hypertensive emergencies: diagnosis and treatment jamie johnston, md university of pittsburgh school...
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Hypertensive Emergencies:Diagnosis and Treatment
Jamie Johnston, MD
University of Pittsburgh
School of Medicine
Today’s Road Map
• Case Presentations
• Definitions
• Evaluation
• Management
• Will not cover pre-eclampsia or pediatric hypertensive emergencies
Case 1
• 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 air ambulance to PUH.– Intubated en route due to declining mental status
Case 1
• 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 PUH - BP 196/130– Positive for Left dense hemiparesis
Case 1
• Hospital day 2– Dilated right pupil– Emergent right frontotemporal craniotomy
and evacuation of clot
• Subsequent Hospital Course– Difficult to control BP– Pneumonia
Case 1
• Renal MRI– Right kidney 8.1 cm with three renal
arteries– Left kidney 12.2 cm with two renal arteries
• Patient transferred to rehab at South Side Hospital on 7/19/07
Question 1
• What is the primary reason for hypertensive emergencies in the USA today?
1. Renovascular Disease2. Pheochromocytoma3. Non-adherence to anti-hypertensive
medication4. Hyperaldosteronism5. Erythropoeitin
What is the primary reason for hypertensive emergencies in the
USA today?
Ren
ovas
cula
r Dis
ease
Pheo
chro
mocy
tom
a
Non-a
dher
ence
to a
nt...
Hyp
eral
doster
onism
Ery
thro
poeitin
0% 0% 0%0%0%
1. Renovascular Disease
2. Pheochromocytoma
3. Non-adherence to anti-hypertensive medication
4. Hyperaldosteronism
5. Erythropoeitin
10
When you hear hoof beats…
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
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
Hypertensive Emergency
• Damage Heart - CHF, MI, angina
Kidneys - acute kidney injury, microscopic hematuria
CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy
Vasculature
Vasculature - aortic dissection, eclampsia
Epidemiology
• Hypertensive emergencies are common– Occur in 1-2% of the hypertensive population– But, 50 million hypertensive Americans– 500,000 hypertensive emergencies/year
• Parallels the distribution of primary hypertension
• Higher in the elderly and African Americans• Incidence in men 2 times higher than in
women
Epidemiology
• Common associations– Previous history of hypertension– Lack of a primary care physician– Non adherence to antihypertensive
regimen– Elicit drug use (cocaine)
PathophysiologySudden increase in Systemic Vascular Resistance
BP
Mechanical Stress with endothelial injury, increased permeability, Coag/Plt activation, fibrin deposition
1) Fibrinoid necrosis
2) Ischemia
3) Activation of RAA
4) Proinflammatory cytokines
Vaughan and Delanty Lancet 2000; 356:411
Underlying Etiology?
• Unclear, but some candidates
– ACE DD genotype
– Absence of the and subunit of ENaC
– Elevated adrenomedullin levels*
– Elevated natriuretic peptide level*
– Abnormalities in oxidative stress markers and endothelial dysfunction*
– *Correct after effective BP treatment
Question 2
• What is the most common complaint in hypertensive emergency?
1. Neurologic defect
2. Gross Hematuria
3. Chest pain
4. Headache
5. Epistaxis
What is the most common complaint in hypertensive emergency?
Neu
rolo
gic d
efec
t
Gro
ss H
emat
uria
Ches
t pai
n
Hea
dache
Epis
taxi
s
0% 0% 0%0%0%
1. Neurologic defect
2. Gross Hematuria
3. Chest pain
4. Headache
5. Epistaxis
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
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
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
Hypertensive emergency is associated with a threshold BP of
Sys
tolic
> 2
25 m
m H
g
Dia
stol
ic >
110
mm
Hg
Sys
tolic
> 2
50 m
m H
g
Dia
stol
ic >
120
mm
Hg
All
of the
above
0% 0% 0%0%0%
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
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
Initial Evaluation
• Focused history– History of hypertension?– How well is hypertension controlled?– What antihypertensives?– Adherence to antihypertensive regimen?– Last dose of antihypertensive?
Initial Evaluation
• Social History– Recreational Drugs
• Amphetamines• Cocaine• Phencyclidine
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
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
Initial Evaluation
• Neurologic Exam– Hypertensive Encephalopathy - mental
status changes, nausea, vomiting, seizures– Lateralizing signs uncommon and suggest
cerebrovascular accident
• Retinal Exam– Lost art– Keith-Wagener-Barker Classification
Keith-Wagener-Barker Classification
• Grade 1– Mild narrowing of the arterioles– “Copper Wire”
• Grade 2– Moderate narrowing -
Copper wire and AV nicking
• Changes associated with long standing essential hypertension
Normal
Grade 1
Keith-Wagener-Barker Classification
• Grade 3– Severe Narrowing -
Silver wire changes, hemorrhage, cotton wool spots, hard exudates
• Grade 4– Grade 3 + Papilledema
• Grade 3 and 4 highly correlated with progression to end organ damage and decreased survival
Grade 3 KWB Retinopathy
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
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
Management
• Elevated BP without target organ damage
• Hypertensive urgency
• Oral meds
• Goal - gradual reduction of BP over 24 - 48 hours
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
How Quickly?
• Cerebral Blood Flow Autoregulation– Cerebral Blood constant in normotensive
individuals over range of MAPs of 60 -120 mm Hg.
– In chronically hypertensive patients autoregulatory range is higher
– MAP Range 100-120 to 150-160 mm Hg
• Autoregulation also impaired in the elderly and those with cerebrovascular disease
How Quickly?
• General rule is to lower MAP by 20% in first hour
• Should always be done with close clinical observation
Management
• Where?– ICU with close monitoring– Severe requires intra-arterial BP
monitoring
• Which Parenteral meds?
• Depends on the situation
Question 4
• Which of the following drugs should not be used to treat hypertensive emergency?
1. Sublingual Nifedipine2. Labetolol3. ACE Inhibitors4. Nicardipine5. 1 and 3
Which of the following drugs should not be used to treat hypertensive
emergency?
Sublin
gual N
ifedi
pine
Lab
etolo
l
ACE In
hibito
rs
Nic
ardip
ine
1 a
nd 3
0% 0% 0%0%0%
1. Sublingual Nifedipine
2. Labetolol
3. ACE Inhibitors
4. Nicardipine
5. 1 and 3
Preferred Agents
• Beta blockers– Labetolol– Esmolol
• Calcium Entry blocker– Nicardipine
• Dopamine-1 receptor agonist– Fenoldapam
• Vasodilators - nitroprusside/nitroglucerin
Scenarios
• Our Case - Acute ischemic stroke/cerebrovascular bleed
• Agents– Fenoldopam– Labetolol– Nicardipine
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
Cardiac Conditions
• Acute Pulmonary Edema with systolic dysfunction– Nicardipine– Fenoldopam– Sodium nitroprusside– Nitroglycerin– Loop diuretic
Cardiac Conditions
• Acute Pulmonary Edema with diastolic dysfunction– Esmolol, metoprolol, labetolol– verapamil– Nitroglycerin– Loop diuretic
Cardiac Conditions
• Acute myocardial ischemia– Esmolol, labetolol– Nitroglycerin
Sympathetic Crisis
• Generally in association with recreational drugs such as cocaine, amphetamine or phencyclidine
• Sudden cessation of clonidine or Beta-adrenergic antagonist
• Pheochromocytoma - rare
Question 5
• Which of the following drugs should be avoided in sympathetic crises with hypertensive emergency?
1. Phentolamine2. Benzodiazepine3. Labetolol4. Nicardipine5. Fenoldopam
Which of the following drugs should be avoided in sympathetic crises with
hypertensive emergency?
Phen
tola
min
e
Ben
zodia
zepin
e
Lab
etolo
l
Nic
ardip
ine
Fen
oldopa
m
0% 0% 0%0%0%
1. Phentolamine
2. Benzodiazepine
3. Labetolol
4. Nicardipine
5. Fenoldopam
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)
Sympathetic Crisis
• Recommended Drugs– Nicardipine– Fenoldopam– Verapamil– Benzodiazepine– If pheo suspected use phentolamine
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
Aortic Dissection
• Vasodilator alone?– Causes reflex tachycardia– Increases cardiac ejection velocity– Increases aortic shear forces– Extends the dissection
Aortic Dissection
• Standard therapy– Beta-adrenergic blocker plus vasodilator– Esmolol + Nicardipine or fenoldopam
• Nitroprusside can be used as well
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
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
What happened to sodium nitroprusside?
• Mansoor and Friedman. Heart Disease 2002; 4:358– Sodium nitroprusside recommended for all
hypertensive emergencies except eclampsia
• Marik and Varon. Chest 2007; 131:1949– Sodium nitroprusside recommended for
• acute aortic dissection • acute pulmonary edema with systolic
dysfunction
“riding the pride”
• Disadvantages of sodium nitroprusside– Decrease cerebral blood flow and increases
intracranial pressure– Can reduce regional blood flow in coronary artery
disease– Risk of cyanide toxicity
• Use when other agents not effective– Monitor thiocyanate levels– Avoid in renal or hepatic dysfunction
Have we made progress?
• First described by Volhard and Fahr– Die Brightsche Nierenkrankenheit: Klinik
Patholgie und Atlas. Berlin, Germany, Springer 1914:247
• Keith, Wagener, Barker Am J Med Sci, 1939;197:332– Mean survival of patients with htn and
grade 4 retinopathy was 10.5 mo with none living beyond 5 years
We have made progress
• Development of antihypertensive drugs
• Increased diagnosis of hypertension
• Increased ICU settings
• Survival of patients with hypertensive urgency and emergency is 18 years compared to 21 years in those with uncomplicated hypertension
Thank you!
Questions?
Messerli N Engl J Med 1995;3321038.
Messerli N Engl J Med 1995;3321038.
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