The document discusses hypertensive emergencies and urgencies. It defines hypertensive emergencies as severe high blood pressure with impending or progressive organ damage, while urgencies involve severe elevation in BP without organ damage. Various intravenous antihypertensive medications are reviewed for treating emergencies, including vasodilators like sodium nitroprusside, nicardipine, and nitroglycerin, as well as adrenergic inhibitors like labetalol, esmolol, and phentolamine. The ideal drug lowers blood pressure without compromising organ blood flow and has a rapid onset and offset of action with minimal side effects. Treatment goals and medication choices depend on the underlying cause and end organ

1. HYPERTENSIVE EMERGENCIES
AND URGENCIES
Dr Manjuprasad Moderator:Dr
Padmaja Udaykumar

2. • Hypertension (HTN) or high blood pressure - arterial
hypertension
• Chronic medical condition- BP
• Heart - work harder than normal to circulate blood
through the blood vessels
2

3. JNC- 7
• Normal – SBP<120 and DBP<80
• Prehypertension – SBP 120-139 or DBP 80-89
• Stage I hypertension – SBP 140-159 or DBP
90-99
• Stage II hypertension – SBP >160 or DBP
>100
– Hypertensive urgency
– Hypertensive emergency 3

4. • Hypertensive emergencies:
Severe elevation in BP complicated by impending or
progressive target/end organ damage
• Hypertensive urgencies:
Severe elevation in BP without any target organ damage
4

5. CNS - encephalopathy, intracranial
hemorrhage, Grade 3-4 retinopathy
Kidneys - acute kidney injury,
microscopic hematuria
Vasculature - aortic dissection, eclampsia
Heart - CHF, MI,
angina
5

6. Conditions constituting evidence of
end organ damage
• Hypertensive encephalopathy
• Intracerebral hemorrhage
• Stroke
• IHD- AMI, acute LVF with papilloedema,
angina
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7. • Eclampsia
• Life threatening arterial bleed
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8. ETIOLOGY
• Poor treatment or abrupt discontinuation of the
treatment
• Renal parenchymal disease
• Drugs
• Coarctation of aorta
• Pre eclampsia/ eclampsia
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9. PATHOPHYSIOLOGY
• Failure of normal autoregulation
• Release of vasoconstrictors from stressed walls
• Endothelium plays an important role in BP
homeostasis
• Increase in pressure starts a cycle
9

10. MANAGEMENT
• BP should never be reduced to normal values
- Risk of ischemia and infarction.
• Gen rule:
- MAP should be lowered no more than 20% in first hour
- If pt remains stable, BP lowered to 160/110 in next 2-6
. hrs
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11. Treatment goals achieved by
- continuous infusion of a short acting, titratable,
parenteral antihypertensive agent along with constant
BP monitoring
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12. TREATMENT
Medication options
1. Oral antihypertensives
• Chronic hypertensive
• Hypertensive urgency
2. IV antihypertensives
• Hypertensive emergency
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13. 13

14. IV antihypertensive
• Vasodilators
sodium nitroprusside
nitroglycerine
nicardipine
fenoldopam
hydralazine
enalaprilat
• Adrenergic
inhibitors
labetalol
esmolol
phentolamine
14

15. Ideal IV antihypertensive
• Lower BP without compromising blood flow to critical organs
• Vasodilators- preserve organ blood flow in the face
. of decreased perfusion
- also tend to increase cardiac output
15

16. Profile of ideal antiHTN
• Preserves GFR
• Few or no drug reactions
• Rapid onset and offset of action
• Minimal hypotension
• Minimal need of continuous BP monitoring
• No acute tolerance
16

17. • Ease of use and convenient
• Safe and no toxic metabolites
• Minimal sympathetic activation
• Multiple formulations for short and long term use
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18. Sodium Nitroprusside
MOA:- direct smooth muscle dilator
- Nitric oxide component
-reduces preload and after load
- causes cerebral vasodialation
• Ultra short acting
• Immediate onset - DoA : 10min
18

19. • Dose:
0.1-0.5mcg/kg/min IV infusion
titrate to desired effect
rates>10mcg/kg/min
Adverse effects/Precautions:
Cyanide toxicity
precipitous drop in BP
continuous BP monitoring
reflex tachycardia
Nausea and vomiting
Increased ICP
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20. Uses
Drug of choice:
• Perioperative HPT
• Cocaine toxicity
• Aortic dissection(combination)
• Neurologic syndromes
20

21. Nitroglycerine
MoA:
• Potent vasodilator
• Decrease preload (CO + BP)
• Decreases coronary vasospasm
• Dose: cont infusion
start 5mcg/min, incr by 5mcg/min
every 3-5min to 20mcg/min
If NO Response
increase by 10mcg/min every 3-5min,up
200mcg/min
• Onset : 2-5min/DoA : 5-10min
21

22. • Adverse effects/precautions:
– Constant monitoring is essential
– Tolerance from uninterrupted use (12hr withdrawal)
– Headache, tachycardia, flushing
• Contra ind:
– Concurrent use with PDE-5 inhibitors - causes significant
hypotension
– Head trauma/cerebral haemorrhage
– Severe anaemia
• Drug of choice:
– Acute HF
– ACS
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23. Nicardipine
• Ca channel blocker – selective arterial vasodilator
• Onset: 1-5min
DoA: 15-30min
Dose: start 5mg/hr IV infusion, titrate every
15min to max 15mg/hr.
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24. Advantages:
• Cause cerebral and coronary vasodilatation
• Precautions: can worsen/cause HF and
liver failure
can exacerbate renal insuff.
• Ideal for CNS emergencies
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25. Fenoldapam
MoA:
• Peripheral dopamine agonist (high vs low doses)
causes selective neuro vasodilatation
• mesenteric vasodilatation
• increases renal blood flow and sodium excretion
Onset – <5min, but more gentle, lasts for 30min
Standard BP monitoring is sufficient, no toxic
metabolites
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26. Dosing:
• Start at 0.1-0.3mcg/kg/min IV infusion
• May be increased in increments of 0.05-
0.1mcg/kg/min every 15min, until target BP
reached
• Max infusion rate – 1.6mcg/kg/min
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27. Precautions:
• Pts with glaucoma
• Dose related tachycardia can occur – angina
• Close BP monitoring
• Close K+ monitoring
• Caution with raised ICP
Drug of choice
• Renal insufficiency
• Stroke ( combination with nicardipine)
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28. Hydralazine
MoA:
• Decreases systemic resistance by direct vasodilation
of arterioles
Dose:
• 5-20mg IV bolus or 10-40mg IM repeat every 4-6hrs
• boluses takes 20min to work
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29. Adverse effects/Precautions
• Tachycardia, flushing, headache
• Sodium and water retention
• Increased ICP
• Adjust dose in severe renal dysfunction
• Response may be delayed and unpredictable
• Still drug of choice in pregnancy(Eclampsia)
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30. Enalaprilat
• The active component of Enalapril (hydrolyzed in liver
and kidney)
MoA:
• ACE inhibitor
Dose:
• 0.625-2.5mg every 6hr IV
• Onset – within 30 min + long half life
Adverse effects/Precautions
• Contra-indicated – volume depletion, renal vascular
disease
• Prolonged t½
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31. Labetalol
MoA:
• selective alpha blocker – reduce vascular smooth
m. resistance
• non-selective Beta blocker – ↓ cardiac inotropy and
myocard O2 consumption → prevent reflex
tachycardia
31

32. Dose:
Bolus: effect in 5-10min,max effect at 20min. (DoA:
2-6hrs).
• Cont. infusion: 0.5 – 2mg/min – titrate to
response, max 300mg
• Difficult to titrate due to very wide dose range
32

33. Advantages:
• smooth onset
• Transition to oral Rx easy (dose equivalent)
• Improve cerebral blood flow – stroke pt
• No need for ICU/Arterial line
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34. • Adverse effects/precautions
– Relative CI – Heart failure, heart block, Asthma
(bronchoconstriction)
– Vomiting, scalp tingling
– Impaired hepatic function
• Contraindicated in HPT secondary to Cocaine
use
(B-blocker effect outway the alpha effect, thus
unapposed alpha constriction)
• Drug of choice:
– Aortic dissection
– Hypertensive emergencies
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35. Esmolol
MoA:
• highly selective beta blocker
Dose:
bolus: 250-500mcg/kg IV over 1-3min
• infusion: 50-100mcg/kg/min
• may repeat bolus after 5min or increase
infusion rate to 300mcg/kg/min
Onset 1-2min / short acting
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36. Adverse effect/Precautions
• Hypotension common
• nausea
• Asthma
• 1st degree AV block
• heart failure
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37. Contraindications
• Sinus bradycardia
• Heart block
• Cardiogenic shock
• Bronchial asthma
• Uncompensated CF
Drug of choice:
• Aortic dissection ( with nitrate)
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38. Phentolamine
MoA:
• alpha adrenergic receptor blocker
Dose:
• load 5-20mg IV every 5min or
• infusion 0.2-0.5mg/min
• Onset 1-2min
Adverse effect/precautions
• tachycardia
• flushing/headache
• MI
• cerebrovascular spasm
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39. • Contra-indications
– renal impairment
– Concurrent use with PDE-5 inhibitors
– coronary or cerebral arteriosclerosis
• Drug of choice
– Cocaine associated HPT crisis
– Pheochromocytoma HPT crisis
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40. Neurological emergencies
40

41. Hypertensive encephalopathy
– reduce MAP by 25% or diastole to 100mmHg
over 8 hrs
– If neurology worsens, suspend Rx
– Drug of choice:
• Sodium nitroprusside
• Labetalol
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42. Acute Ischemic stroke
• often loss of cerebral autoregulation
• ischemic region more prone to hypoperfusion
• thus BP reduction not recommended
• unless SBP>220 or DBP>120
• UNLESS planning fibrinolysis – SBP<185
and DBP< 110
Drug of choice:
• Labetalol
• Nicardipine
• Sodium Nitroprusside
42

43. Acute ICH/SAH
• Treatment based on clinical/radiographic
evidence of raised ICP
• Raised ICP – MAP<130 (1st 24hrs)
• No raised ICP – MAP<110
Drug of choice:
• Sodium Nitroprusside
• Labetalol
• Nicardipine
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44. Cardiovascular emergencies
44

45. ACS
• Treat if SBP>160 and or DBP>100
• Reduce MAP by 20 -30% of baseline
• Nitrates should be given till symptoms
subside or until DBP<100
Drug of choice:
• Nitroglycerine
• Labetalol
• Nicardipine
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46. Acute HF (pulmonary edema)
• Treat with vasodilator (additional to diuretics)
• Sodium Nitroprusside in conjunction with
• Morphine, oxygen and loop diuretic
• Enalaprilat also an option
46

47. Aortic dissection
• anti-hypertensive Rx is aimed at reducing the
shear stress on aortic wall (BP and Pulse)
• immediate lowering of BP – lifesaving
• maintain SBP<110, unless signs of end
organ hypoperfusion
preferred Rx is combination of Morphine,
• B-blocker and vasodilator
• Nitroprusside + Labetalol
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48. Other disorders
48

49. Cocaine toxicity/pheochromocytoma
– Hpt and tachycardia rarely require specific Rx
– Alpha adrenergic blockers – preferred
– B – blockers can be added, but only after
alpha blockade.
Drug of choice
• Phentolamine
• Labetalol
• Diazepam
49

50. Pre-eclampsia/Eclampsia
– Goal SBP<160 and DBP<110 in pre-and-
intrapartum periods.
– Platelets < 100 000, BP should be maintained <
150/100
– IV Magnesium to prevent seizures
Drug of choice:
• Methyldopa
• Hydralazine
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51. Perioperative hypertension
– Target BP to within 20% of baseline, except if
potential for life threatening arterial bleeding
– Typically related to catecholamine surge post-
op.
Drug of choice:
• B-blocker
• Labetalol
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53. References
• Goodman and Gilman – 12th edition
• Rang and Dales pharmacology 7th edition
• Textbook of medical pharmacology – Padmaja
udaykumar
• Hypertensive emergencies- Louis Muller
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55. • Cheese reaction, cold remedy
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