1. Hypertensive Crisis
Isman Firdaus, MD
FIHA, FAPSIC, FAsCC, FESC, FSCAI
Pusat Jantung Nasional, Harapan Kita Hospital
Departement of Cardiology and Vascular Medicine
2. Epidemiology
Hypertensive Emergency
Estimates are that about 1% of those
with hypertension will present with
hypertensive emergency each year
That is >500,000 Americans per year
Correct and quick diagnosis and
management is critical
Mortality rate of up to 90%
3.
4.
5. Definitions:
• Hypertension:
– Stage I: 140-159/90-99
– Stage II: >160/100
• Hypertensive Urgency:
– Systolic BP >180 or Diastolic BP >120 in the
absence of end-organ damage
6. Definitions Continued:
• Hypertensive Emergencies:
– SBP >180 OR DBP>120 in the presence of end-
organ damage
• Malignant Hypertension: End-organ damage--
eyes, kidneys, brain (hemorrhage/infarct)
affected
• Hypertensive encephalopathy: Cerebral edema
leading to neurological symptoms
7. Treatment Options
• Hypertensive Urgency:
– Goal: Reduce BP to <160/100 over several hours
to day
• Elderly at high risk of ischemia from rapid
reduction of BP, therefore slower reduction in
BP in this patient population
– Previously treated hypertension:
• Increase dose of existing med or add another
med
• Reinstitution of med in non-compliant patients
8. Treatment Continued
• Hypertensive Emergency:
– Goal: Lower Diastolic BP to approximately 100-105
over 2-6 hours; max initial fall not to exceed 20 -
25%
• More aggressive decrease can lead to ischemic
stroke and myocardial ischemia
– If focal neurological sx presentobtain MRI to r/o
acute stroke (rapid BP correction contraindicated)
– Parenteral antihypertensives (IV Drip)
recommended over oral agents in hypertensive
emergency
9.
10.
11.
12.
13. Heart failure—TH, BB, ACEI, ARB, ALDO
Post MI—BB, ACEI, ALDO
High CVD risk—TH, BB, ACEI, CCB
Diabetes—TH, BB, ACEI, ARB, CCB
Chronic Renal Failure—ACEI, ARB
Recurrent stroke prevention—TH, ACEI
KEY: ACEI, angiotensin converting enzyme inhibitor; ALDO, aldosterone antagonist; ARB,
angiotensin receptor blocker; BB, b blocker; CCB, calcium channel blocker; TH, thiazide.
Oral Drug Choices often Based on
Comorbid Conditions
17. Diltiazem Multiple Effects
-
ANTI-
ANGINAL
ANTI-
ARRHYTHMIC DILTIAZEM
• Anti-arrhythmic
• Arterial dilator
• Negative inotropic
• Regression of LVH
• Post-infarct protection
if no LVF
SYSTEM
CIRCULATION
ARTERIOLAR
DILATION
AFTERLOAD
BP
ATRIAL FIB
(with digoxin)
PSVT
Opie, 2001
18. Parenteral Drugs for Treatment of Hypertensive
Emergencies ( Vasodilators )
Drugs Onset of action Duration of action
Nicardipine * 5 min 1 hr
Sodium Nitropruside immediate 1-2 min
Fenoldopam < 5 min 30 min
Nitroglycerin * 2-5 min 2-3 min
Enalaprilat 15-30 min 6 hr
Hydralazine 10-20 min 4-6 hr
Diltiazem * 5 min 30 min
Trimetaphan 5-10 min 10 min
* Available in Indonesia
19. Pathophysiologic Effects Diltiazem
• Potent vasodilator
– Inhibits vascular smooth muscle contractility and decreases
peripheral vascular resistance
• Reduce Coronary resistance
– Dilates coronary arteries and increases coronary blood flow
• Decrease Heart rate
– Rate-Pressure Product (HR x SBP) reduce myocardial oxygen
demand
– Absence of reflex tachycardia
• No adverse effects on glucose or carbohydrate metabolism
Drugs. 1990;39:757.
20. • Ischemic cardiac muscle is improved by
① Increasing insufficient coronary blood volume (O2 supply)
② Decreasing cardiac performance（HER two-sided effect）
Two-sided effect for myocardial ischemia
Thick coronary vasodilating effect
Collateral vasodilating effect
BP lowering effect
HR decreasing effect
①Increasing vascular flow in
ischemic cardiac muscle
②Decreasing cardiac performance
Improvement of O2 supply and demand in
ischemic cardiac muscle
Cardioprotective Efficacy
23. NICARDIPINE and DILTIAZEM
NICARDIPINE DILTIAZEM
Target organ Arteriole (ca
Channel)
Arteriole (ca
Channel)
Clinical effect Vasodilatation :
BP decreased
Vasodilatation :
BP decreased
Heart Rate
24. Diltiazem Injection can use for patients who have Normally HR until High
Nicardipine I.V Diltiazem I.V
< 60 60 - 80 > 80
Heart Rate
(beat/minute)
Differentiation between Diltiazem and Nicardipine on Heart Rate
25.
26. Subject : 11 patients with hypertension
emergency
Design : Open study
Diltiazem injection Drip infusion: 5~40
μg/kg/min
Average BP reduced
224/119 mmHg to 170/95 mmHg (mean
change 27.3 +9.0 %, P<0.001)
HR controlled
Current Therapeutic Research.1987: 42:1223.
Antihypertensive drugs and Heart Rate
28. Nicardipine i.v.
Hirayama A, Katayama Y, et al:Neurological Research 16; 97-99, 1994
35 patients who had surgical evacuation of spontaneous intracerebral haematomas after cerebral hemorrhage
Herbesser i.v.: 12, Nitroglycerin i.v.: 13, Nicardipine i.v.:10
Compare the intracranial pressure when the same blood pressure reduction level is achieved in each group.
①CPP index=△CPP/△SBP
②CPP index coming close to 1 indicates less
increase of intracranial pressure.
Comparison of intracranial pressure
change by different antihypertensives.
Change
of
intracranial
pressure
Comparison of Cerebral perfusion pressure
index (CPP index) by different antihypertensives.
CPP
index
Herbesser i.v. Nitroglycerin i.v. Nicardipine i.v.
Herbesser i.v. Nitroglycerin i.v.
20
10
0
2.0
1.5
0.0
1.0
6.7
14.2
17.0
1.33±0.07
1.80±0.11
1.63±0.13
p<0.05
p<0.05
（mmHg）
Target
Medication
Methods
Antihypertensive drugs cause increase of ICP
29. Diltiazem i.v. reduced cardiac event rate
in patients with unstable angina.
Target
Gobel E, et al. Lancet 346:1653-1657, 1995
Nitroglycerin i.v. group (n=61)
Herbesser i.v. group (n=60)
Incidence
during
i.v.(%)
40
30
20
10
0
Myocardial infarction refractory angina Myocardial infarction
+
refractory angina
10
5
28
10
38
15
p=0.02*
p=0.007**
Methods
129 patients with unstable angina
Randomized, double blind comparative trial
Diltiazem i.v. group (n=60) :25mg i.v.+5mg/h continuous i.v. (increase dose to 25mg/h)
Nitroglycerin i.v. group (n=61) : Physiologic saline i.v.+1mg/h continuous i.v. (increase dose to 5mg)
30. Intravenous bolus injection
0.2 mg / kgBW
Intravenous drip infusion
( 5-15 µg / kgBW / minute )
10-20 % MBP reduction
from baseline
Switch to oral HERBESSER® CD 200
Diltiazem (Herbesser) Chart Injection
Dose Flow Chart
Stable BP until 1 hr
Observe every 10-20 minutes
Dose
calculation
31. Intravenous bolus injection
10-15 mg IV (0,2-03 mg/KgBB) 1-2 min
20-30 mg/hr (15 menit)
>20 % MAP reduction
from baseline
Switch to oral drugs
Diltiazem (Herbesser) Chart Injectio
For Hypertensive Crisis
Dose
calculation
MAP > 15% Tidak
Intravenous drip infusion 50 mg/hr (20 min)
Observe every 10 minutes
10mg/hr ( 1-4 hr)
Observe every 10 minutes
