A 51-year-old man presented to the emergency department with sudden onset of left-sided weakness, severe headache, slurred speech and left facial droop. His blood pressure was extremely elevated at 260/172. Imaging showed he had suffered a right basal ganglia hemorrhagic stroke. His history of poorly controlled hypertension due to non-adherence to medications was likely a major contributing factor to his stroke.

1. Internal medicine
training session (2)
Hypertension
Dr. Ahmed Othman Abodooh
Assistant lecturer of internal medicine, Sohag university

2. Case (1)

3. Case (1)
 36 y/o white female
 􀂃 PMH
 − Recently returned to work 10
weeks after the birth of first child
 − Family history of diabetes
 − No history of smoking

4.  Tests Ordered Before Your Visit Today
 ECG-normal
 Labs
 Cr: 0.9 mg/dL; Na: 135 mmol/L;
 glucose: 97 mg/dL; HCT: 35;
 TSH: 2.1; K: 4.2 mmol/L
 Total cholesterol: 160 mg/dL
 HDL: 66 mg/dL
 LDL: 120 mg/dL
 Vitals
 HR: 88 bpm, BP: 138/89mm/Hg,
 BMI: 23

5. What is her BP stage?
 normotensive
 prehypertension
 stage 1 hypertension

6. What is her BP stage?
 normotensive
 prehypertension
 stage 1 hypertension

8. What do you recommend
now?
 A. Diet and lifestyle modification
 B. Begin drug therapy
 C. Ask her to come back for a BP
recheck in one week.
 D. All of the above.
 E. A & C

9. What do you recommend
now?
 A. Diet and lifestyle modification
 B. Begin drug therapy
 C. Ask her to come back for a BP
recheck in one week.
 D. All of the above.
 E. A & C

11. week Follow-up She returns in a
week. She’s begun a daily exercise
program and her BP on return is
138/88 mm Hg. What is the correct
diagnosis?
 A. Normal BP
 B. Prehypertension
 C. Stage 1 hypertension
 D. Not sure

12. 1-week Follow-up
 she returns in a week. She’s begun a daily
 exercise program and her BP on return is
 138/88 mm Hg. What is the correct diagnosis?
 A. Normal BP
 B. Prehypertension
 C. Stage 1 hypertension
 D. Not sure

13. Treatment Alternatives, What is
the best treatment for her at this
point?
 A. Diet and lifestyle modification,
and regular
 follow-up of her BP
 B. Drug therapy
 C. Both of the above
 D. Have her fill out her “bucket
list” and enjoy the
 last year of her life.

14. Treatment Alternatives
 What is the best treatment for Vicki
at this point?
 A. Diet and lifestyle modification,
and regular follow-up of her BP
 B. Drug therapy
 C. Both of the above
 D. Have her fill out her “bucket
list” and enjoy the
 last year of her life.

15. Our patient @1-12 year later

17. Present Days Everything
to be EVIDENCE
BASED…!!!!!

18. RECOMMENDATIONS
1-5 –address questions 1 and 2 concerning
thresholds and goals for BP treatment.
6,7,8 – address question 3 concerning selection of
antihypertensive drugs.
9 – summary of strategies based on expert opinion
for starting and adding antihypertensive drugs.

19. Case 2
 MR Ali is 70 year old ,complaining
from headache ,no evidence of
D.M,or CKD his blood pressure is
145/90 at the first reading then
140/85 at the second reading.

20. What will you do?
 A- Start antihypertensive drug.
 B-Diet modification and follow up
 C-both A,B

21. What will you do?
 A- Start antihypertensive drug.
 B-Diet modification and follow up
 C-both A,B

22. RECOMMENDATION 1
 In the general population aged ≥60 years,
initiate pharmacological treatment to lower BP at
SBP of ≥150 mm Hg or
DBP of ≥ 90mm Hg and
treat to a goal
SBP < 150 mm Hg and
DBP <90 mmHg.
 Strong recommendation – Grade A.

23. Corollary
Recommendation
 In the General Population aged ≥60 yrs,
If pharmacological treatment for high BP results in
lower achieved SBP (for example <140 mm Hg) and
treatment is not assosciated with adverse effects on
health or quality of life, treatment does not need to be
adjusted.
 Expert opinion – Grade E.

24. Case 3
 MR Hemdan is 50 year old
,complaining from headache ,no
evidence of D.M,or CKD his blood
pressure is 145/90 at the first
reading then 140/90 at the second
reading.

25. What will you do?
 A- Start antihypertensive drug.
 B-Diet modification and follow up
 C-both A,B

26. What will you do?
 A- Start antihypertensive drug.
 B-Diet modification and follow up
 C-both A,B

27. RECOMMENDATION 2
 In the general population < 60 yrs,
Initiate pharmacological treatment to lower BP
at DBP of ≥90 mmHg and
treat to a goal
DBP of lower than 90 mmHg.
 For ages 30-59 years,Strong recommendation -Grade A.
 For ages 18-29 years.Expert opinion –grade E.

28. DBP trials
 HDFP(Hypertension Detection and Follow uP)
 Hypertension – Stroke Cooperative
 MRC
 ANBP
 VA Cooperative
 Treatment to a lower DBP goal lower than 90 mm Hg reduces
cerebrovascular events,HF,overall mortality.
 No benefit of treatment to a target DBP of 80,85 mm Hg compared to 90
mm Hg – HOT trial(not statistically significant in outcomes).

29. RECOMMENDATION 3
 In the General Population younger than 60years,
initiate pharmacological treatment to lower BP
at SBP of ≥140 mm Hg and
treat to a goal SBP of < 140 mm Hg.
 Expert opinion – Grade E.

30. Case 4
 MR khaled admitted to hospital with
generalized body swelling and
decrease in urine output on
examination he has genealized
anasarca and his BP 135/85,he has
albumin+++ in urine and his 24 hr
urinary protein is 5000 mg with
serum creatinine is 3.2 mg/dl

31. What will you do?
 A- Start antihypertensive drug.
 B-no need to start

32. What will you do?
 A- Start antihypertensive drug.
 B- no need

33. RECOMMENDATION 4
 In the Population aged 18 years or older with CKD,
Initiate pharmacological treatment to lower BP at
SBP of ≥ 140 mm Hg
or
DBP of ≥ 90 mmHg
and
treat to goal
SBP of < 140 mm Hg and
DBP < 90 mm Hg.
 Expert opinion – grade E.
(Younger <70 yrs with eGFR or measured GFR <60 ml/min/1.73m2
People of any age with albuminuria >30mgalb/g of creatinine)

34. RECOMMENDATION 5
 In the Population aged 18 years or older with diabetes,
initiate pharmacological treatment to lower BP at
SBP of ≥ 140 mm Hg or
DBP of ≥90 mm Hg
and treat to a
goal SBP < 140 mm Hg
goal DBP < 90 mm Hg
 Expert opinion Grade E.

35. Back to MR ALI
 MR Ali is 50 year old ,complaining
from headache ,no evidence of
D.M,or CKD his blood pressure is
145/90 at the first reading then
140/90 at the second reading.

36. With what you will start?
 A-Thiazide diuretics
 B-BB
 C-loop diuretics(Lasix)
 D-Aldomet

37. With what you will start?
 A-Thiazide diuretics
 B-BB
 C-loop diuretics(Lasix)
 D-Aldomet

38. RECOMMENDATION 6
 In the General NonBlack population,including those with Diabetes,
initial AntiHypertensive treatment should include a
Thiazide -type Diuretic,
Calcium Channel Blocker(CCB),
Angiotensin Converting Enzyme inhibitor(ACEI),or
Angiotensin Receptor Blocker(ARB).
 Moderate recommendation –GradeB.

39. Not recommended as first line drugs
 Dual alpha1 +b blocking agents (Carvedilol)
 Vasodilating b blocking agents (Nebivolol)
 Central a2 adrenergic agonists (Clonidine)
 Direct vasodilators (Hhydralazine)
 Alodsterone receptor antagonists (Spironolactone)
 Peripherally acting adrenergic antagonists (Reserpine)
 Loop diuretics(Furosemide)
ONTARGET trial was not eligible because Hypertension was not
required for inclusion in the study.(Telmisartan,Ramipril).

40. RECOMMENDATION 7
 In the General Black population,
including those with Diabetes,
initial antihypertensive treatment should include a
thiazide – type diuretic or CCB.
 For general black population:Moderate Recommendation –GradeB.
 For black patients with diabetes:Weak recommendation –GradeC.

41. RECOMMENDATION 8
 In the population aged 18 years or older
with CKD and hypertension,
initial (or add-on) antihypertensive treatment should include
ACEI or ARB to improve kidney outcomes.
 This applies to all CKD patients with hypertension regardless
of race or diabetes status.
 Moderate Recommendation – GradeB.

42. What if patient is a black and having CKD?
 In black patients with CKD and proteinuria,an ACEI or ARB is
recommended as initial therapy because of the higher likelihood
of progression to ESRD. AASK trial.
JAMA.2002;288(19):2421-2431
 In black patients with CKD but without proteinuria,the choice
for initial therapy is less clear and includes a thiazide- type
diuretic,CCB,ACEI or ARB.
 ACEI /ARB can be used as an initial drug or second line drug.

43. Case 5
 Fahmy Amer
 55 y/o male presents for follow-up.
 Past Medical History
 − Blood pressure on initial presentation was 160/95,
now 15o/90
 − Non-smoker, no known CAD
 − Fasting glucose 140 mg/dL (repeated from previous
visit, when it was 142 mg/dL); A1C: 8.2%
 − Initial therapy: Diet modification, increased exercise,
and started 25 mg of HCTZ

44. Next action?
 A. Continue dietary modification and
exercise recommendations
 B. Begin therapy with an ACEi, ARB, or
CCB
 C. Refer to dietitian for diet counseling
 D. Begin metformin
 E. All of the above
 F. A & B only

45. Next action?
 A. Continue dietary modification
and exercise recommendations
 B. Begin therapy with an ACEi, ARB,
or CCB
 C. Refer to dietitian for diet
counseling
 D. Begin metformin
 E. All of the above
 F. A & B only

46. 2-Week Follow-Up
 Mr. Amer returns, having visited with the dietitian
and is trying to implement his recommendations.
He has started walking daily. His BP at this visit is
140/90; 2hr postprandial glucose is 126 mg/dL.
What should we consider next?
 A. Increase the dose of the ACEi/ARB or CCB
 B. Consider additional up-titration or new
medications for diabetes, High BP or cholesterol as
needed.
 C. Initiate a dose of aspirin, if not already started
 D. All of the above

47. 2-Week Follow-Up
 Mr. Amer returns, having visited with the dietitian
and is trying to implement his recommendations.
He has started walking daily. His BP at this visit
is 136/84; 2hr postprandial glucose is 126 mg/dL.
What should we consider next?
 A. Increase the dose of the ACEi/ARB or CCB
 B. Consider additional up-titration or new
medications for diabetes, High BP or cholesterol
as needed.
 C. Initiate a dose of aspirin, if not already started
 D. All of the above

48. 1-Month Follow-Up
 Mr. Amer returns for follow-up.
 His BMI is 29;
 2hr postprandial glucose is 92
mg/dL;
 HgA1c is 6.8% and his BP is 120/75.

49. Trials results have an effect…

50. The placebo effect…

52.  Thiazide diuretics
Natrilix SR, Hypotense,Indamide
 CCC
Epilat (3),Adalat,Nimotop
Norvasc(5-10),alkapress,windipine,myodura

53. ACEIs
Capoten,capotril,hypopress
Enalapril(5-20), Ezapril(10)
Zestril(5-10-20), sinopril
Coversyl(5-10)
Tritace(1.25-2.5-5-protect)

54.  ARBS
 Tareg(40-80-160)
 Candesar(4-8),Atacand
 Erastapex(5-20-40)

55. RECOMMENDATION 9
 If goal BP is not reached within a month of treatment,
Increase the dose of the initial drug or
add a second drug from one of the classes in recommendation6 (thiazide-
type diuretic,CCB,ACEI,ARB).
 If goal BP cannot be reached with 2 drugs,
add and titrate a third drug from the list provided.
 Donot use an ACEI and ARB together in the same patient.
 If goal BP cannot be reached using the drugs in recommendations, because
of a contraindication or the need of > 3 drugs to reach goal
BP,antihypertensive drugs from other classes can be used.
 Referral to a hypertension specialist.
 Expert opinion –GradeE.

60. Case 6
 51 year old man admitted to an
outside hospital
 CC: Sudden onset of left-sided
weakness, severe headache, slurred
speech and left facial droop
 BP 260/172
 Head CT Scan showed Right basal ganglia
hemorrhage with shift
 HPI: Transported by ambulance to
SUH.
 Intubated en route due to declining
mental status

61. Case 6
 PMH - Hypertension - according to
wife, patient was non-adherent
with prescribed medications
 Out patient medications and allergies -
not available
 Family History +for HTN/CVA
 Exam SUH - BP 196/130
 Positive for Left dense hemiparesis

62. Case 6
 Hospital day 2
 Dilated right pupil
 Emergent right frontotemporal
craniotomy and evacuation of clot
 Subsequent Hospital Course
 Difficult to control BP
 Pneumonia

63. Define his hypertension crisis.
 A-Hypertension emergency
 B-Hypertension Urgency

64. Define his hypertension crisis.
 A-Hypertension emergency
 B-Hypertension Urgency

65. Question 1
 What is the primary reason for
hypertensive emergencies today?
1. Renovascular Disease
2. Pheochromocytoma
3. Non-adherence to anti-hypertensive
medication
4. Hyperaldosteronism
5. Erythropoeitin

66. What is the primary reason
for hypertensive emergencies
in the USA today?
1. Renovascular Disease
2. Pheochromocytoma
3. Non-adherence to
anti-hypertensive
medication
4. Hyperaldosteronism
5. Erythropoeitin
10

67. Hypertensive Emergency
 According to the Joint National
Committee on Hypertension Report
 Severely elevated blood pressure with
signs and symptoms of acute end organ
damage
 Requires hospitalization
 Requires parenteral medication

68. Hypertensive Urgency
 Severely elevated blood pressure
without signs and symptoms of
acute end organ damage
 Can be managed as an outpatient
 Can be managed with oral
medications

69. Hypertensive Emergency
 Damage
Heart - CHF, MI, angina
Kidneys - acute kidney
injury, microscopic
hematuria
CNS - encephalopathy,
intracranial hemorrhage,
Grade 3-4 retinopathy
VasculatureVasculature -
aortic dissection,
eclampsia

70. Epidemiology
 Common associations
Previous history of hypertension
Lack of a primary care physician
Non adherence to
antihypertensive regimen
Elicit drug use (cocaine)

71. Etiology
 Essential hypertension : Inadequate blood pressure control and noncompliance are
common precipitants (MOST COMMON)
 Renovascular
 Eclampsia/pre-eclampsia
 Acute glomerulonephritis
 Pheochromocytoma
 Anti-hypertensive withdrawal syndromes
 Head injuries and CNS trauma
 Renin-secreting tumors
 Drug-induced hypertension
 Burns
 Vasculitis
 Post-op hypertension
 Coarctation of aorta (very rare)
2nd common

72. Question 2
 What is the most common complaint in
hypertensive emergency?
1. Neurologic defect
2. Gross Hematuria
3. Chest pain
4. Headache
5. Epistaxis

73. What is the most common complaint
in hypertensive emergency?
1. Neurologic defect
2. Gross Hematuria
3. Chest pain
4. Headache
5. Epistaxis

74. Clinical Presentation
 Variable
 Zampaglione et al (Hypertension
27:144, 1996)
 14, 209 ER visits in one year period
 108 met definition of hypertensive
emergency (0.8%)
 Mean Systolic BP 210 + 32
 Mean Diastolic BP 130 + 15

75. Clinical Presentation
 Frequency of signs and symptoms
Chest Pain 27%
Dyspnea 22%
Neuro defect 21%
Interestingly….
Headache was only 3% and epistaxis was 0%
in this study

76. Question 3
 Hypertensive emergency is associated with
a threshold BP of
1. Systolic > 225 mm Hg
2. Diastolic > 110 mm Hg
3. Systolic > 250 mm Hg
4. Diastolic > 120 mm Hg
5. All of the above

77. Hypertensive emergency is
associated with a threshold
BP of
1. Systolic > 225 mm Hg
2. Diastolic > 110 mm Hg
3. Systolic > 250 mm Hg
4. Diastolic > 120 mm Hg
5. Non of the above

78. Threshold BP
 There is no specific BP where hypertensive
emergencies occur
 But, organ dysfunction is rare with diastolic
BPs < 130 mm Hg
 Rate of increase may be more important
 Hence, encephalopathy will occur at lower BPs
in pregnancy and in children

79. Initial Evaluation
 Focused history
 History of hypertension?
 How well is hypertension controlled?
 What antihypertensives?
 Adherence to antihypertensive regimen?
 Last dose of antihypertensive?

80. Initial Evaluation
Social History
Recreational Drugs
Amphetamines
Cocaine
Phencyclidine

81. Initial Evaluation
 Confirm BP in both arms
 Use appropriate sized BP cuff
 Cuff that is too small
BP cuffs that are too small falsely
elevate BP measurements in
obese patients

83. Initial Evaluation
 Assess for end-organ damage
 Vascular Disease
 Assess pulses in all extremities
 Auscultate over renal arteries for bruits
 Cardiopulmonary
 Listen for rales (CHF)
 Murmurs or gallops

84. Initial Evaluation
 Neurologic Exam
 Hypertensive Encephalopathy - mental
status changes, nausea, vomiting,
seizures
 Lateralizing signs uncommon and
suggest cerebrovascular accident
 Retinal Exam

85. Lab Testing
 ECG
 LVH, look for signs of ischemia, injury,
infarct
 Renal Function Tests (urine included)
 Elevated BUN, Creatinine, proteinuria,
hematuria
 CBC
 CXR - pulmonary edema, aortic arch,
cardiac enlargement

86. Lab Testing
 Aortic Dissection?
 Suspect with severe tearing chest pain, unequal
pulses, widened mediastinum
 Contrast Chest CT Scan or MRI
 Pulmonary Edema/CHF
 Transthoracic Echocardiogram
 Differentiate between systolic dysfunction,
diastolic dysfunction, mitral regurgitation

87. Management
 Elevated BP without target organ
damage
 Hypertensive urgency
 Oral meds
 Goal - gradual reduction of BP over
24 - 48 hours

88. ORAL DRUGS FOR HTN
URGENCIES
Drug Initial dose Onset duration Adverse effects

89. Management
 Elevated BP with target organ
damage
 Hypertensive emergency
 Parenteral meds
 Goal - Reduce diastolic BP by 10-
15% or to 110 mm Hg over a period
of 30 - 60 minutes

90. 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 (no
intermittent IV boluses/oral/sublingual drugs- drastic
BP fall).

91. Normalisation of BP is usually not
recommended*
How fast and how much BP to be lowered to be given importance.

92. Why ??
Sudden fall in BP may cause acute hypoperfusion of vital organs
and results in myocardial ischemia or infarction, hemiplegia,or
acute renal failure.
Older patients with long lasting hypertension and preclinical organ
involvement (LVH, atherosclerosis and arteriolar remodelling) are
at risk of these complications as the lower limit of autoregulation
shifted to right.

93. Management
 Where?
 ICU with close monitoring
 Severe requires intra-arterial BP
monitoring
 Which Parenteral meds?
 Depends on the situation

94. Question 4
 Which of the following drugs should not be
used to treat hypertensive emergency?
1. Sublingual Nifedipine
2. Labetolol
3. ACE Inhibitors
4. Nicardipine
5. 1 and 3

95. Which of the following drugs should not
be used to treat hypertensive
emergency?
1. Sublingual
Nifedipine
2. Labetolol
3. ACE Inhibitors
4. Nicardipine
5. 1 and 3

96. Preferred Agents
 Beta blockers
 Labetolol
 Esmolol
 Calcium Entry blocker
 Nicardipine
 Dopamine-1 receptor agonist
 Fenoldapam
 Vasodilators - nitroprusside/nitroglucerin

97. Sodium nitroprusside
 Potent short acting arterial and venous dilator
(reduces pre- and after- load)
 Rapid onset of action.(seconds)
 Continuous intra-arterial BP monitoring required.
 Infusion chamber and tubing to be covered.
  intracranial pressure (caution in intracerebral hemorrhage)
 Induces coronary steal (non selective coronary vasodilation)
 Increases mortality in pts with acute MI. (NEJM,1982)
 Thiocyanate toxicity (nausea,vomiting,lactic acidosis and altered mental status)
 Usually rare, seen in pts with renal ,hepatic dysfunction.

98. Fenoldopam
 A peripheral dopamine-1 receptor antagonist (DA1). {highly
specific}
 10 –fold more potent than dopamine as a renal vasodilator.
 Antihypertensive effect by combined natriuretic and vasodilatory effect
(esp. intrarenal arteries)
Not to be used as prophylactic agent for preventing CIN
(CAFCIN Trial)
Agent of choice in hypertensive emergencies assosciated with renal
dysfunction.
 Adv effects – hypotension ,hypokalemia

99. Nicardipine
 Second generation DHP CCB.
 Strong cerebral and coronary vasodilation.
 Onset of action 5-15 min, Duration being 2-6 hrs.
 Increases both stroke volume and coronary blood flow with a favourable effect on
myocardial oxygen balance.
 CAD with Systolic HF. C/I in Aortic stenosis.
 Dosage independent of weight.
 Infusion rate of 5mg/h – 2.5 mg/h increments every 5 min –max being 15 mg/h.
 IV Nicardipine maintained BP in Treatment range > IV Labetalol (CLUE trial)
J Emerg Med 1987:5:463-473

100. Clevidipine
Third generation, intravenous, dihydropyridine caclium channel
antagonist.
FDA approval (2008)
Ultra short half life of about 1 min.
Potent arterial vasodilation (no effect on venous capacitance,
myocardial contractility)*
No significant adverse effect on heart rate’.
Injectable emulsion.
99.9% bound to protein.
Safe in pts with renal,hepatic dysfunction.
C/I –allergies to soy products,eggs and egg products,defective lipid
metabolism.
*Rivera et al .,2010,Polly et al 2011.
50mg/100ml

101. Dosage
•An IV infusion at 1–2 mg/hour is recommended for initiation and
should be titrated by doubling the dose every 90 seconds.
• As the blood pressure approaches goal, the infusion rate should be
increased in smaller increments and titrated less frequently.
•The maximum infusion rate for Cleviprex is 32 mg/hour.
•Most patients in clinical trials were treated with doses of 16 mg/hour
or less.
No more than 1000 mL (or an average of 21 mg/hour) of Cleviprex
infusion is recommended per 24 hours..
Am J Cardiovascular Drugs 2009;9;117-134

102. Labetalol
 Combined selective 1 adrenergic and non selective β
adrenergic receptor blocker (1:7).
 Hypotensive effect – in 2-5 min after IV admin.
 Maintains cardiac output (unlike other BB).
 Reduces SVR, but does not decrease PBF.
 Cerebral,renal,coronary blood flow maintained.
 Less placental transfer can be used in pregnancy induced HTN
emergency.
 Metabolised by liver.
 Oral/IV.

103. Esmolol
 Ultrashort acting cardioselective β adrenergic blocking agent.
 Ideal β blocker in critical cases.
 Useful in severe postoperative HTN.
 Onset of action is within 60 sec
 Duration of action being 10-20min.
 Rapid hydrolysis of ester linkages by RBC esterases(metabolism), not
dependent on renal or hepatic function.
 0.5 to 1mg/kg loading dose over 1min,followed by an infusion -
50ug/kg/min.(max 300ug/kg/min)

104. Not to use
Sublingual NifedipineDrug is poorly soluble, not absorbed through buccal mucosa
Sudden uncontrolled and severe reductions in BP,may precipitate
cerebral,renal and myocardial ischemic events.
Lack of clinical documentation attesting to a benefit from its use.
The Cardiorenal Advisory Committee of the FDA has concluded “that
the practice of administering SL/oral nifedipine should be abandoned
because this agent is not safe nor efficacious”.
.

105. Scenarios
 Our Case - Acute ischemic
stroke/cerebrovascular bleed
 Agents
 Fenoldopam
 Labetolol
 Nicardipine

106. CVA or Ischemic Stroke
 BP elevation after CVA or ischemic
stroke can be protective to preserve
cerebral perfusion
 Hold on aggressive lowering unless
 Thrombolytic therapy anticipated or
 BP excessively high ( SBP > 220 mm Hg or
DBP >120)
 BP Goal for thrombolytic therapy is to
lower SBP if > 185 or DBP >110

107. Cardiac Conditions
 Acute Pulmonary Edema with
systolic dysfunction
 Nicardipine
 Fenoldopam
 Sodium nitroprusside
 Nitroglycerin
 Loop diuretic

108. Cardiac Conditions
 Acute Pulmonary Edema with
diastolic dysfunction
 Esmolol, metoprolol, labetolol
 verapamil
 Nitroglycerin
 Loop diuretic

109. Cardiac Conditions
 Acute myocardial ischemia
Esmolol, labetolol
Nitroglycerin

110. Sympathetic Crisis
 Generally in association with
recreational drugs such as cocaine,
amphetamine or phencyclidine
 Sudden cessation of clonidine or
Beta-adrenergic antagonist
 Pheochromocytoma - rare

111. Question 5
 Which of the following drugs should be
avoided in sympathetic crises with
hypertensive emergency?
1. Phentolamine
2. Benzodiazepine
3. Labetolol
4. Nicardipine
5. Fenoldopam

112. Which of the following drugs should be
avoided in sympathetic crises with
hypertensive emergency?
1. Phentolamine
2. Benzodiazepine
3. Labetolol
4. Nicardipine
5. Fenoldopam

113. Sympathetic Crisis
 Beta-adrenergic antagonists will result in
unopposed alpha-adrenergic stimulation
 In cocaine use, Beta blockers can
 Increase blood pressure
 Worsen coronary artery vasoconstriction
 Decrease survival
 Avoid beta blockade (including non selective
agents such as labetolol)

114. Sympathetic Crisis
 Recommended Drugs
Nicardipine
Fenoldopam
Verapamil
Benzodiazepine
If pheo suspected use
phentolamine

115. Aortic Dissection
 Treatment is paramount
 75% of patients with ascending aortic
dissection die in 2 weeks of the acute
episode without successful therapy
 5 year survival is 75% with successful
intervention
 Khan et al. Chest 2002, 122:311
 Kouchoukos New Engl J Med 1997; 336:1876

116. Aortic Dissection
 Vasodilator alone?
Causes reflex tachycardia
Increases cardiac ejection
velocity
Increases aortic shear forces
Extends the dissection

117. Aortic Dissection
 Standard therapy
Beta-adrenergic blocker plus
vasodilator
Esmolol + Nicardipine or
fenoldopam
 Nitroprusside can be used as
well

118. Acute Post Operative Hypertension
 Frequent in post-operative state (20-75%)
 Hyper-responsiveness to surgical trauma
 Increased stress hormones?
 Activation of RAA?
 Also hypothermia, hypoxia, carbon dioxide
retention, bladder distention

119. Acute Post Operative Hypertension
 Prevention
 Safe to give antihypertensives pre-op
 Hold diuretics
 Treatment - BP thresholds vary
 Control pain and anxiety
 While NPO use nicardipine, esmolol or
labetolol
 Resume oral medications when possible

120. Thank you!
Questions?