Hypertensive Crisis.ppt

HYPERTENSIVE
CRISIS
JWAN ALI AHMED ALSOFI

Outline of this lecture:
 What is Heart Hypertensive Crisis?
 Epidemiology.
 Classification of Hypertensive Crisis.
 Causes of Hypertensive Crisis
 Clinical presentation of Hypertensive
Crisis
 Managment of Hypertensive Crisis
Jwan Ali AlSofi

What is Hypertensive Crisis?
•The term hypertensive crisis is defined as a
severe elevation in blood pressure (BP),
generally considered to be a diastolic
blood pressure greater than 120 mm Hg
Jwan Ali AlSofi

What is Hypertensive Crisis?
•This disorder can be further classified as
hypertensive urgency or hypertensive
emergency when there is evidence of
acutely progressive end-organ damage.
•If these disorders are not treated promptly,
a high rate of morbidity and mortality will
occur the 5-year mortality for patients with
a history of hypertensive crisis is 26%
Jwan Ali AlSofi

Epidemiology
• Approximately 1% of hypertensive pts. may develop
hypertensive crises during their lifetime.
• Annual incidence of hypertensive emergencies being
1-2 cases/1,00,000 pts.
• Higher rates have been reported in African Americans, low
socioeconomic people, in developing countries.
• Incidence in men 2 times higher than in women
Epidemiology
Jwan Ali AlSofi

BLOOD PRESSURE – CLASSIFICATION
(for adults >= 18 years old)
DIAS.
PRESSURE
(mmHg)
SYS.
PRESSURE
(mmHg)
CATEGORY
<80
<120
OPTIMAL
<85
<130
NORMAL
85-89
130-139
HIGH NORMAL(PRE
HT):
HYPERTENSION
90-99
140-159
STAGE 1 (MILD)
100-109
160-179
STAGE 2 (MODERATE)
>=110
>=180
STAGE 3 (SEVERE) Jwan Ali AlSofi

Definitions of hypertensive crisis:-
• Hypertensive emergencies:- are defined as severe
elevations in BP (>180/120 mm Hg) associated with
evidence of new or worsening target organ damage.
• Hypertensive urgencies:- are situations associated with
severe BP elevation (>180/120 mm Hg) in otherwise stable
patients without acute or impending change in target
organ damage or dysfunction.
• Accelerated hypertension (aka malignant hypertension):- A
severe increase in blood pressure to 180/120 mmHg or
higher (and often over 220/120 mmHg) with signs of
retinal haemorrhage and/or papilloedema (grade 3-4). It is
usually associated with new or progressive target organ
damage.
Jwan Ali AlSofi

Definition of HTN-emergency:-
Jwan Ali AlSofi

Classification of Hypertensive Crisis
Jwan Ali AlSofi

• Renovascular Disease
• Pheochromocytoma
1. Non-adherence to anti-HTN medications (most
common)
2. Hyperaldosteronism
3. Anti-hypertensive withdrawal syndromes
4. Head injuries and CNS trauma
5. Post-op hypertension
6. Drug-induced hypertension
Causes of hypertensive emergencies ?
Jwan Ali AlSofi

• As with hypertensive emergencies ,severe BP
elevations may result from inadequate control or poor
adherence to current antihypertensive drug regimens.
• Another cause for patients reaching hypertensive
urgency is previous inaccurate BP measurements that
underestimate or do not detect increased BP at all
(e.g. poor patient technique for self‐monitoring).
Causes of hypertensive Urgencies ?
Jwan Ali AlSofi

Causes Hypertensive Urgencies
Drugs:
• Non-Narcotic Analgesics :
- Non-steroidal anti-inflammatory agents including
aspirin
- Selective COX-2 inhibitors
• Sympathomimetic agents:
- Decongestants
- Diet pills
- Cocaine
• Stimulants:
-Methylphenidate, amphetamine.
Jwan Ali AlSofi

Causes Hypertensive Urgencies
• Lifestyle:
- High salt diet, excessive alcohol use.
• Comorbid Conditions:
- Thyroid storm, trauma, renovascular disease, acute
ischemic stroke or adrenal dysfunction
Jwan Ali AlSofi

Clinical Presentation of HC
Emergency
• Characterized by severe increase in
systolic and/or diastolic blood pressure
associated with signs or symptoms of
acute end-organ damage.
• Usually, SBP > 180 mm Hg - DBP >
120 mm Hg
• Requires an immediate BP reduction in
few minutes - hours.
• Requires an ICU care & IV drugs
Urgency
• Elevated BP ( usually systolic > 180
mmHg &/or diastolic > 120 mmHg ) but
without evidence of end-organ
damage.
• Usually asymptomatic; severe
headache, shortness of breath,
epistaxis, severe anxiety.
• Adequate treatment of these conditions,
a BP lowering within 24-48 hrs by
administration of oral drugs.
• ICU admission is usually not required
• Controlled by oral medications.
Jwan Ali AlSofi

Emergency
• Rarely develop in patients without a
previous history of hypertension
• occur in patients with
pheochromocytoma or renal vascular
disease
• CNS:-
• Cerebral infarctions,
• HTN Encephalopathy
• intracranial or subarachnoid hemorrhage.
• Heart:-
• acute heart failure (HF) and pulmonary
edema
• acute myocardial infarction,
• unstable angina.
• Acute dissection,
• Eclampsia .
Urgency
• Not all patient present with
same symptoms
• 90% of patients had a history
of hypertension
• Headache (42%) and dizziness
(30%).
• visual changes,
• chest discomfort,
• nausea,
• epistaxis,
• Fatigue
• psychomotor agitation.
Jwan Ali AlSofi

ACUTE PROGRESSIVE
END-ORGAN DAMAGE

• Single organ damage in approximately 83%.
• Two organ damage found in 14%,multiorgan damage
in 3 % pts.
Most common clinical presentations :
- cerebral infarction (24%)
- pulmonary oedema (22%)
- HTN encephalopathy (16%)
- Cong. HF (12%)
•Less common presentations –
- IC hemorrhage,
- Aortic dissection
Acute End-organ Damage
(Complication of HC).
Jwan Ali AlSofi

ACUTE END ORGAN DAMAGE- CNS
1. Neurological –
-normal: increase in BP cerebral arterioles vasoconstrict cerebral blood flow
(CBF) remains constant
-hypertensive emergency: loss of autoregulation ability (decomp.) dialation of
cerebral vessel exsessive cerebral blood flow+ leakage from cappilaries
RESAULT:
1. Hypertensive encephalopathy- 3RD MOST COMMON (16.3%)
2. Cerebral vascular accident/cerebral infarction –
MOST COMMON (24.5%)
1. Subarachnoid hemorrhage
2. Intracranial hemorrhage
3. Retinopathy Keith-Wagner- GRADES 3 AND 4.
4. Eclampsia
Jwan Ali AlSofi

Hypertensive retinopathy:-
Acute/severe
hypertensive
retinopathy
Jwan Ali AlSofi

HYPERTENSION CRISIS- RETINA
Retinal hemmorhages (grade 3)-
ACCELERATED HT
Pappiledema (grade 4)-
MALIGNANT HT
Jwan Ali AlSofi

Hypertensive Encephalopathy
• Is a presentation of hypertensive emergency
• Our brains are under tight control. With severe rises in BP,
autoregulation fails and leads to cerebral edema.
• Hypertensive encephalopathy is defined as the presence of
signs or symptoms of cerebral edema secondary to severe
and/or sudden rises in BP. It’s characterized by:
• Severe Hypertension with 1+ of:
1. Seizures
2. Lethargy
3. Cortical Blindness
4. Coma
• It is a diagnosis of exclusion
Jwan Ali AlSofi

Of note, there is little evidence to
suggest that headache alone is a sign
of a hypertensive emergency, however,
in combination with visual changes,
lethargy, seizures or altered mental
status it may be an indication of
hypertensive encephalopathy.

ACUTE END ORGAN DAMAGE- CVS
2. Cardiovascular
- Myocardial ischemia/infarction – 4TH (12%).
- Acute left ventricular dysfunction
- Acute pulmonary edema – 2ND MOST COMMON
(22.5% )
- Aortic dissection
Jwan Ali AlSofi

ACUTE END ORGAN DAMAGE- Renal
3. RENAL
ARTERIOSCLEROSIS, FIBRINOID NECROSIS  overall
impairment of renal protective autoregulation mechanisms!
RESAULT:
- Worsening renal function - Acute renal failure/insufficiency (↑BP)
- Hematuria + red blood cell (RBC) cast formation
- Proteinuria.
4. Microangiopathic hemolytic anemia
Jwan Ali AlSofi

MALIGNANT HYPERTENSION
- Is a HYPERTENSIVE EMERGENCY!!!
- Leading to an acute end organ damage
- Less than 1% of ht patients develop the
malignant phase
- Avarage age of diagnosis is 40
- Men>women
Jwan Ali AlSofi

MALIGNANT HYPERTENSION-
PATHOPHYSIOLOGY
BP =PVR*CO(SV*HR)
Rate at which MAP rises more important than absolute rise
Acute rise in BP Failure of vasoconstriction Endothelial
by autoregulation damage
FIBRINOID Activates coag. and Deposition. of proteins/
NECROSIS inflammation fibrinogen in vessel
wall
- RAAS plays an important role in initiating and perpetuating BP rise by causing
vasoconstriction and fluid retention.
- THIS CYCLE MUST BE STOPPED IN ORDER TO PREVENT FURTHER VASCULAR
INJURY AND TISSUE ISCHEMIA!
Jwan Ali AlSofi

MANAGEMENT OF HC
Jwan Ali AlSofi

• The treatment of hypertensive crises must balance
preventing further end-organ damage while
maintaining tissue perfusion.
• The initial goal for blood pressure reduction is not to
obtain a normal blood pressure.
• Rapid and aggressive reductions in blood pressure can
actually induce cerebral, myocardial, or renal
ischemia or infarction if the blood pressure falls below
the range at which tissue perfusion can be maintained
by autoregulation.
MANAGEMENT
History Examination Assessment Treatment
Jwan Ali AlSofi

• Duration and degree of pre existing hypertension
• Details of antihypertensive therapy
• Compliance with medications
• Use of the over counter drugs
• History of recent operations.
History Examination Assessment Treatment
HISTORY
Jwan Ali AlSofi

CLINICAL SYMPTOMS
C.V:
• palpitations,
• arrhythmias,
• chest pain,
• dyspnea,
• pul. Edema.
BRAIN:
• headaches,
• nausea,
vomiting,
• blindness,
• seizures,
• coma
KIDNEY:
• oliguria,
• hematuria,
• proteinuria,
• electrolyte
imbalance,
• uremia,
• azothemia
EYE:
• flashes,
• scotoma
GENERAL:
• sweating,
• pallor,
• flushes,
• tinnitus,
• epitaxis,
• fear of death
Jwan Ali AlSofi

Lab tests & investigations may be required:-
- CBC,
- ECG,
- urinalysis,
- renal function
- Echo.
- consider head imaging if neurological symptoms
are present
ASSESMEN with INVESTIGATION
Jwan Ali AlSofi

Emergency
• rarely develop in patients
without a previous history of
hypertension
• occur in patients with
pheochromocytoma or renal
vascular disease
• Cerebral infarctions,
encephalopathy and
intracranial or subarachnoid
hemorrhage.
• acute heart failure (HF) and
pulmonary edema and acute
myocardial infarction, unstable
angina. Acute dissection,
eclampsia.
Urgency
• headache (42%) and
dizziness (30%). Other
symptoms include visual
changes, chest discomfort,
nausea, epistaxis, fatigue,
and psychomotor agitation.
• Not all patient present with
same symptoms
• 90% of patients had a
history of hypertension
Jwan Ali AlSofi

TREATMENT OF HYPERTENSIVE
EMERGENCY

MALIGNANT HYPERTENSION-
THERAPY - general
- HOSPITALIZATION
- RELAXATION (NON STRESSED ENV.)
SCREEN FOR END ORGAN DAMAGE
INITIAL AIMS:
1. CORRECTION OF MEDICAL COMPLICATION
2. REDUCTION OF MAP BY 20-25% IN THE 1ST HOUR
3. REDUCTION OF DIASTOLIC PRESSURE TO 13 OVER MINUTES
TO HOURS HOURS=110 mmHg (BUT NOT BELOW <95 mmHg –
IN ORDER NOT TO CAUSE CEREBRAL HYPOPERFUSION)
BP should be reduced
- immediately-
- gradually
(Specifically)
DRUGS should be used i.v
Jwan Ali AlSofi

Hypertensive Emergency
THERAPY – IV DRUGS
Jwan Ali AlSofi

THERAPY – IV DRUGS cont.
2 MAIN CLASSES OF DRUGS:
1.Vasodilators:
Nitroprusside
Nitroglycerine
Nicardipine
Hydralazine
Enalapril
Fenoldopam
2. Adrenergic inhibitors
Labetalol (a+b blocker)
Esmolol (b-1 selective blocker)
Phentolamine (a1 blocker)
Jwan Ali AlSofi

THERAPY – SPECIFIC DRUGS
1. NITROPRUSSIDE :
- 1ST CHOICE FOR HT CRISIS!
- ONSET 30 SEC FOR FEW MIN
VEINS + ARTERIES
DECREASE PRELOAD = USED IN ACUTE MI!
SIDE EFFECT: THIOCYANIDE TOXICITY, METHEMOLOBINEMIA,
HYPOTHYRODISM
2. NITROGLYCERIN:
- Coronary vasodilator
- Direct venodilator (variable arterial effects)
SIDE EFFECT: headaches and tachycardia ,Methemoglobinemia
3. LABETALOL:
Combined alpha & beta blocker
Beta blockade blunts reflex tachycardia from alpha blockade
Myocardial depression
Caution in patients with reactive airway disease
Jwan Ali AlSofi

Hypertensive Emergency –
THERAPY – SPECIFIC DRUGS
4. FENOLDOPAM : (DOPAMIN AGONIST)
Short acting (30 MIN)
Rapid elimination upon discontinuation
No dosing adjustment for pre-existing renal or hepatic impairment
Increases renal blood flow and maintains GFR
5. HYDRALAZINE (oral):
- Strict arteriole vasodialator
-3rd 4th option in HT crisis.
Jwan Ali AlSofi

Hypertensive Emergency THERAPY:
SPECIFIC RECOMMENDATION FOR DIFFERENT
CLINICAL FORMS (exmamples)
1. Hypertensive encephalopathy
Preferred medications :
Labetalol
Nicardipine
Esmolol
Medications to avoid :
Nitroprusside (was used in the past- caused ICP )
Hydralazine
Treatment guidelines: Reduce mean arterial pressure (MAP) 25% over 8
hours.
Jwan Ali AlSofi

Hypertensive EmergencyTHERAPY:
2. Aortic dissection –
Immediate redn. 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.
Preferred medications
Labetalol
Nicardipine
Nitroprusside (with beta-blocker)
Esmolol
Morphine sulfate
Medications to avoid
Avoid beta-blockers if there is aortic valvular regurgitation or suspected
cardiac tamponade, HYDRALAZINE (increase shear stress)
Treatment guidelines: Maintain SBP <110 mm Hg, unless signs of end-organ
hypoperfusion are present.
+Narcotic analgesics
TIME TO ACHIEVE: 20 MINUTES!!!!!
Jwan Ali AlSofi

3. Preeclampsia/eclampsia
Hydralazine
Labetalol
Nifedipine
Medications to avoid
Nitroprusside
Angiotensin-converting enzyme inhibitors
Esmolol
Treatment guidelines: In women with eclampsia or preeclampsia, SBP should
be <160 mm Hg and DBP <110 mm Hg in the prepartum and intrapartum
periods. If the platelet count is <100,000 cells mm3 BP should be
maintained below 150/100 mm Hg. Patients with eclampsia or
preeclampsia should also be treated with IV magnesium sulfate to
avoid seizures
Jwan Ali AlSofi

4. CARDIAC CRISIS
L.V FAILURE AND PUL. EDEMA
Nitroglycerin
Enalaprilat
Nitroprusside
Treatment guidelines: Treatment with vasodilators (in addition to diuretics) for SBP
≥140 mm Hg. IV or sublingual nitroglycerin is the preferred agent
BP CONTROL IS SECONDARY to the primary problem - open the infarct
related artery and treat pain, diurese and oxygenate those in pulmonary
edema
Jwan Ali AlSofi

4. RENAL INSUFFICENCY:
Goal is to prevent further renal damage by
maintaining adequate blood flow.
Preferred medications:
Nitroprusside
Jwan Ali AlSofi

Hypertensive Emergency-
PROGNOSIS
Median survival duration:144 months
for all patients presenting to ED with hypertensive
emergency.
5 yr survival rate :74%.
Jwan Ali AlSofi

TREATMENT OF HYPERTENSIVE EMERGENCY
GOAL
• reduce MAP by no more than 20-25%, DBP to 100-
110mm Hg within few minutes to 2 hours.
• More aggressive and rapid BP reduction (Acute
Pulmonary edema ,Aortic dissection)
• More slowly for acute cerebrovascular damages with
monitoring of neurological status.
• Constant infusion of intravenous agents required
MANAGEMENT
Jwan Ali AlSofi

Target of BP in HYPERTENSIVE EMERGENCY
Jwan Ali AlSofi

GOAL
• reduce MAP by no more than 20-25%, DBP to 100-
110mm Hg within few minutes to 2 hours.
• More aggressive and rapid BP reduction (Acute
Pulmonary edema ,Aortic dissection)
• More slowly for acute cerebrovascular damages with
monitoring of neurological status.
• Constant infusion of intravenous agents required
Jwan Ali AlSofi

URGENCY

GOAL
• Overall Goal of Management: reduce SBP by ~ 25% over
24‐48 hours.
• More conservative BP lowering reduces the risk of
potential adverse effects (i.e. perfusion complications
worsening incidence of MI, stroke, and death) associated
with more aggressive BP lowering if the blood pressure
falls below the range at which tissue perfusion can be
maintained by autoregulation .
• All treatment strategies should consider the patient’s
comorbidities and risk of adverse events.
• Treated by oral medications not IV.
URGENCY
Jwan Ali AlSofi

TREATMENT OF HYPERTENSIVE URGENCY
GOAL
• Overall Goal of Management: reduce SBP by ~ 25% over
24‐48 hours.
• More conservative BP lowering reduces the risk of
potential adverse effects (i.e. perfusion complications
worsening incidence of MI, stroke, and death) associated
with more aggressive BP lowering if the blood pressure
falls below the range at which tissue perfusion can be
maintained by autoregulation .
• All treatment strategies should consider the patient’s
comorbidities and risk of adverse events.
MANAGEMENT
Jwan Ali AlSofi

Take-Home Points
 Fundoscopy and urine dip are key in the
assessment of the severely hypertensive
patient who you are working up for a possible
hypertensive emergency
 Keep a high index of suspicion for
hypertensive encephalopathy in the severely
hypertensive and altered or comatose patient
with or without seizures or cortical blindness
 Treat the patient and not the number
Jwan Ali AlSofi

Hypertensive Crisis.ppt

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Hypertensive Crisis.ppt

Similar to Hypertensive Crisis.ppt (20)

More from Jwan AlSofi

More from Jwan AlSofi (20)

Recently uploaded

Recently uploaded (20)

Hypertensive Crisis.ppt

Editor's Notes