Hypertension is defined as blood pressure above 140/90 mmHg or use of antihypertensive medication. Hypertensive emergencies involve severe elevation of blood pressure and evidence of acute target organ damage, requiring immediate but careful intervention to lower blood pressure within 30 minutes. Hypertensive urgencies involve severely elevated blood pressure without organ damage, allowing more gradual blood pressure reduction over 24 hours as an outpatient. Treatment depends on the clinical presentation and may include vasodilators like nitroprusside or adrenergic inhibitors like labetalol to carefully lower blood pressure while avoiding complications of too rapid a decrease.

1. ACUTE SEVERE HYPERTENSION
DR NASIR MOHI UD DIN
DNB RESIDENT

2. HYPERTENSION
Hypertension is defined as systolic blood
pressure (SBP) of 140 mmHg or greater,
diastolic blood pressure (DBP) of
90 mmHg or greater, or taking antihypertensive
medication.
VI JNC, 1997

3. SBP-mmHg DBP-mmHg
NORMAL <120 AND<80
PREHYPERTENSION 120-139 or 80-89
STAGE 1 140-159 or 90-99
STAGE 2 >=160 >=100
HYPERTENSION(JNC-7class.)

4. BLOOD PRESURE MEASURING.

5. Incidence In India
• 25% of urban population and 10 % of rural
population suffer from hypertension
• 70% of all hypertensive patients are stage I
hypertension
• 12% of all hypertensive suffer from isolated
systolic hypertension

6. .Evaluation and management of acute severe hypertension

7. HYPERTENSIVE URGENCY
• Severely elevated arterial BP (SBP >180
and/or DBP >120 mm Hg) with nonspecific
complaints but without evidence of acute
target organ damage
• It has less serious prognosis than
hypertensive emergency in spite of severe
hypertension
• Most of the hypertensive crisis presentations
(75%) are hypertensive urgencies

8. HYPERTENSIVE EMERGENCY
• severe elevation of arterial BP (systolic >180
mm Hg and/or diastolic 110 to 120 ) and
evidence of acute target organ damage.
• life-threatening (mortality 20 % if untreated)
• requires immediate but careful intervention
• Hypertensive emergency is diagnosed if SBP is
>180 and/or DBP is >120 mm Hg and at least
one of the following clinical situations is
present

9. Presentation of hypertensive emergencies
• Ischemic stroke: 24%
Pulmonary edema: 22%
• Hypertensive encephalopathy: 16%
• Acute heart failure: 14%
• Acute myocardial infarction: 12%
• Intracerebral hemorrhage: 5%
• Dissecting aortic aneurysm:2%
• Subarachnoid hemorrhage
• Acute renal failure
• Eclampsia (SBP > 170, DBP > 110 mm Hg): 5%

10. Symptoms of hypertensive emergencies and urgencies
Hypertensive Urgencies Hypertensive Emergencies
Headache 22% Chest Pain 27%
Epistaxis 17% Dyspnea 22%
Somnolence 9% Neurological deficits 21%
Chest Pain 9% Somnolence 10%
Dyspnea 9% Paraesthesia 8%
Neurological deficit 7% Nausea ,Vomiting, Dizziness, Headache,
12%

11. Auto regulation of cerebral blood flow
• -In normotensive individuals cerebral perfusion
remains constant in spite of fluctuation of mean
arterial pressure (MAP) between 60 and 130mm Hg
• -In hypertensive individuals there is a shift to the
right in the cerebral auto regulation curve: the
cerebral perfusion remains constant at higher
range (between MAP 80 and 160 mm Hg)

12. .

13. Pathogenesis
• Following diseases represent the most
common underlying causes of hypertensive
emergencies:
• Essential hypertension: 90%
• Renal hypertension
• Malignant hypertension.
• Phaeochromocytoma
• Pre eclampsia
• Cerebrovascular disease

14. PHYSICAL
• Use an approach based on organ systems to identify
signs of end-organ damage
-CNS: focal neuro deficits , seizures ,stupor, coma,
papilledema, hemorrhages, exudates, or evidence of
closed-angle glaucoma
-CVS: JVD , lung auscultaion for crackles , peripheral
edema , extra heart sounds, equal and symmetric BP
and pulses bilaterally.
-Check for abdominal masses and bruits.

15. Work-up
• 1. Short history and physical examination
• 2. Repeated measurement of BP to confirm
severe elevation of BP
• 3. ECG
• 4. Chest X-ray
• 5. Funduscopy

16. Contd
• 6. Lab: serum elecrtolytes, creatinine, urea,
urinalysis, CBC, troponin and CK-MB if needed
• 7. Abdominal U/S: if dissecting aortic
aneurysm is suspected
• 8. Echocardiography if needed
• 9. CT scan of the brain: if neurological deficit is
present

17. Treatment strategy
• sometimes immediate treatment is needed before
diagnostic tests are completed or before laboratory
results are available! but top priority:
• Primum nihil nocere (Hippocrates)
First do no harm
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 number

18. Treatment of hypertensive urgencies:
• -immediate therapy: gradual lowering of elevated
BP within 24 hours to avoid the development of
serious complications
• -controlled lowering of elevated BP (reduction of
mean arterial pressure by 25%, aim DBP 100 -110 mm
Hg) to avoid sudden drop of BP and cerebral hypo
perfusion
• -outpatient treatment is possible

19. ORAL DRUGS
DRUG DOSAGE ADV. EFF.
CAPTOPRIL
(ACE inhibitor)
6.25-25MG q 6hrs. Hypotension in high renin
states
CLONIDINE
(a2 agonist-
centrally acting)
0.1-0.2 mg PO
initially then 0.1mg
hrly, Upto max
0.8mg in 24hrs.
Sedation, bradycardia , dry
mouth
NIFEDIPINE
(CCB)
10 mg PO
Repeated after 30
mins
Headache, Flushing
edema, dizziness , nausea

20. Treatment of Hypertensive Emergencies
• a. General guidelines:
-immediate therapy: prompt lowering of
elevated BP within 30 min.to avoid and
limit the risk of serious complications
(cerebral hyper perfusion, perivascular
edema, increased ICP)

21. Contd
• -controlled lowering of elevated BP to a safer
noncritical level but not to normal range
(reduction of mean arterial pressure by 25%,
• Aim SBP 160-170, aim DBP 100-110mm Hg) to
avoid sudden drop of BP and reduction of
cerebral perfusion and development of brain
infarction.

22. Medical treatment
• -The medical treatment of hypertensive
emergencies depends on the clinical
presentation
• -No treatment should be started without
clinical evaluation
• -Clinical evaluation should be performed
without delay

23. DRUGS
• Once the diagnosis of hypertension is made
and end-organ damage confirmed,the BP
should be lowered by about 25% of the mean
arterial pressure.
• There are 2 main classes of drugs:
-Vasodilators
-Adrenergic inhibitors

24. VASODILATORS
DRUG DOSAGE ADV.EFFE
Nitroprusside
(directly acting
vasodilator)
0.25-10mcg/kg/min Thiocyanate,cyanide
poisoning
Nitroglycerine 0.25 – 5mcg/kg/min
iv infusion
Flushing,headache,methemo
globin
Nicardipine
(CCB)
5mg/hr iv infusion
increased by 1-2 mg
every 15 min upto
15mg/hr
Tachycardia,flushing.avoid-heart
failure
Hydralazine
(DAV)
10-20mg iv bolus Flushing,tachy,avoid-A.diss,MI
Enalapril
(ACE Inhibitor)
10-40mg IM,1.25-
5MG iVq6hr
Hypotension,renal
failure,hyperkalemia
Fenoldopam 0.1-0.3mcg/kg/min Flushing,headache,tachy

25. DRUG DOSAGE ADV.EFF
Labetalol
(a+b blocker)
20-80mgiv bolus every
10 min,2mg.min iv
infusion
Heart block,ortho
hypotension.avoid-heart
failure,asthma
Esmolol
(b-1 selective
blocker)
200-500 mcg/kg/min for
4min,then 150-
300mcg/kg/min
Hypotension,avoid-heart
failure,asthma
Phentolamine
(a1 blocker)
5-15mg iv Tachycardia,flushing,headache
ADRENERGIC INHIBITORS

26. Differential
-Steroid use
-Use of over-the-counter or recreational
sympathomimetic drugs
-Pheochromocytoma
-Acute vasculitis
-Serotonin syndrome
-Other CNS pathology
-Coarctation of the aorta

27. RAPID BP REDUCTION
– Acute myocardial ischemia :IV NTG, b-blockers ,
ACE inhibitors.
• CHF with pulmonary edema :iv NTG, furosemide,
morphine.
• Acute aortic dissection : iv nitroprusside + b-blockers
or iv trimethaphan + b-blockers.
• Hypertensive encephalopathy or sub-arachnoid
hemorrhage :iv nitroprusside , labetalol or
nimodipine .
• MAO- tyramine interactions with acute hypertension
: iv phentolamine.

28. Specific Treatment
• AORTIC DISSECTION: Immediate reduction. In BP and mainly ,
shear stress(change in BP with change in time) is essential to
limit the extension of damage as surgery is being considered .
Eliminate pain and reduce systolic BP to 100-120 or lowest
level that permits perfusion . BP reduction should proceed
with reduction in force of LV contraction. Labetalol or
nitroprusside + b-blocker like propranolol agents of choice.
• MI: NTG, b-blockers , ACE inhibitors.
• ACUTE LVF: usually associated with pulmonary edema and
diastolic/systolic dysfunction. IV nitroprusside , NTG agents of
choice . Titrate until BP controlled and signs of heart failure
alleviated.
• RENAL INSUFFICIENCY: is a cause and effect of high BP . Goal
is to prevent further renal damage by maintaining adequate
blood flow . Nitroprusside effective.

29. Pre-eclampsia/ Eclampsia
• Preeclampsia
– mild = 140/90 with proteinuria
– severe = 160/110, 5 gm protein, Sx
• "Standard" therapy is hydralazine
• Other agents: Nifedipine , labetalol,
methyldopa
• Nitroprusside (risk of fetal CN toxicity)
• Additional measures: MgSO4; Delivery

30. FOLLOW-UP
• The Joint National Committee on High Blood Pressure has
published a series of recommendations for appropriate
follow-up, assuming no end-organ damage.
-For a systolic BP 140-159 mm Hg/diastolic 90-99 mm Hg,
confirm BP within 2 months.
-For systolic BP 160-179 mm Hg/diastolic 100-109 mm Hg,
evaluate within a month.
- For systolic BP 180-209 mm Hg/diastolic 110-119 mm Hg,
evaluate within a week.
-For systolic BP greater than 210 mm Hg/diastolic greater than
120 mm Hg, evaluate immediately.

31. Conclusions
• -Hypertensive Emergencies and Urgencies are clinical
presentations associated with severe elevation of BP which
needs to be lowered immediately or gradually to prevent
brain edema and increase in ICP but controlled(aim SBP 160,
aim DBP 110 mm Hg) to avoid sudden drop of BP and
reduction in cerebral perfusion
• -Differential diagnosis should be considered before starting
possible harmful treatment
• -medical treatment should be started according to the
clinical presentation

32. THANK YOU
FOR
YOUR ATTENTION