Hypertensive crisis

1. Case Based approach to Hypertensive
Crisis and Management
Dr. Prashant Kumar

2. Case Scenario
 Mr. Rahul, 52yr male presents to emergency room with worsening
headache and confusion, numbness and weakness involving right
side of body and blurry vision for the past 12 hrs.
 On examination, pulse is 84/min regular, BP is 230/130mmHg, room
air oxygen saturation 94%, confused & mild motor weakness (4/5)
in the right arm.
2
MCQ following

3. Case Scenario
 He is a known case of hypertension, bilateral renal artery
stenosis & dyslipidemia on irregular treatment.
3

4. MCQ No. 1
Working diagnosis of the patient Mr. Rahul can be best
described as:
1. Secondary hypertension presenting as hypertensive
emergency
2. Secondary hypertension presenting as hypertensive
urgency
3. Primary hypertension presenting as hypertensive
emergency
4. Primary hypertension presenting as hypertensive urgency
4

5. Approach
5
• STEP 2
Assess Target Organ Involvement
STEP 1
Assess the severity of hypertension & urgency of treatment
STEP 2
Assess Target Organ Involvement
STEP 3
Send relevant investigation(s)
STEP 4
Treatment Goals
STEP 5
Which Drug (s) to Use
STEP 6
Drugs for Specific Situation

6. STEP 1
Assess the severity of hypertension &
urgency of treatment
6

7. Assess the severity of hypertension &
urgency of treatment
Definition:
Prehypertension:
Systolic Blood Pressure120–139 mmHg and
Diastolic Blood Pressure 80–89 mmHg
Hypertension:
Stage 1: 140- 159 mmHg/ 90-99 mmHg
Stage 2: > 160 mmHg/ > 100 mmHg
Hypertensive crisis: Hypertensive urgency or emergency
(Generally > 180/ 110 mmHg)
7
The JNC 8 (2013) Hypertension Guidelines

8. Assess the severity of hypertension &
rapidity of treatment needed
Hypertensive urgency:
Acute rise in blood pressure without acute end-organ damage;
diastolic blood pressure usually >120 mm Hg
Hypertensive emergency:
Acute rise in blood pressure with acute end-organ damage; diastolic
blood pressure usually > 120 mm Hg
8

9. Accelerated hypertension:
Markedly elevated blood pressure is accompanied by target
organ damage (grade 3 retinopathy), but no papilledema
Malignant hypertension:
Markedly elevated diastolic blood pressure (>130 mmHg)
accompanied by papilledema (grade 4 retinopathy)
9
Dropped
terms

10. Causes of hypertensive emergency and urgency
Essential hypertension
• High blood pressure that doesn't have a known secondary
cause
Secondary hypertension
• High blood pressure that's caused by another medical
condition

11. Secondary Causes of Hypertensive Emergency
and Urgency
Cardiovascular
Renal
Central Nervous System
Drugs
Endocrine
Others

12. Cardiovascular
• Acute Coronary Syndrome
• Congestive Heart Failure
• Coarctation of the aorta
• Dissection of the aorta
12

13. Renal
• Renal parenchymal disease
• Renal artery stenosis
• Glomerulonephritis
• Tubulointerstitial nephritis
• Renal aplasia
• Renal cell carcinoma
13

14. Central Nervous System Disorders
• Head injury
• Cerebral infarction
• Cerebral hemorrhage
• Brain tumour
• Spinal cord injury
14

15. Endocrine Disorders
• Pheochromocytoma
• Cushing syndrome
• Primary hyperaldosteronism
• Renin-secreting tumour
15

16. Drugs
• Antihypertensive medication withdrawal- e.g.. B blockers,
Clonidine etc.
• Cocaine, sympathomimetics, phencyclidine, erythropoietin,
cyclosporine
• Amphetamines
• Lead intoxication
16

17. Others
• Postoperative patient
• Burns
• Diabetes Mellitus
• Systemic Lupus Erythematosus
• Systemic sclerosis
• Hemolytic Uremic Syndrome
• Thrombotic Thrombocytopenic Purpura
• Autonomic hyperreactivity
– Guillain-Barre´ syndrome
– Acute Intermittent Porphyria
17

18. Pathophysiology
18

19. STEP 2
Assess Target Organ Involvement
19

20. Clinical features
• History and physical examination
• History—duration and severity of hypertension, previous BP records &
and H/o any anti hypertensive drug
• Relevant symptoms
– Chest pain, dyspnea, edema, acute fatigue
– Epistaxis
– Headache, change in the level of consciousness, seizure, motor
weakness
20

21. Clinical features
• Palpitation, diaphoresis, tremors suggestive of
phaeochromocytoma
• Weight gain, thinning of skin suggestive of Cushing’s
Syndrome
• History of comorbid condition
• Compliance of medication
21

22. Clinical features
• Physical Exam
– Feel all peripheral pulse
– Measure BP in both arms
– Look for JVP, pedal edema, auscltate for crepitation, Gallop and
abdominal bruits
– Focus on areas of potential target-organ damage
- CNS - Heart
- Pulmonary - Renal - Retina
22

23. Clinical clues
End-organ damage in hypertension
CNS: Hypertensive encephalopathy
Cerebral infarction
Subarachnoid hemorrhage
Intracranial hemorrhage
23

24. Clinical clues
End-organ damage in hypertension
CVS: Myocardial ischemia and infarction
Acute left ventricular failure
Acute pulmonary edema
Aortic dissection
24

25. Renal
• Hematuria
• Oliguria
25

26. Common Symptoms of Crisis
Shortness of breath (29%)
Chest pain (26%)
Headache (23%)
Altered mental status (20%)
Focal neurologic deficit (11%)
Microangiopathic hemolysis with reversible renal insufficiency (27%)
26
Jason N. Katz, MD, et al. Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe
hypertension: The Studying the Treatment of Acute hypertension (STAT) Registry. Hypertension. 2009

27. STEP 3
Send relevant investigation
27

28. Relevant Investigation
• CBC and peripheral blood smear- hemolytic anemia
• Glucose- hypoglycemia
• Electrolytes- hyperkalemia
• BUN/Cr- Raised
• Urine- proteinuria, hematuria, RBC cast
• CXR- Pulmonary edema, aortic dissection
• ECG- Ischemia, Infarction pattern
• ECHO- RWMA, LV function, Valve abnormalities
• Head CT- hemorrhage, Infarction
28

29. Relevant Investigation
• USG KUB- For structure abnormality like polycystic kidney
disease
• Reanl doppler or renal angiogram- For renal artery stenosis
• Urinary VMA, Metanephrine, 5HIAA – Pheochromocytoma
• Plasma cortisol or dexamethasone suppression test- Cushing
Syndrome
29

30. MCQ No. 2
One of the following is recommended in hypertensive crisis but
least often performed in ICU patients
1. Invasive arterial blood pressure monitoring
2. CT scan even in presence of unilateral weakness
3. Cardiology review if there are changes in ECG
4. Fundoscopic examination and ophthalmology review in
normal vision
30
In STAS Registry only 13% of the patients underwent fundus examination

31. Hypertensive Retinopathy
Modified Scheie classification
• Grade 0 - No changes
• Grade 1 - Barely detectable arterial narrowing
• Grade 2 - Obvious arterial narrowing with focal
irregularities
• Grade 3 - Grade 2 plus retinal hemorrhages and/or
exudates
• Grade 4 - Grade 3 plus disc swelling
31

32. 32
Generalized
narrowing
of the
arterioles
Generalized
narrowing
plus focal
constriction
Hemorrhages,
and exudate,
edema of the
disc

33. Fundus examination
Hypertensive Retinopathy – Grade 4
33

34. STEP 4
Treatment goals
34

35. MCQ No. 3
The following is the treatment goals in hypertensive
crisis
1.Reduce blood pressure to 40 % in all by Intravenous drugs
2.Reduce blood pressure to normal within 2 hours in all
patients
3.Only routine oral medication to be resumed
4.Reduce blood pressure 15 to 20 % in one hour then
gradually to normal in 24 to 48 hours
35

36. Treatment
Weigh benefits of decreasing BP against risks of decreasing end-
organ perfusion.
Important steps include:
– Appropriately evaluating patients with an elevated BP
– Correctly classifying the hypertension
– Determining aggressiveness of therapy
An important point to remember in the management of the
patient with any degree of BP elevation is to “treat the patient
and not the numbers.”
36

37. Treatment
 Initial considerations:
– Relaxation and de-stress
– Consider the context of the elevated BP (e.g. severe pain)
– Screen for end-organ damage
– No evidence of end-organ effects –Oral medicines –
monitor - discharged with follow–up
37

38. Treatment
 Hypertensive urgency:
– Immediate goal—lower blood pressure within 24–72
hours
– Treatment setting—clinical discretion is required
– Medications—oral medications with rapid onset of
action; occasionally intravenously
38

39. Treatment
 Hypertensive emergency:
– Immediate goal—lower MAP by 15–20% within 2 hours,
25% within 12 hours, 30% within 48 hours
– Treatment setting—intensive care unit, intra-arterial BP
monitoring
 Medications—intravenous
39

40. Treatment
 Medication options:
– Oral antihypertensives
– IV antihypertensives
40

41. Treatment
There are 2 main classes of drugs
1.Vasodilators
– Nitroglycerin
– Sodium Nitroprusside
– Fenoldopam
– Hydralazine
– Nicardipine
– Clevidipine
– Enalaprilat
2. Adrenergic inhibitors
– Labetalol
– Esmolol
– Metoprolol
– Phentolamine
41

42. Target Blood Pressure Goal
Hypertensive Emergency Target Blood Pressure
Hypertensive Encephalopathy MAP lowered by maximum20% or DBP 100-110mmHg within first hour then gradual
reduction in BP to normal range over 48-72 hour
Ischemic stroke MAP lowered no more than 15-20%,DBP not less than 100-110mmHg in first 24 hour
Ischemic stroke plan-tPA SBP < 185mmHg or DBP <110 mmHg
Intra cerebral hemorrhage MAP lowered by 20%–25%
Aortic dissection SBP 100–120 mm Hg
42

43. STEP 5
Which Drug(s) to Use
43

44. 44

45. Common Oral Medications for Hypertensive
Urgencies
Drug Dose Onset of Action Side effect
Labetalol 200–400 mg po 20–120 min Bronchoconstriction, heart block, aggravate heart failure
Clonidine 0.1–0.2 mg po 30–60 min Rebound hypertension with abrupt withdrawal
Captopril 12.5–25 mg
Sublingually
15–60 min Can precipitate acute renal failure in setting of bilateral
renal artery stenosis
Nifedipine,
extended
release
30 mg po 20 min Avoid short-acting oral or Sublingual due to risk of stroke,
acute myocardial infarction, severe hypotension
Amlodipine 5–10 mg po 30–50 min Headache, tachycardia, flushing, peripheral edema
Katz JN, Gore JM, Amin A, et al. Practice patterns, outcomes, and end-organ dysfunction for patients with
acute severe hypertension: the Studying the Treatment of Acute hypertension (STAT) registry. Am Heart J
2009; 158:599–606.
45

46. MCQ No. 4
All of the following commonly drop blood
pressure precipitously except:
1. Sodium Nitroprusside
2. Hydralazine
3. Nifedipine
4. Labetalol
46

47. Sublingual Captopril
• Administered sublingually, in which case the
onset of action may occur within 10-20
minutes, with the maximal effect reached
within 1 hour
• Initial Dose 25 mg
47
Amgad HH et al. Evaluation of the clinical outcome of captopril use for hypertensive urgency in
Khartoum State’s emergency centres. African Journal of Emergency Medicine 11 (2021) 202–
206
Tab Angiopril 25 mg
Tab Capotril 25 mg

48. Drug Dose Onset of Action Duration Adverse effects Pearls
Sodium
Nitroprusside
0.25–10 mg/kg/min IV
infusion
Within seconds to
minutes
1-2 min Tachyphylaxis
Muscle twitching
Avoid in renal
failures
Nitroglycerin 5–100 mg/min IV infusion 1–5 min 10–20 min Tachyphylaxis
Tachycardia
Variable response
Hydralazine 10–20 mg IV bolus 10–20 min 3-10 hours Drug induced lupus Unpredictable
effects
Phentolamine 5–15 mg IV bolus 1–2 min 2 – 4 hours Arrhythmia
Bradycardia
Used in adrenergic
crisis
Enalaprilat 1.25–5 mg every 6 h IV
bolus
15–30 min 4 hours Bradycardia
Variable response
Avoid in renal
failure
Parenteral medications used for treatment of hypertensive crisis
48

49. Drug Dose Onset of Action Duration Adverse effects Pearls
Labetalol 20 mg bolus every 10-20
min, Maximum 300 mg
or 0.5–2 mg/min IV
infusion
5–10 min 2-6 hours Bradycardia
Metoprolol 2.5 -20 mg 20 min 3-4 hours Bradycardia
Esmolol 80 mg bolus over 30 secs
then
150 mg/kg/min IV infusion
1–2 min 10-20 min Bradycardia
Parenteral medications used for treatment of hypertensive crisis
49

50. Drug Dose Onset of Action Duration Adverse effects Pearls
Diltiazem
Inj. Dilzem
25mg/5ml)
Bolus 0.25 mg/ kg
Infusion – 5-20 mg/ h
1-3 min 1-3 hours Bradycardia Initial bolus
recommended
Verapamil
(Inj. Clovera
5mb/2ml)
Bolus 0.075 mg/ kg- 0.15 3-5 min 0.5 – 6 hours Bradycardia
Nicardipine
NA
2.5 -15 mg/ h 5-15 min 4- 6 hours Tachycardia
Clevidipine
NA
Continuous infusion – 1-
21mg/h
2-4 min 5 – 15 min Bradycardia
Parenteral medications used for treatment of hypertensive crisis
50

51. Special indications and warnings for parenteral medications
Drug Special Indications Warnings
Nitroglycerin
Inj. NIG 25/50 mg
Most hypertensive
emergencies,
coronary ischemia
Headache; can develop tolerance, tachycardia, vomiting,
methemoglobinemia, flushing
Sodium
Nitroprusside
Inj. Nipress 50 mg
Most hypertensive
emergencies
Can develop cyanide toxicity,
acidosis, methemoglobinemia, increased intracranial
pressure, nausea, vomiting, muscle twitching
Labetalol
Inj. Lobet 5/10/20/100 mg
Most hypertensive
emergencies,
aortic dissection
Avoid in acute heart failure, bradycardia, and
Broncho constrictive disease
Esmolol
Inj. Esmocard 100 mg
Aortic dissection Avoid in acute heart failure, broncho constrictive disease, and
heart block
Hydralazine
Inj. Hydralaze 25 mg
Eclampsia reflex tachycardia, headache
Phentolamine
Inj. Fentanor 10 mg
Catecholamine excess Flushing, headache, tachycardia
Enalaprilat
NA
Acute left ventricular
failure
Avoid in acute myocardial ischemia
51

52. 52

53. Labetalol
• Combined alpha and beta blocker
• Dose: 10–80 mg IV bolus every 10 minutes to a
maximum dose of 300 mg
• Infusion: 0.5–2 mg/min
• Onset/duration of action: 5–10 minutes/ 3–6 hours
• Adverse effects- Bradycardia, bronchospasm
• Avoid in congestive heart failure (CHF), bronchial
asthma
53
Does not reduce
the
Cardiac Output

54. Metoprolol
• Selective β-1 blocker
• Dose: 5 mg repeat up to total dose of 15 mg
• Onset duration: 5 min/ 8 hours
• Adverse effects: Bradycardia, Hypotension
54
Inj. Betaloc 1 mg/ ml – 5 ml

55. Esmolol
• Short acting cardioselective beta- blocker
• Dose: 500 mcg/Kg IV bolus can be repeated after 5 minutes
• Infusion: 50–300 mcg/Kg/min
• Onset/duration of action after discontinuation: 1–5
minutes/15–30 minutes
• Avoid in patients with heart block, CHF, asthma
• May precipitate Bradycardia, CHF, heart block, bronchospasm
55
Inj. Cardesmo
Inj. Esmocard
Inj. Miniblock
Inj. Neotack

56. 56

57. Nicardipine
• Second-generation dihydropyridine calcium-channel blocker
• high vascular selectivity and strong cerebral and coronary
vasodilatory activity
• Dose 5 -15 mg/h
• Onset/ duration of action: 5-15 min/ within 30 min
• Increase both stroke volume and coronary blood flow with a
favorable effect on myocardial oxygen balance
• Can be used in coronary artery disease & systolic heart failure
57
Not
Available
in India

58. Clevidipine
• Third-generation dihydropyridine calcium-channel
blocker. Stroke volume and cardiac output usually
increase by reducing the peripheral vascular resistance
• Dose: 1–2 mg/ hour can be increased
• Onset/ offset of action: 1 min/ metabolized by plasma
esterases
• Clevidipine is insoluble in water and formulated as a
20% phospholipid emulsion for injection
• Lipid overload if used in large quantity
58
Not
Available
in India

59. Diltiazem
• Non-dihydropyridine calcium channel blocker
• Oral dose: 60 -120 mg BD maximum 360 mg in
two divided dose
• IV: 0.25 mg/kg bolus repeated if needed then
infusion of 5-10 mg per hour
• Slow infusion must me continuously monitored –
can precipitate heart block in sensitive individuals
59
Tab Dilzem 30/60/120
SR 90
Inj. Dilzem 25mg

60. Verapamil
• Non-dihydropyridine calcium channel blocker
• Oral dose 80 mg TDS maximum 480 mg per day in
divided doses
• IV 5-10 mg slow IV under monitoring
• Can be repeated after 30 minutes -if inadequate
response then take up oral maintenance
60
Tab Calaptin 40/80
Inj. Calaptin 5 mg

61. 61

62. Nitroglycerine
• Nitrates produce NO and activates cGMP and relaxation of
vascular smooth muscles
• Dose: 5–100 mcg/min IV infusion
• Onset/duration of action: 2–5 minutes/ 5–15 minutes
• Mostly venodilator with modest arterial dilation
• Tolerance, Headache, tachycardia, flushing, vomiting,
Methemoglobinemia
62
Tab Nitrocontin 2.6 mg
Inj. NG-Care 25 mg/ 5 ml

63. Fenoldopam
• Selective D1 receptor partial agonist vasodilation
of most arterial beds, including renal, mesenteric,
and coronary arteries
• Onset/ Duration: 4 minutes/ < 10 minutes
• Linear dose–response relationship at usual
clinical doses
• Dose: 0.05 -0.3 mcg/kg/min
63
Begin simultaneous oral medicines
By Baxter
Available

64. Phentolamine
• Pure α-blockade
• Reflex tachycardia, orthostatic hypotension
• Dose: 5–15 mg IV bolus, repeat every 5–15 minutes
• Infusion: 0.2–5 mg/min
• Onset/duration of action after discontinuation: 1–2
mins/ 10–30 mins
• Used in syndromes with excess catecholamine
(pheochromocytoma)
64

65. Sodium Nitroprusside
• It is both arterial and venous dilator and works on both the resistance
and capacitance vessels with rapid onset and offset of action
• Dose: 0.25–10 mcg/Kg/min IV infusion
• Onset/ duration of action after discontinuation: Seconds/ 2–3 minutes
• Historically used for most hypertensive emergencies
• Dose can be titrated to a target BP
• Infusion bag, and delivery set must be light-resistant or covered
• Nausea, vomiting, muscle twitching on prolonged use (>24–48 hours)
• Thiocyanate/cyanide intoxication, metabolic acidosis in patients with
renal impairment
• Thiocyanate level >10 mg/dL should be avoided
65
Drug to be avoided
Marik PE, Varon J. Hypertensive crises: challenges and management.
Chest 2007; 131:1949–1962

66. Hydralazine
• Acts directly on the arterial bed – reduce diastolic pressure more
than systolic and cause reflex tachycardia – angina may be
precipitated due to increased cardiac work and steal
phenomenon
• Dose: 10–20 mg IV bolus may be repeated every 30 minutes till
goal BP is reached or unacceptable tachycardia develops
• Onset/duration of action: 10–30 mins/2–4 hours
• Avoid in patients with increased ICP, ischemic heart disease, and
aortic dissection without concomitant β- blockade
66
Drug to be avoided

67. STEP 6
Drugs for specific situation
67

68. Acute Pulmonary Edema
Systolic Dysfunction
• Nitroglycerin
• Loop diuretic
Diastolic Dysfunction
• Esmolol, Metoprolol,
labetalol or verapamil in
combination
• Low dose-Nitroglycerin
and
• Low dose-Loop diuretic
68

69. Acute Coronary Syndrome
 Preferred medications- Beta-blockers (Labetalol or Esmolol) with a
Vasodilator (Nitroglycerin)
 Treat if SBP >160 mmHg and/or DBP>100mm Hg
 Reduce BP by 20-30% of baseline
 Thrombolytics are contraindicated if BP is >185/100 mm Hg
• The drugs of choice are intravenous nitroglycerin, -blockers, and
angiotensin-converting enzyme (ACE) inhibitors
69

70. Hypertensive encephalopathy
 Goal is to reduce MAP by 20% over next 8 hours
 Labetalol or Clevidipine are drugs of choice
 Avoid Drugs with adverse effects on the central nervous
system agents such as clonidine, reserpine, and methyldopa
 Avoid Nitroprusside (used in past) is a powerful arteriolar
dilator, so a rise in ICP may occur
70

71. Intracerebral hemorrhage
 Labetalol, Esmolol, Nicardipine are agents of choice
 Avoid Nitroprusside, Hydralazine
 Raised ICP, maintain MAP just below 130 mm Hg (or SBP
<180 mm Hg) for first 24 hours
 No raised ICP, maintain MAP <110 mm Hg (or SBP <160
mm Hg) for first 24 hours
71

72. Subarachnoid Hemorrhage
– Nicardipine, Labetalol, Esmolol are agents of choice
– Avoid Nitroprusside, Hydralazine
– Maintain SBP <160 mm Hg until the aneurysm is treated or
cerebral vasospasm occurs
– Oral Nimodipine is used to prevent delayed ischemic
neurological deficits, but it is NOT indicated for treating acute
hypertension
72

73. Acute ischemic stroke
 Labetalol, Nicardipine, Clevidipine -agents of choice
 High BP can cause hemorrhagic transformation of infarct,
cerebral edema
 But, if CPP is low, ischemic penumbra may occur
 Intervene if SBP > 220 or DBP > 120 or MAP > 145 mmHg
(unless associated with end-organ damage is due to high BP)
 For thrombolysis, BP < 185/110
73

74. Acute Aortic Dissection
Type A dissection
• Require surgery
Type B- dissection
• Managed medically
74

75. Acute Aortic Dissection
 Combination of a beta blocker with a vasodilator to reduce
the force of ventricular contraction
 Labetalol/ Esmolol with Nitroglycerine
75

76. Pregnancy-induced hypertension
 Preeclampsia, eclampsia, HELLP (hemolysis, elevated liver
enzyme, low platelet) syndrome
 Posterior reversible encephalopathy syndrome (PRES) is a
specific hypertensive emergency during pregnancy
 It is characterized by headache, confusion, seizures, and
visual loss
 It occurs predominantly due to accelerated hypertension
and eclampsia
76

77. Pregnancy Induced Hypertension
• Use Hydralazine, Labetalol, Nifedipine
• Avoid Nitroprusside, ACE inhibitors, Esmolol
• SBP <160 mm Hg and DBP <110 mm Hg
• Platelet count < 100,000 cells mm3 BP should be maintained below
150/100 mm Hg.
• IV magnesium sulfate to avoid seizures
77

78. Renal emergencies
 Pathophysiology includes a variety of mechanisms, such as
increased vascular resistance, activation of the renin-angiotensin-
aldosterone axis and hyperparathyroidism
 Goal is to prevent further renal damage by maintaining adequate
blood flow
 Sodium Nitroprusside and labetalol are useful
 Short-term dialysis is sometimes necessary
78

79. Adrenergic Crises
Achieving adequate α-blockade
• Prazosin 2.5/ 5 mg BD or TDS maximum 20 mg
• Doxazosin 1/ 2 mg OD maximum 16 mg
• Terazosin 1/2/5 mg OD
β-blockers
• Propranolol 10 mg QID
79

80. Acute Postoperative Hypertension
Adequate control of blood pressure during OT
• Reduce Surgical stimulation
• Avoid fluids overload
Analgesics
• Opioids
• Non-opioids
Beta Blockers- Esmolol, or Labetalol
CCB- Nicardipine, Clevidipine
80

81. Continue outpatient management to normal
BP. Identify and treat causes of secondary
hypertension.
Oral therapy to decrease
mean arterial BP 25% in 24 hr
Initiate oral therapy to maintain
stable BP
Hypertensive
urgency
Consider inpatient vs.
outpatient therapy based on
patient’s clinical picture and
reliability
Parenteral therapy to decrease mean
arterial BP by up to 25% in 2 hr or unit
organ damage satbilized
No acute
organ damage
Measure
BP
Systolic >180 mmHg or
Diastolic > 120 mmHg
Systolic <180 mmHg or
Diastolic < 120 mmHg
Acute or ongoing
organ injury
No acute
organ damage
Hypertensive
emergency;
Admit to intensive
care unit
Outpatient treatment with oral
therapy and nonpharmacologic
interventions
81

82. MCQ No. 5
Which of the Drugs is available in India??
1. Enalaprilat
2. Nicardipine
3. Clevidipine
4. None of the above
82

83. Thank you
83