indication With compelling indications Normal <120 and <80 Encourage Prehypertension 120–139 or 80–89 Yes No antihypertensive drug indicated. Drug(s) for compelling indications. ‡ Stage 1 Hypertension 140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications. ‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension > 160 or > 100 Yes Two-drug combination for most † (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).
  6. 7. HYPERTENSIVE EMERGENCY <ul><li>associated with acute end-organ damage </li></ul><ul><li>requires immediate treatment with a titratable short-acting IV antihypertensive agent </li></ul><ul><li>BP lowered immediately </li></ul>
  7. 8. HYPERTENSIVE URGENCY <ul><li>severe hypertension without end-organ damage </li></ul><ul><li>usually treated with oral antihypertensive agents </li></ul><ul><li>BP should be lowered within 24 to 48 hours </li></ul>
  9. 10. END ORGAN DAMAGE IN HYPERTENSIVE EMERGENCY ORGAN SYSTEM CONDITION Central Nervous System Hypertensive encephalopathy Stroke Renal Acute renal failure Cardiopulmonary Acute congestive heart failure Acute coronary syndrome Acute myocardial infarction Acute pulmonary edema with respiratory failure Dissecting aortic aneurysm Ophthalmologic Exudates Papilledema Retinal hemorrhages
  10. 11. INITIAL EVALUATION - HISTORY <ul><li>Hypertensive history </li></ul><ul><ul><li>Previous control </li></ul></ul><ul><ul><li>Antihypertensive medications with dosing </li></ul></ul><ul><ul><li>Adherence with medication regimen </li></ul></ul><ul><ul><li>Time from last dose </li></ul></ul><ul><li>Use of prohibited drugs or other medications </li></ul>
  11. 12. INITIAL EVALUATION – PHYSICAL EXAMINATION <ul><li>Identify evidence of end-organ damage </li></ul><ul><ul><li>Palpation of pulses in all extremities </li></ul></ul><ul><ul><li>Ausculation for renal bruits </li></ul></ul><ul><li>Focused neurologic and funduscopic examination </li></ul>
  12. 13. LABORATORY EXAMINATIONS <ul><li>Complete blood count </li></ul><ul><li>Creatinine, BUN </li></ul><ul><li>Potassium </li></ul><ul><li>12-L ECG </li></ul><ul><li>Urinalysis </li></ul><ul><li>Chest X-ray </li></ul><ul><li>Cranial CT Scan </li></ul>
  13. 14. GOALS OF THERAPY <ul><li>Hypertensive urgency </li></ul><ul><ul><li>Lower blood pressure gradually over 24 to 48 hours with oral medications </li></ul></ul><ul><li>Hypertensive Emergency </li></ul><ul><ul><li>lower BP immediately but in a controlled manner, so as not to fall off the autoregulatory curve and risk ischemia and additional end-organ damage. </li></ul></ul>
  14. 15. MANAGEMENT OF HYPERTENSIVE EMERGENCY <ul><li>Reduce DBP by 10 to 15% or to ~ 110 mm Hg over a period of 30 to 60 minutes </li></ul><ul><li>In patients with aortic dissection, BP should be reduced rapidly, targeting a SBP of < 120 mm Hg and mean arterial pressure (MAP) < 80 mmg Hg </li></ul><ul><li>Resting MAP should not be reduced more than 25% within 60 mins </li></ul><ul><li>Once stable, reduce BP to 160-100 to 110 mmg Hg within the next 2 to 6 hours </li></ul>
  16. 17. RECOMMENDED ANTIHYPERTENSIVE AGENTS FOR HYPERTENSIVE CRISES Condition Preferred Antihypertensive Agent Acute Pulmonary Edema/Systolic Dysfunction Nicardipine, Fenoldopam, Nitroprusside in combination with nitroglycerin and loop diuretic Acute Pulmonary Edema/Diastolic Dysfunction Esmolol, Metoprolol, Labetalol or Verapamil, in combination with low-dose nitroglycerin and loop diuretic Acute Myocardial Ischemia Labetalol, Esmolol in combination with nitroglycerin Hypertensive Encephalopathy Nicardipine, Labetalol, Fenoldopam
  17. 18. RECOMMENDED ANTIHYPERTENSIVE AGENTS FOR HYPERTENSIVE CRISES Condition Preferred Antihypertensive Agent Acute Aortic Dissection Labetalol or combination of Nicardipine and Esmolol; combination of Nitroprusside with either esmolol or IV metoprolol Pre-Eclampsia, Eclampsia Labetalol or Nicardipine Acute Renal Failure/ Microangiopathic Anemia Nicardipine, Fenoldopam Sympathetic Crisis Verapamil, Diltiazem, Nicardipine in combination with Benzodiazepine
  18. 19. RECOMMENDED ANTIHYPERTENSIVE AGENTS FOR HYPERTENSIVE CRISES Condition Preferred Antihypertensive Agent Acute Ischemic Stroke/ Hypertensive Bleed Nicardipine, Labetalol, Fenoldepam
  19. 20. NICARDIPINE <ul><li>Dose: 5-15 mg/hr IV </li></ul><ul><ul><li>Increase by 2.5 mg/hr every 5 mins to a maximum of 15 mg/hr </li></ul></ul><ul><li>Onset of Action: 5-10 minutes </li></ul><ul><li>Duration of Action: 15 -30 min, may exceed 4 hours </li></ul><ul><li>Special Indications: Most hypertensive emergencies except acute heart failure, caution with coronary ischemia </li></ul><ul><li>Adverse Effects: tachycardia, headache, flushing, local phlebitis </li></ul>
  20. 21. NITROGLYCERIN <ul><li>Potent venodilator, affects arterial tone only at high doses </li></ul><ul><li>Causes hypotension, reflex tachycardia </li></ul><ul><li>Dose: 5-100 μ g/min as IV infusion </li></ul><ul><ul><li>Increase by 5 μ g/min every 5 to 10 mins </li></ul></ul><ul><li>Onset of Action: 2-5 mins </li></ul><ul><li>Duration of Action: 5-10 mins </li></ul><ul><li>Special Indications: Coronary ischemia </li></ul><ul><li>Adverse Effects: Headache, vomiting, methemoglobinemia, tolerance with prolonged use </li></ul>
  21. 22. HYDRALAZINE <ul><li>Dose: 10-20 mg IV; 10-40 mg IM </li></ul><ul><li>Onset of Action: 10-20 mins IV; 20-30 mins IM </li></ul><ul><li>Duration of Action: 1-4 hrs IV; 4-6 hrs IM </li></ul><ul><ul><li>Fall in BP can last up to 12 hours </li></ul></ul><ul><ul><li>Half-life of 3 hours, half-time of effect on BP is ~ 10 hours </li></ul></ul><ul><li>Special Indications: Eclampsia </li></ul><ul><li>Adverse Effects: Tachycardia, vomiting, flushing, headache, aggravation of angina </li></ul>
  22. 23. VASODILATORS <ul><li>Sodium nitroprusside </li></ul><ul><li>Fenoldopam </li></ul><ul><li>Enalaprilat </li></ul>
  23. 24. ADRENERGIC INHIBITORS <ul><li>Labetalol </li></ul><ul><li>Esmolol </li></ul><ul><li>Phentolamine </li></ul>
  24. 25. NIFEDIPINE <ul><li>Poorly soluble, not absorbed through the oral mucosa </li></ul><ul><li>Rapidly absorbed from the GI tract </li></ul><ul><li>Onset of Action: 5-10 mins </li></ul><ul><ul><li>Peak effect from 30 to 60 mins </li></ul></ul><ul><li>Duration of Action: 6-8 hrs </li></ul><ul><li>BUT sudden uncontrolled and severe reductions in BP may precipitate cerebral, renal and myocardial ischemic events </li></ul>
  25. 26. CAPTOPRIL <ul><li>Dose: 25 mg PO/SL </li></ul><ul><li>Onset of Action: 15-30 mins (PO), 10-20 mins (SL) </li></ul><ul><li>Duration of Action: 6-8 hr (PO), 2-6 hrs (SL) </li></ul><ul><li>Precautions: Hypotension, Renal Failure, Bilateral Renal Artery Stenosis </li></ul>
  26. 27. CLONIDINE <ul><li>Dose: 75-150 mcg PO </li></ul><ul><li>Onset: 30-60 mins </li></ul><ul><li>Duration of Action: 8-16 hrs </li></ul><ul><li>Precautions: Hypotension, drowsiness, dry mouth </li></ul>
  27. 28. AMLODIPINE <ul><li>Dose: 2.5-5 mg PO </li></ul><ul><li>Onset of Action: 1-2 hr </li></ul><ul><li>Duration of Action: 12-18 hr </li></ul><ul><li>Precautions: Tachycardia, hypotension </li></ul>