2. Case report- Patient information
Pharmacotherapy of hypertension crisis
Discussion
Non-medication suggestion
References
2
3. Name： Mr. Lai
Age： 32y/o
Ht/BW：175cm／103.8kg
BMI：33.8
DOA：101/01/27 DOD：101/02/03
3
4. 1/2-10 nephrologic ward for survey Nephrotic syndrome
of nephrotic syndrome
chest tightness and dyspnea since
21:00 and symptoms were not
relieved by rest. He was sent to ER
1/27 high blood rpessure was BP: 220/139 mmHg.
measured with ST elevation over V1- There was no increasing cardiac
3 from EKG enzyme.
2/3 was out of hospital BP: 105/71 mmHg.
4
5. Past medical history
1. Nephrotic syndrome with acute on chronic renal
failure(spot urine Pro/Cr: 3.17)
2. CHF (LVEF:54%)
3. Microcytic anemia(alpha thalassemia and iron-
deficiency)
4. Pulmonary hypertension
5. Type-2 DM, HbA1c:6.9%
6. Hyperlipidemia , nephrotic syndrome related,
7. Chronic hepatitis B
8. Hypertension
Family history：None
5
6. Personal history：
Allergy(-), Betel nut(-), Alcohol (-)
Smoking: 0.14包/天 x 5 years
Travel: China x 1M (2011/12)
Animal contact(-)
Physical examination
BP=220/139 mmHg
PR: 90 /min RR: 18 /min BT: 37.3 ℃
6
7. Plan to do
1. Check I/O and BW QD
2. Aggressively control blood sugar, BP, lipid
3. Avoid NSAID or other nephrotoxic agent
4. Check serum total protein/albumin, urine protein,
creatinine
5. Keep ACEI/ARB use, may add Aliskiren 1# QD if poor
response
6. Burinex and albumin
7. Low salt diet + water restriciton
8. F/U spot urine protein/Cr
7
16. 16
JNC7 (The Seventh Report of the Joint National Committee on Prevention,Detection,Evaluation, and Treatment of High Blood Pressure).2004
17. Presence of very elevated BP—greater than 180/120 mmHg
It’s divided into hypertensive urgencies and emergencies
Hypertensive Urgency(普通危急)
Hypertensive urgency occurs when blood pressure spikes,
but there is no damage to the body's organs as a result.
Hypertensive Emergency(非常危急)
When organ damage occurs as a result of severely elevated
high blood pressure, this is considered a hypertensive
emergency.
17
Pharmacotherapy A Pathophysiologic Approach Seventh Edition hypertensive urgencies and emergencies
18. Treatment direction
• Hypertensive urgencies are ideally managed by adjusting maintenance
therapy by adding a new antihypertensive and/or increasing the dose of
a present medication. This is the preferred approach to these patients as
it provides a more gradual reduction in BP to stage1(140-159/90-99mm
Hg)
Caution
• Very rapid reductions in BP to goal values should be discouraged
because of potential risks(include cerebrovascular accidents, MI, and
acute kidney failure)
18
Pharmacotherapy A Pathophysiologic Approach Seventh Edition hypertensive urgencies and emergencies
19. Captopril Clonidine Labetalol
• In doses of 25 to 50 mg • 0.2 mg clonidine can be • Can be given in a dose
• Onset of is 15 to 30min given initially for of 200 to 400 mg,
• Significant adverse patients with followed by additional
effects include cough, hypertensive rebound doses every 2 to 3
hypotension, following withdrawal of hours
hyperkalemia, clonidine
angioedema, and renal • Until the DBP falls
failure (especially in below 110 mm Hg or a
patients with bilateral total of 0.7 mg
renal artery stenosis, in clonidine has been
whom it should be administered. A single
avoided) dose may be all that is
necessary
19
Pharmacotherapy A Pathophysiologic Approach Seventh Edition hypertensive urgencies and emergencies
20. Treatment direction
• Require immediate BP reduction to limit new or progressing target-organ damage .
Hypertensive emergencies require parenteral therapy, at least initially
Goal
• The goal in hypertensive emergencies is not to lower BP to less than 140/90 mm Hg;
rather, a reduction in mean arterial pressure of up to 25% within minutes to hours is
the initial target. If then stable, BP can be reduced to 160/100–110 mmHg within the
next 2 to 6 hours. Precipitous drops in BP may lead to end-organ ischemia or
infarction. If patients tolerate this reduction, additional gradual reductions toward goal
BP values can be attempted after 24 to 48 hours. The exception to this guideline is for
patients with an acute ischemic stroke where maintaining an elevated BP is needed for
a much longer period of time.
20
Pharmacotherapy A Pathophysiologic Approach Seventh Edition hypertensive urgencies and emergencies
21. Nitroprusside IV Nitroglycerin Fenoldopam
• Direct-acting • Ideal for the • Is a dopamine-1
vasodilator management of agonist
• Metabolized to hypertensive • It can improve
cyanide and then emergency in the renal blood flow
to thiocyanate, presence of and may be
which is eliminated myocardial especially useful in
by the kidneys ischemia patients with
• But can be • Can cause severe kidney
problematic in headache insufficiency
patients with
chronic kidney
disease
21
Pharmacotherapy A Pathophysiologic Approach Seventh Edition hypertensive urgencies and emergencies
22. Nicardipine Hydralazine
• Nicardipine provides • The hypotensive response
arterial vasodilation,and of hydralazine is less
can treat cardiac ischemia predictable than with
similar to nitroglycerin other parenteral agents.
• may provide more • Its major role is in the
predictable reductions in treatment of eclampsia or
BP hypertensive
encephalopathy
associated with renal
insufficiency.
22
Pharmacotherapy A Pathophysiologic Approach Seventh Edition hypertensive urgencies and emergencies
23. Discussion
Q1:What are the hypertension crisis symptoms of Mr. Lai ?
Q2:Urgency or emergency in this case ?
Q3:How to treat hypertensive crisis ?
Q4:Whether treatment is appropriate ?
Q5:What is the cause of hypertensive crisis ?
23
24. Q1:What are the hypertension crisis symptoms of Mr. Lai?
MR. LAI ‘s Diagnosis HYPERTENSION CRISIS SYMPTOMS
Chief complaint: chest tightness BP: >180/120 mm Hg
(DBP>120 mm Hg)
dyspnea
CNS abnormalities dizziness, N/V,
Data BP: 220 /139 mmHg encephalopathy,
BW: 103.500kg confusion, weakness,
BMI: 33.795 stroke
Admission diagnosis： Acute coronary syndrome Cardiac HF, MI,
complications angina pectoris,
acute pulmonary
Nephritic syndrome edema,
(Pro/Cr: 3.17) acute coronary
CHF(LVEF:54%) syndrome
Type-2 DM Ocular symptoms blurred vision,
Hyperlipidemia loss of eyesight,
hemorrhages
Chronic hepatitis B
Renal complications hematuria,
Physical examination： ST elevation over V1-3 proteinuria,
pyelonephritis,
24
No increasing CE elevated BUN
26. Q2:Urgency or emergency in this case ?
Although, hypertensive crisis is divided into
emergency and urgency, we know by the textbook.
But signs and symptoms of these disorders are
nonspecific and may overlap.
Without a thorough patient history it is often difficult
to know whether target organ dyamage is new or has
progressed.
The distinction usually depends on the clinical
assessment of the life-threatening nature of each
episode.
from Applied Therapeutics- The Clinical Use of Drugs 9th ;20:1,2 26
26
27. Q3:How to treat hypertensive crisis?
Emergency (TOD) Anti HTN (IV)
Hypertensive Crisis
Urgency (NTOD) Anti HTN (PO)
TOD=Target organ damage from Pharmacotherapy 7th & JNC7
27
36. Q5:What is the cause of hypertensive crisis?
Past history:
Hypertensive emergencies generally occur in patients with
catecholamine producing adrenal tumors(pheochromocytoma),
renal vascular disease, or accelerated essential hypertension
Essential HTN: 符合賴先生的診斷
Acute life-threatening elevations of BP can also occur in previously
normotensive individuals with acute glomerulonephritis, head
injury, or severe burns; during pregnancy and with use of
recreational drugs aswell as from abrupt drug withdrawal,
drug–drug interactions
36
from Applied therapeutics 9th
37. Q5:What is the cause of hypertensive crisis?
Past history: 符合Applied therapeutics 9th
1. Nephrotic syndrome (spot urine Pro/Cr: 3.17) with
acute on chronic renal failure
2. Congestive heart failure, severe generalized LV
hypokinesia (LVEF:54%)
3. Microcytic anemia, due to both alpha thalassemia and
iron-deficiency anemia
4. Pulmonary hypertension, PASP: 43mmhg, diagnosed
via cardiac echo on 2012/1/6
5. Type-2 diabetes mellitus, HbA1c:6.9%
6. Hyperlipidemia, nephrotic syndrome related
7. Chronic hepatitis B
8. Hyperetension
37
38. Non-medication suggestion
Lifestyle modifications are the cornerstone of
management for preventing and treating hypertension.
賴先生有明顯體
重過重(103.8kg)的
問題BMI(33.8)
可詢問醫生是否可
利用藥物減少體重，
來降低許多疾病的
風險。
38
38
from Pharmacotherapy 7th
40. Reference
JNC7
Pharmacotherapy 7th
Applied therapeutics 9th and 10th
Basic and clinical pharmacology 11th
Koda-Kimble et al. Essential Hypertension. In: Koda-Kimble MA, Young LY,
Kradjan WA, et al, eds. Applied Therapeutics: The Clinical Use of Drugs. 9th
ed. Baltimore, MD: Lippincott Williams & Wilkins; 2009.
Norman M Kaplan, MD. Treatment of hypertension in the elderly,
particularly isolated systolic hypertension, UpToDate, 2009.
Steven E Weinberger, MD. Treatment of hypertension in asthma and COPD,
UpToDate, 2010
Health Center, Keio University, Tokyo, Japan hypertension in thyroid
disordersiEndocrinol Metab Clin North Am. 1994 Jun;23(2):379-86
台灣高血壓治療指引第一版
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