hypertensive crisis
TRANSCRIPT
![Page 1: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/1.jpg)
Dr Maged Abulmagd,MD,EDICConsultant intensivist,EBGH
Hypertensive
Crisis
![Page 2: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/2.jpg)
Hypertensive Crisis
• Hypertensive UrgencySBP >180 or DBP>110 w/o TOD
• Hypertensive Emergency SBP >180 or DBP>110 (esp >120) +TODs
![Page 3: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/3.jpg)
• What is the primary reason for hypertensive emergencies in the USA today?
1. A-Renovascular Disease2. B-Pheochromocytoma3. C-Non-adherence to anti-hypertensive
medication4. D-Hyperaldosteronism5. E-Erythropoeitin
![Page 4: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/4.jpg)
The commonest cause of hypertensive emergency in 2011 is undiagnosed,untreated,or undertreated essential hypertension
![Page 5: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/5.jpg)
Epidemiology
Hypertensive emergencies are common
50 million hypertensive Americans
500,000 hypertensive emergencies/year
Higher in the elderly and African Americans
Incidence in men 2 times higher than in women
![Page 6: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/6.jpg)
Urgency
• Rapid reduction in BP >>>> significant morbidity; organ hypoperfusion– Ischemia– Infarction
• Lower gradually over 24 – 48 hours
• Oral medications • pressure induced natriuresis>>> volume
repleting
![Page 7: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/7.jpg)
Emergency
• Reduce DBP by 10 – 15%, or to ~ 110 mm Hg over 30 – 60 minutes
• Aortic Dissection– Rapid lowering over 5 – 10 minutes– SBP < 120 and MAP < 80
![Page 8: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/8.jpg)
Threshold BP
There is no specific BP where hypertensive emergencies occur
Organ dysfunction is rare with diastolic BPs < 120 mm Hg
Encephalopathy will occur at lower BPs in pregnancy and in children
![Page 9: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/9.jpg)
Vaughan and Delanty Lancet 2000; 356:411
![Page 10: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/10.jpg)
Cerebral Autoregulation
![Page 11: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/11.jpg)
![Page 12: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/12.jpg)
Questions
• Define hypertensive urgency and hypertension emergency?
• What are clinical findings associated with hypertensive emergenices?
![Page 13: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/13.jpg)
Question
• What is the most common complaint in hypertensive emergency?
1. Neurologic defect
2. Gross Hematuria
3. Chest pain
4. Headache
5. Epistaxis
![Page 14: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/14.jpg)
Clinical Presentation
Frequency of signs and symptoms Chest Pain 27%
Dyspnea 22%
Neuro defect 21%
Zampaglione et al (Hypertension 27:144, 1996)
![Page 15: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/15.jpg)
Clinical Findings
• Predisposing disease– Thyrotoxicosis/Thyroid storm, Hypothyroidism/Myxedema, goiter– HPT: hypercalcemia (psychosis, constipation,cataract,
nephrocalcinosis, N-DI, dystrophic calcifications of soft tissue (X-ray)
– Cushing’s: Cushinoid– Conn’s: hypokalemic metabolic alkalosis– Pheochromocytoma: perspiration, palpitation, pain (chest, AP),
labile pressure (+/- orthostatic hypotension), pallor– RAS: Renal bruits– OSA/Pickwikian Syndrome: day time somnolence, apnea attacks– Pregnancy: HELLP, Ecclampsia (edema, protienuria, sz)
![Page 16: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/16.jpg)
Clinical Findings
• Complications/TOD– Brain: meningism, FND, delirium, decreased LOC,
seizures, coma.– Retina: blurred vision, papilledema (IV) +/- cotton
wool exudate, flame shape hg.– CVS: chest pain, ACS (MR, ECG, trop), CHF,
pulse/BP bi limbs deficit (AD).– Kidneys: active sediment, proteinuria, hematuria,
tubular casts.
![Page 17: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/17.jpg)
A rare tumor of catecholamine-secreting chromaffin cells, 80% to 90% of which are located in the adrenal medulla.
10% to 20% are located extra-adrenal, usually throughout the sympathetic chain in the thorax, abdomen, and pelvis,are referred to as paragangliomas.
Pheochromocytoma
![Page 18: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/18.jpg)
Hypertensive crisis is managed with intravenous nitroprusside, labetalol or phentolamine
Diagnostic tests
24-hour urine metanephrines and plasma fractionated metanephrines
Pheochromocytoma
![Page 19: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/19.jpg)
Preeclampsia/Eclampsia
• Diastolic pressure should be reduced to 90-100 mmHg.
• Precipitous drops should be avoided as they may compromise placental circulation.
• Hydralazine and labetalol are the usual agents of choice. Nifedipine can also be used.
• ACE inhibitors should not be used due to adverse fetal effects.
![Page 20: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/20.jpg)
Acute Post Operative Hypertension
Frequent in post-operative state (20-75%)Hyper-responsiveness to surgical trauma
Increased stress hormonesActivation of RAA
Hypothermia, hypoxia, carbon dioxide retention, bladder distention
![Page 21: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/21.jpg)
Acute Post Operative Hypertension
Prevention Preoperative antihypertensives Hold diuretics
Treatment • Control pain and anxiety• While NPO use nicardipine, esmolol or
labetolol• Resume oral medications when possible
![Page 22: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/22.jpg)
CARDIOVASCULAR SYSTEM
Cardiac failure
Pulmonary edema
Myocardial ischemia, or Myocardial infarction
Aortic dissection
![Page 23: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/23.jpg)
Aortic dissection
• Goal is to reduce the shear force, and therefore the dP/dt.
• Goal is an SBP of 100-110 achieved with a beta-blocker and an easily titratable vasodilator if necessary.
• A vasodilator should not be used alone
![Page 24: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/24.jpg)
All initial treatment is medical
Decrease pulse rate and BPGoal is systolic 100-120 mmHg & HR 50-60Esmolol & Nitroprusside combinationLabetolol single agent
Ascending require medical stabilization & then surgery Descending require medical stabilization & monitoring
Aortic dissection
![Page 25: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/25.jpg)
Renal Artery Stenosis
What people should be screened for renal artery stenosis?
1-Patients who have uncontrolled blood pressure despite 3 or more medications at maximal dosages
2--people who are younger than 35 or older than 65 who develop sudden or new onset hypertension
![Page 26: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/26.jpg)
Renal Artery Stenosis
The diagnosis is made with ultrasound dopplers to check blood flow rates
Arteriograms are more accurate, but only show an anatomic blockage, and don't help with functional testing
![Page 27: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/27.jpg)
A diagnosis of exclusion. Cerebral oedema may be present on a CT scan but haemorrhage or infarction are absent.
Immediate blood pressure reduction is
mandatory.
Hypertensive Encephalopathy
![Page 28: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/28.jpg)
CVA’s
• Ischemic CVA– Protective physiologic response to maintain
CPP– Impaired auto-regulation– Some evidence for induced HTN– Treat if:
• Thrombolysis (SBP/DBP < 185/110)• End organ damage• SBP > 220, DBP >120 .
![Page 29: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/29.jpg)
CVA’s
• Hemorrhagic CVA– No evidence HTN leads to increased size
of ICH, but there is an association– Evidence suggests lowering BP rapidly
leads to increased mortality– Maintain SBP < 200, DBP < 130– Lowering MAP ~ 15% does not seem to
reduce CBP
![Page 30: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/30.jpg)
Hypertensive Retinopathy
Fundoscopy used to be considered a definitive tool in diagnosing HTN encephalopathy.
Usefull in recognizing acute EOD as in HTN encephalopathy.
Absence of retinal exudates, hemorrhages, or papilledema does not exclude the diagnoses.
![Page 31: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/31.jpg)
HPT Retinopathy
![Page 32: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/32.jpg)
Reversible posterior leukoencephalopathy syndrome
A clinical radiographic syndrome of heterogeneous etiologies.
Characterized by
Headaches
Altered consciousness
Visual disturbances
Seizures
![Page 33: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/33.jpg)
A/W hypertensive encephalopathy, eclampsia, and the use of cytotoxic and immunosuppressant .
It is related to disordered cerebral autoregulation and endothelial dysfunction
Reversible posterior leukoencephalopathy syndrome
![Page 34: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/34.jpg)
Profile of an ideal IV Profile of an ideal IV antihypertensiveantihypertensive
Preserves GFR and renal blood flowFew or no drug reactionsLittle or no potential for exacerbation of co-morbid conditionsRapid onset and offset of actionMinimal hypotension “overshoot”Minimal need for continuous BP monitoring and frequent dose titrationNo acute toleranceEase of use and convenienceSafe and no toxic metabolitesMultiple formulations for short and long term useMinimal symphathetic activation
![Page 35: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/35.jpg)
Case Based Presentation:Hypertension in the ICU
![Page 36: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/36.jpg)
Nitroprusside
• A short-acting easy-to-titrate arteriolar and venous vasodilator.
• Most common adverse effect is hypotension which can be treated by reducing dosage and administering fluids if needed (lasts 1-2 min)
• Other adverse effects include reflex tachycardia and cyanide/thiocyanate toxicity
![Page 37: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/37.jpg)
Nitroprusside• Nitroprusside is metabolized through combination
with hemoglobin to produce cyanomethemoglobin.
• Thyocyanate is then excreted in the urine
• Hepatic insufficiency leads to cyanide accumulation
• renal insufficiency leads to thiocyanate accumulation
![Page 38: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/38.jpg)
Nitroprusside
• Cyanide toxicity manifests as lactic acidosis, confusion, and hemodynamic instability.
• Cyanide toxicity is prevented by avoiding large doses (>3mcg/kg/min) for greater than 72h, especially in patients with hepatic or renal dysfunction.
• Maximal doses of 10 mcg/kg/min should not be administered for more than 10 minutes
![Page 39: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/39.jpg)
Labetalol
• A non-selective β-blocker with associated α-blocking activity, in a 7 to 1 ratio in i.v. formulation.
• Contraindicated in reactive airway disease or second to third degree heart block.
• Caution in patients with second to thir degree heart block.
![Page 40: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/40.jpg)
Nitroglycerin
• A venous and coronary artery dilator.
• Indicated in acute coronary syndromes; has also used in perioperative hypertension.
• Side effects include headache, nausea, bradycardia, hypotension, and methemoglobinemia.
• Prlonged use may cause tachyphylaxis.
![Page 41: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/41.jpg)
Nicardipine• A dihydropyridine CCB with systemic
and coronary vasodilating effects.
• No negative inotropic or a-v conduction effects.
• Used in perioperative hypertension and eclampsia/preeclampsia.
![Page 42: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/42.jpg)
Esmolol
• Short-acting cardioselective β-blocker that can be used in perioperative hypertension and tachycardia.
• A prolonged esmolol infusion is a relatively expensive means of blood pressure control
![Page 43: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/43.jpg)
Enalaprilat
• Its long duration of action and variable response, do not make it an ideal candidate for hypertensive emergencies.
• Contraindicated during preganancy, and in renal failure, esp. in renal artery stenosis.
![Page 44: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/44.jpg)
Hydralazine
• An arteriolar vasodilator.
• Difficult to use due to its variable magnitude and rate of response.
• Improves placental blood flow so good for preeclampsia/eclampsia
• Should therefore not be used in aortic dissection or myocardial ischemia.
![Page 45: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/45.jpg)
Rhoney and Peacock. Am J Health-Syst Pharm. 2009; 66:1343-52.
Specific Indications
![Page 46: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/46.jpg)
A 76-year-old male is admitted to the ICU for recovery after lung volume reduction surgery for severe emphysema. He is alert and his BP is 168/96 mmHg. All of the following are appropriate EXCEPT?
A. Assess for pain
B. Start an antihypertensive treatment with a β-blocker
C. Reassess the patient later since there is no end-organ damage
D. Fundoscopic examination is not indicated for the transient, postoperative, acute hypertensive episode
E. Recommend the consultation of a hypertensive specialist once the patient is transferred to the ward if the blood pressure remains high
![Page 47: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/47.jpg)
Which of the following is correct in regard to measurement of blood pressure in severe hypertension?
A. Automated oscillometric monitors are adequate for blood pressure measurement in the critically ill patient
B. A blood pressure cuff that is too small for the patient may result in a falsely decreased blood pressure measurement
C. Hypothermia causes hypotension; it does not increase blood pressure
D. Intra-arterial pressure monitoring provides the most accurate blood pressure measurement
E. A blood pressure cuff that is wrapped too loosely on the arm may result in a falsely low blood pressure
![Page 48: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/48.jpg)
An acute hypertensive episode (190/110 mmHg), in a known hypertensive patient, is associated with acute congestive heart failure (HR 95/min). All of the following are true EXCEPT
A. Is a medical emergency requiring IV antihypertensive therapy
B. Is a medical urgency requiring oral antihypertensive therapy
C. Could be appropriately treated with a labetalol infusion
D. Requires caution with diuretics in case of diastolic dysfunction
E. Is most likely due to diastolic dysfunction
![Page 49: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/49.jpg)
SummarySummary
HPT crisis - serious condition - associated with EOD, if left untreated
High mortality - untreatedMain causes – non-compliance and poorly
controlled chronic hypertension.Urgency vs emergencyTreatment should be tailored to the
individual’s condition HPT urgency – initial goal max 25% drop in
MAP in first hoursPrecipitous drop just as bad –continuous
monitoring essential
![Page 50: HYPERTENSIVE CRISIS](https://reader036.vdocument.in/reader036/viewer/2022082309/55ce50cebb61eb40068b4580/html5/thumbnails/50.jpg)