HYPERTENSIVE

EMERGENCY

Indonesian Society of Hypertension

BP = CO x SVR

MAP =SBP + 2 DBP

3

Hypertensive emergencies

PATHOPHYSIOLOGY

abrupt SVR due to humoral factors

(de novo or chronic hypertension)

BP

Mechanical stress

Endothelial injury

Vascular ischemia

Release of vasoactive mediators

?

Ault MJ, Ellrodt AG. Am J Emerg Med 1985; 3:10–15

Hypertensive

emergency

Hypertensive urgency

A number of different terms have

been applied to acute severe

elevations in blood pressure, and

the current terminology is

somewhat confusing.

HYPERTENSIVE EMERGENCY

Definition:

• BP >180/120 mm Hg (rapidity of the rise is more important)

• Impending or progressive target organ damage

- Cerebrovascular

- Cardiac

- Renal

- Surgical conditions

- Severe epistaxis

- Severe body burns

- Eclampsia

• Require immediate BP reduction with parenteral agentsChobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

Kaplan NM. Kaplan’s Clinical Hypertension. 2002

…embraces a syndrome of severe elevation of arterial blood

pressure (diastolic blood pressure usually but not always

>140mmHg) with vascular damage that can be manifest as

retinal haemorrhages, exudates and/or papilloedema;

hypertensive encephalopathy; and deterioration in renal

function. Malignant phase hypertension must be regarded as a

hypertension emergency.

Malignant hypertension

2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007, 25:1105–1187

HYPERTENSIVE URGENCY

Definition:

• Severe elevation in BP (in practice, DBP 130 mm

Hg)

• Without progressive target organ dysfunction

• May be associated with headache, epistaxis,

shortness of breath, or severe anxiety (less

severe than emergencies) making the distinction

with emergency become ambiguous

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252Kaplan NM. Kaplan’s Clinical Hypertension. 2002

ACCELERATED HYPERTENSION

Severe elevation of arterial blood

pressure (diastolic blood pressure

usually but not always >140mmHg)

without papilloedema.

2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007, 25:1105–1187

% of

pati

en

ts

Chest pain Dyspnea Neurologic deficit

Most frequent presenting signs in patients

with hypertensive emergencies

Zampaglione B, et al. Hypertension 1996; 27:144–147

“………..it is estimated that 1 to 2% of

patients with hypertension will have a

hypertensive emergency at some time

in their life……….”

Vidt DG. Am Heart J 1986; 111:220–225

Bennett NM, Shea S. Am J Public Health 1988; 78:636–640

Evaluation of patients with

hypertensive emergencies

• Presentation: new symptom related with elevated BP

• Medical history: organ damage, hypertension history and

medications, recreational drugs

• BP measured in both arms with appropriate BP cuff

• Physical examination:

- pulses in all extremities

- auscultation for pulmonary edema,

heart murmurs, renal artery bruits

- neurologic examination

- fundoscopic examination

• Laboratory test, Chest x ray, ECG, Echocardiography, and

brain CT scan

Patients with a hypertensive

emergency should be admitted to

an Intensive Care Unit for

continuous monitoring of BP and

parenteral administration of an

appropriate agent.

Initial Goal of Treatment in Hypertensive

Emergencies

Reduce MAP by no more than 25% in less than 1

hour. Excessive fall may cause renal, cerebral,

coronary ischemia

If stable, to 160/100-110 mm Hg within the next 2-6

hour

If stable, gradual reduction toward normal BP in the

next 24 to 48 hours

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

BLOOD PRESSURE CONTROL DURING ACUTE

ISCHEMIC STROKE

1. Remain controversial. It has been a common practice after acute cerebral infarction to reduce or withhold BP treatment until the clinical condition has stabilized 1)

2. Elevated BP during acute stroke is thought to be a compensatory physiological response to improve cerebral perfusion to the ischemic brain tissues

3. American Stroke Association Guidelines: patients with recent ischemic stroke whose SBP is 220 mm Hg or DBP 120 to 140 mm Hg, cautious reduction of BP by 10% to 15% is suggested (careful monitoring of neurological deterioration. Careful infusion of sodium nitroprusside is indicated if DBP is 140 mm Hg2

1) Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –12522) Adams HP Jr et al. Stroke. 2003;34 :1056 –1083.

“Pending more data, the consensus of the

panel is that emergency administration of

antihypertensive agents should be

withheld unless the DBP is 120 mm Hg or

unless the SBP is 220 mm Hg”

“A reasonable goal would be to lower

blood pressure by 15% to 25% within the

first day”Adams, Jr HP, et al. Stroke 2007;38;1655-1711

ACUTE ISCHEMIC STROKE

Lowering of the BP is currently

recommended only when the SBP is

200 mm Hg, the DBP is 110 mm Hg,

or the MAP is 130 mm Hg.

ACUTE HEMORRHAGIC STROKE

Marik PE, Varon J. Chest 2007;131;1949-1962

Drug Special indications Adverse efects

Sodium nitroprusside

Most hypertensive emergencies Caution with high intracranial pressure or azotemia

Nausea, vomiting, muscle twitching, sweating, thiocynate and cyanide intoxication

Nicardipine HCl

Most hypertensive emergencies except acute heart failure. Caution with coronary ischemia

Tachycardia, headache, flushing,

local phlebitis

Fenoldopam mesylate

Most hypertensive emergencies Caution with glaucoma

Tachycardia, headache, flushing, nausea

Nitroglycerin Coronary ischemia Headache, vomiting, methemo- globinemia, tolerance with prolonged use

Enalaprilat Acute left heart failure. Avoid in acute MI

Precipitous fall in pressure in high-renin states; variable reponse

Hydralazine HCl

Eclampsia Tachycardia, flushing, headache, vomiting, aggravation of angina

Labetolol HCl Most hypertensive emergencies except acute heart failure

Vomiting, scalp tingling, broncho- constriction, dizziness, heart block, orthostatic hypotension

Phentolamine Catecholamine excess Tachycardia, flushing, headache

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

Drug Dose Onset of action Duration of action

Sodium nitroprusside

0.25–10 g/kg/ min as IV infusion

Immediate 1–2 min

Nicardipine HCl 5–15 mg/h IV 5–10 min 15–30 min, may exceed 4h

Fenoldopam 0.1–0.3 g/kg/ min IV infusion

5 min 30 min

Nitroglycerin 5–100 g/min as IV infusion 2–5 min 5–10 min

Enalaprilat 1.25–5 mg every 6 h IV 15–30 min 6–12 h

Hydralazine HCl 10–20 mg IV

10–40 mg IM

10–20 min IV

20–30 min IM

1–4 h IV

4–6 h IM

Labetolol HCl 20–80 mg IV bolus every 10 min

0.5–2.0 mg/min IV infusion

5–10 min 3–6 h

Phentolamine 5–15 mg IV bolus 1–2 min 10–30 min

Parenteral Drugs for the Treatment of Hypertensive Emergenies

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

Usual Adult Dose for Hypertensive Emergency

0.2 mg orally once. Additional doses of 0.1 mg may be given as

needed and tolerated every hour to control this patient's blood

pressure. The maximum recommended total daily dose in any

case of emergent hypertension is 0.8 mg.

Eleven severely hypertensive patients: severe left ventricular

failure, hypertensive encephalopathy, cerebral haemorrhage,

dissecting aortic aneurysm, renal failure, and severe epistaxis.

0-15 mg or 0-3 mg clonidine was given every 40 minutes. Doses of

clonidine required for control ranged from 0-15 mg (one ampoule)

to 09 mg (mean 0-56 mg).

It is concluded that clonidine is effective and safe in the treatment

of hypertensive emergencies.

FDA off-label

Management of hypertension in patient undergoing

surgery

1. Elective surgery:

Oral antihypertensive agents if BP 180/110 mm Hg.

2. Urgent surgery:

Rapidly acting parenteral agents: sodium

nitropruside, nicardipine, or labetolol.

3. Sudden intra-operative hypertension:

Parenteral antihypertensive agents as used in the

management of hypertensive emergencies.

4. Oral treatment must be interrupted postoperatively:

periodic dosing of iv enalaprilat or transdermal

clonidine hydrochloride may be useful.

Chobanian AV et al. The JNC 7 Complete Version. Circulation 2003;42:1206-52

Classification of hypertension during pregnancy

BP ≥140/90 mm Hg

Chronic < 20 weeks > 20 weeks

— proteinuria: chronic hypertension

+ proteinuria: chronic hypertension

with superimposed preeclampsia* — proteinuria: gestational hypertension

+ proteinuria: preeclampsia** * 2-3x

* * > 300 mg/24h

Chobanian AV et al. The JNC 7 Complete Version. Circulation 2003;42:1206-52

Hydralazine

5 mg iv bolus, then 10 mg every 20 to 30 minutes to a maximum of 25 mg, repeat in several hours as necessary

Labetolol (2nd line)

20 mg iv bolus, then 40 mg 10 minutes later, 80 mg every 10 minutes for 2 additional doses to a maximum of 220 mg

Nifedipine (controversial)

10 mg per oral, repeat every 20 minutes to a maximum of 30 mg. Caution when using nifedipine with magnesium sulfat, can cause precipitous BP drop

Sodium nitroprusside ( rarely when others fail)

0.25 g/kg/min to a maximum of 5 g/kg/min. Fetal cyanide poisoning may occur if used for more than 4 hours

Treatment of Acute Severe Hypertension in Preeclampsia

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

Agent Comments

MethyldopaPreferred on the basis of long-term follow-up studies supporting safety

Beta blockersReports of intrauterine growth retardation (atenolol). Generally safe

LabetalolIncreasingly preferred to methyldopa because of reduced side effects

Clonidine Limited data

Calcium

antagonists

Limited data. No increase in major teratogenicity with exposure

Diuretics Not first-line agents. Probably safe

ACEIs, angiotensin II receptor antagonists

Contraindicated.

Reported fetal toxicity and death

Treatment of Chronic Hypertension in Pregnancy

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

Treatment should be started if BP 150-160/100-110 mm Hg

Drug Dosage Additional comments

Methyldopa 500-3000 mg in 2-4 divided dose

Drug of choice due to extensive experience

Labetolol 200-1200 mg in 2-3 divided dose

Similar in efficacy and safety to methyldopa

-blockers variable Possibility of fetal bradicardia, lower birth weight (when used early in pregnancy)

CCB variable Accumulating data support maternal and fetal safety; may interact with magnesium sulfate

-blockers variable Scant data for use in pregnancy

Clonidine 0.1-0.8 in 2-4 divided dose

Limited data

Thiazide diuretics Variable May be associated with diminished volume expansion; may be necessary in volume sensitive hypertension at lower dose

ACE-inhibitors Contraindicated Neonatal anuric renal failure

ARB contraindicated Neonatal anuric renal failure

Antyhypertensive therapy of chronic hypertension in pregnancy

August P, Falkner B. 2001

TREATING HYPERTENSION DURING LACTATION

1. All antihypertensive agents that have been studied are excreted into human breast milk

2. Mothers who wish to breast-feed should withhold antihypertensive treatment and reinstitute antihypertensive therapy following discontinuation of nursing

3. No short-term adverse effects has been reported from exposure to methyldopa or hydralazine

4. Propanolol and labetolol are preferred if beta blocker is indicated.

5. ACE-Is and ARBs should be avoided in the basis of reported fetal and neonatal renal effects.

6. Diuretics may reduce milk volume and thereby suppress lactation Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

CONCLUSION

1. Emergency

- Progressive or impending target organ damage

- Require immediate BP reduction with parenteral

agent

2. Treatment

- Require close BP monitoring. Should not cause

hypotension

- Different BP goal in acute ischemic stroke

- Drug regimen without clear outcome studies