ARTERIAL HYPERTENSION

DR.MAGDI AWAD SASI29/12/205 7TH OCTOPER HOSPITAL

CCU TEAMBMC---EMERGENCY COURSE

Hypertension “A systolic blood pressure (SBP) of ≥140 mm Hg, diastolic blood

pressure (DBP) of ≥ 90 mm Hg or taking antihypertensive medication”

In nondiabetic non CRD.

•Clinic BP ≥ 140/90 mmHg & subsequent ABPM daytime average or HBPM average BP≥ 135/85 mmHg Stage

1•Clinic BP >= 160/100 mmHg and

subsequent ABPM daytime average or HBPM average BP ≥ 150/95 mmHg

Stage 2

•Clinic systolic BP ≥ 180 mmHg, or clinic diastolic BP ≥ 110 mmHg

Stage 3

Diagnosing hypertension

If a BP reading is ≥ 140 / 90 mmHg; patients should be offered ABPM to confirm the diagnosis.

Patients with a BP reading of ≥ 180/110 mmHg should be considered for immediate treatment.

Ambulatory blood pressure monitoring (ABPM): At least 2 measurements per hour during the person's

usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements.

If ABPM is not tolerated or declined HBPM should be offered.

Home blood pressure monitoring (HBPM):

For each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated.

BP should be recorded twice daily, ideally in the morning and evening.

BP should be recorded for at least 4 days, ideally for 7 days.

Discard the measurements taken on the first day and use the average value of all the remaining measurements.

PRAUCATION Measuring Blood Pressure

REST---Pt. should be seated in a chair back supported, with arm bared and at heart level

Pts. should refrain from smoking or caffeine intake 30 minutes prior to BP measurement.

Measurement should begin after at least 5 minutes of rest

Appropriate cuff size should be used to ensure accurate measurement; the bladder of the cuff should encircle at least 80% of the arm.

Use of a mercury sphygmomanometer

preferred

A recently calibrated aneroid manometer or a validated electronic device can be used

Follow-up RecommendationsInitial BPSBP DBP Follow-up<130 <85 Recheck in

2y130-139 85-89 Recheck in

1y149-159 90-99 Confirm in

2m160-179 100-109 Eval/refer 1m> 180 > 110 Eval/refer

immediately

Evaluation of Patients with HTN

1)Identify known causes of HTN

2)Assess for the presence OR absence of target organ damage and cardiovascular disease

DM OBESITY

SEDENTARY LIFE DRUGS

ENDOCRINE CAUSES

ADVICE:

STOP •Predisposing cause before starting treatment

Search •For end organ damage by H ; C.F. ,INVES

SELECT

•Select the proper drugs

Proper drug

+cheap

tolerated

availableUPDATE

frequency

TREATMENT : ABPM/HBPM ≥ 135/85 mmHg (i.e. stage 1

hypertension): Treat if < 80 years of age AND target organ damage: Established cardiovascular disease, renal disease,

diabetes or a 10year cardiovascular risk equivalent to 20% or greater.

ABPM/HBPM ≥ 150/95 mmHg (i.e. stage 2

hypertension): Offer drug treatment regardless of age. For patients < 40 years consider referral to exclude secondary causes.

Step 1 treatment:

Patients < 55-years-old: ACE inhibitor

Patients > 55-years-old or of Afro-Caribbean origin: CCBs (C)

Step 2 treatment

ACE inhibition + calcium channel blocker(A +C)

Step 3 treatment Add a thiazide diuretic (D, i.e. A + C + D) NICE now advocate using either chlorthalidone (12.5-25.0 mg once

daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide.

NICE define a clinic BP ≥ 140/90 mmHg after step 3 treatment with

optimal or best tolerated doses as resistant hypertension. They suggest step 4 treatment or seeking

expert advice.

Step 4 treatment:

Consider further diuretic treatment.

If potassium < 4.5 mmol/l add spironolactone 25mg OD.

If potassium > 4.5 mmol/l add higher-dose thiazide-like diuretic ttt.

If further diuretic therapy is not tolerated, or is contraindicated or ineffective, consider an alpha- or beta-blocker. If BP still not controlled seek specialist advice.

Centrally acting antihypertensives

1) Methyldopa: used in the management of

hypertension during pregnancy. 2) Clonidine: the antihypertensive effect is

mediated through stimulating alpha-2 adrenoceptors in the vasomotor centre.

3) Moxonidine (Physiotense ® 0.2 mg tab): used in the management of essential hypertension when conventional antihypertensive have failed to control blood pressure

NICE NEW RECOMMENDATION

In the past there was overtreatment of 'white coat' hypertension. The use of ambulatory blood pressure monitoring (ABPM) aims to reduce this. There is also good evidence that ABPM is a better predictor of cardiovascular risk than clinic blood pressure readings.

Calcium channel blockers are now considered superior to thiazides.

Bendroflumethiazide is no longer the thiazide of choice.

βB is not recommended as a 1st or 2nd line anti-hypertensive agent, particularly in obese population because of its association with impaired glucose tolerance.

The NICE guidelines on HTN advise against using beta-blockers as routine 'first line' therapy for uncomplicated hypertension.

GOAL OF CONTROL BP: Goal BP less than 130/85 mmHg

for patients with DM, CKD and established CVD like IHD. (BHS).

While in non-diabetic patients with CVD, the target BP is less than 140/90 mmHg. (JNC) and (ACC/AHA)

WHAT IS IMPORTANT? NOT the degree of BP elevation

BUTThe clinical status of the patient that defines an

emergency.The degree of target organ

involvement that determines the rapidity with which the BP is

lowered

Hypertensive crisis

Defined as a critical elevation in blood pressure in which diastolic pressure >120 mm Hg. The presence of acute or ongoing end-organ damage constitutes a hypertensive emergency, whereas the absence of such complications is known as a hypertensive urgency.

Hypertensive emergencies

Are associated with end-organ damage and need to be treated immediately.

Require a reduction in blood pressure within a few hours, usually using intravenous medications given in an intensive care unit.

Hypertensive urgencies HTN that requires control within hours

but without evidence of end-organ damage.

((Asymptomatic)) Require prompt medical attention, but blood pressure can

be lowered over 24 to 48 hours, sometimes in a closely monitored outpatient setting.

It Can usually be managed by oral agents.

Malignant HTN

It is Marked HTN with papilledema, retinal hemorrhages or exudates (basically a subset of hypertensive emergency)

Goal of treatment for hypertensive emergency is :

Reduction of DBP to 100-110 mmHg

OR Reduction in MAP by 20-25%,

whichever is the greater number, over the first 2-6 hours .

Vessel

muscleHeart

CVSLVH MI

AFLVF CCF

CVS EFFECT OF HTN:

HTN

LVH

D.FAILURE

ANGINA PECTORIS

IHD

MI LVF

CCF

AF

End-Organ Damage in Hypertensive Emergencies

BrainHypertensive Encephalopathy Ischemic StrokeHemorrhagic StrokeSubarachnoid Hemorrhage

RetinaHemorrhagesExudatesPapilledemaCardiovascular

SystemUnstable AnginaAcute Heart FailureAcute Myocardial InfarctionAortic Dissection

KidneyHematuriaProteinuriaDecreasing Renal Function

References: 1. Varon J, Marik PE. Chest. 2000;118(1):214-227. 2. Rynn KO et al. J Pharm Prac. 2005;18(5):363-376.

Causes of hypertensive emergencies :

1. Essential HTN 2. A. Renal parenchymal disease: Acute GN, TTP/HUS,

vasculitis B. Renovascular disease: Renal artery stenosis 3. Endocrine: Pheo, Cushing’s, renin-secreting tumor 4. Drugs: Cocaine, amphetamines most common;

reported with epo, cyclosporine; anti-hypertensive withdrawal

5. Pregnancy: Eclampsia 6. CNS disorders: head injury, CVA, increased ICP h.

Autonomic hyperreactivity: Guillain-Barre, porphyria

Presentation: Dyspnea Chest pain Palpitation Parasthesia /numbness Heaviness/ paralysis Confusion Sever sudden headache

What is the risk of rapid reduction of BP?

1. Ischemic cardiac event2. Ischemic cerebral event3. Retinal artery occlusion4. Acute renal deteioration

SERIOUS HTN INVESTIGATION

Blood suger RFT CBC ECG CXR CARDIAC ENZYMES CT scan brain if CNS compliant

MAP is considered to be the perfusion pressure seen by organs in the body. It is believed that a MAP is greater than 60 mmHg is enough to sustain

the organs of the average person(normally between 65 and 110 mmHg). MAP may be used similarly to Systolic blood pressure in for target blood pressure.

Both have been shown advantageous targets for sepsis, trauma, stroke, intracranial bleed, and hypertensive emergencies.

If the falls below this number for an appreciable time, vital organs will not get enough Oxygen perfusion, and will become hypoxic, a condition called ischemia.

Total Peripheral Resistance (TPR) is represented mathematically by the formula:

R = ΔP/Q[2]

R is TPR. ΔP is the change in pressure across the systemic circulation from its beginning to its end. Q is the flow through the vasculature (equal to cardiac output)

In other words:

Total Peripheral Resistance =(Mean Arterial Pressure - Mean Venous Pressure) / Cardiac

Output

MAP= DP +1/3(SP-DP) Therefore, Mean arterial pressure can be

determined from:[3]

MAP= ( CO X SVR ) + CVP where: CO is cardiac output SCR is systemic vascular resistance CVP is central venous pressure and usually small

enough to be neglected in this formula.

Equation: MAP = [(2 x diastolic)+systolic] / 3

Diastole counts twice as much as systole because 2/3 of the cardiac cycle is spent in diastole. An MAP of about 60 is necessary to perfuse coronary arteries, brain, kidneys.

Usual range: 70-110

Optimal Properties of a Parenteral Antihypertensive Agent

Rapid onset of action Predictable dose response Titratable to desired BP Minimal dose adjustments Minimal adverse effects No association with coronary steal or increased

ICP Ease of use and convenience

Available Parenteral Agents to Treat Hypertensive Emergencies

Calcium Chanel Blockers

Nicardipine Clevidipine

Adrenergic Receptor Blockers

Esmolol Labetalol

Vasodilators Hydralazine

Nitrovasdilators Nitroglycerin Nitroprusside

ACE Inhibitor Enalaprilat

TR Malignant hypertension

Classically: severe headaches, nausea/vomiting, visual disturbance

However chest pain and dyspnoea common presenting symptoms

Papilledema Severe: encephalopathy (e.g. seizures).

Fundus Photos

Management:

Reduce diastolic but no lower than 100mmHg within 12-24 hrs

Bed rest Most patients: oral therapy e.g. atenolol If severe/encephalopathy: IV sodium nitroprusside /

labetalol

AMI Admit Analgesia Angised S/L Assurance Drug benefit his pain and BP ACE –I ; B blocker ,?diuretic

ACUTE LVF/PUL.EDEMA Assure Admit Air—100% O2 Analgesia if conscious---venlitor Diuretics and monitor urine out put RFT---- if no urine----Dialysis Treat the underlying cause

Nitroglycerin SL /topical /Drip dilates capacitance vessels ((low

dose)) dilates arterioles ((high dose)) Enalaprilat Lasix low survival rate with diuretics

alone Nitoprsside drip Goals –reduce BP /20-30% ,diuresis

Acute aortic dissection TR: Avoid arteriodilators /venodilators Urgent admission Analgesia --Morphine Start B.Blockers-Esmolol bolus and

drip Diltiazem /verapamil OK if B

blocker cant be used Nicardipine drip (( AFTER BB )) Nitroprusside drip ((AFTER BB))

AAD CONT. Main stay of therapy:

B blocker + VasodilatorGOAL:SBP 100-120HR < 60 /minReduction of shear forces by

decreasing BP + HR

DIAGNOSIS - BP >140/90

MOSTLY YOUNG PRIMIS / >35, IN 3RD TRIMESTER (NOT BEFORE 20 WEEKS)

A) HYPERTENSION OF PREGNACY - BP >140 / 90 mmHg ALONE OR WITH MILD OEDEMAB) PREECLAMPSIA - B.I) MILD PREECLAMPSIA -

BP <160/100, MILD OEDEMA

TYPES-1) PREGNANCY INDUCED

HYPERTENSION (PIH)

HYPERTENSION DURING PREGNANCY

DIAGNOSIS - BP >140/90

B.II) SEVERE PREECLAMPSIA -BP >160/110, MARKED OEDEMA, PROTEINURIA 2+, HEADACHE,VISUAL DISTURBANCES, ABDOMINAL PAIN, OLIGURIA, THROMBOCYTOPENIA,BILIRUBIN, LIVER ENZYMES, CREATININE, FOETAL GROWTH RETARDATION, PULMONARY OEDEMA--C) ECLAMPSIA - WITH CONVULSION

TYPES-1) PREGNANCY INDUCED

HYPERTENSION (PIH)

HYPERTENSION DURING PREGNANCY

The target BP in patients with pre-existing hypertension is < 150/100 mmHg

OR 140/90 mmHg in the presence of end organ failure.

. As in patients with longstanding HTN aggressive BP control may compromise placental function, so diastolic blood pressure should be preserved > 80 mmHg. Any increase in BP above baseline should prompt a search for new pre-eclampsia

Consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold.

75 mg of aspirin daily from 12 weeks. Oral/ IV labetalol is now first-line following the 2010 NICE guidelines.

Nifedipine, or hydralazine can be used as alternatives after considering sideeffect profiles for the woman, foetus and new-born baby.

Delivery of the baby is the most important and definitive management step.

MgSo4 is used peri-delivery to reduce the risk of seizures, and may have adjunctive effects on lowering BP and would be considered as the potential next step after BP lowering by IV labetalol. (Firstly Labetalol IVI then MgSo4 IVI).

PRECLAMPSIA TR MgSo4 –seizures Labetolol bolus Nifedipine PO Nicardipine may be better Hydralazine ?? GOALS: < 160/110 <150/100 if platelets <

100000/mm3

IV Treatment of Acute Hypertension Is a Vital Consideration in Neuroemergencies

Abbreviations: AIS, acute ischemic stroke; ICH, intracerebral hemorrhage; IV, intravenous; aSAH, aneurysmal subarachnoid hemorrhage; SBP, systolic blood pressure.

References: 1. Jauch EC et al. Stroke. 2013;44(3):870-947. 2. Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) Investigators. Crit Care Med. 2010;38(2):637-648. 3. Connolly ES et al. Stroke. 2012;43(6):1711-1737.

Key Considerations for Choosing an Antihypertensive Agent in Acute Stroke

Primary Effects of Available Agents

What the Guidelines State…

Abbreviations: AHA, American Heart Association; ASA, American Stroke Association; aSAH, aneurysmal subarachnoid hemorrhage; BP, blood pressure; DBP, diastolic blood pressure; IV, intravenous; SBP, systolic blood pressure.

References: 1. Connolly ES et al. Stroke. 2012;43(6):1711-1737. 2. Jauch EC et al. Stroke. 2013;44(3):870-947. 3. CARDENE I.V. (nicardipine hydrochloride) Premixed Injection Prescribing Information. Cary, NC: Cornerstone Therapeutics Inc.; 2013.

63

ACUTE ISCHEMIC STROKE TR Labetolol Nicardipine If fibrinolytic therapy

planned ,treat if > 185/110 mmHg Must avoid worsening ischemia by

dropping BP too much No more than 10-15% first

24hours.

SAH / ICH Labetolol Nicardipine , ?Nimodipine Esmolol Caution:Maintain CPP while preventing rebleeding SBP < 160 mmHg (( MAP < 130mmHg) SBP > 120 mmHG to maintain CPPEvidence of ICP increaesing = maintain MAP 130mmHg

MAIN CONCEPTS OF TREATMENT OF HTN EMERGENCIES IN

GENERAL:

Note that these recommendations are more consensus-of-experts quality than true RCT-proven guidelines a. Hypertensive emergencies

Require ICU admission, A-line, and

aggressive BP control, usually with IV agents

Goal is reduction of BP to DBP of 100-110 mmHg (but reduce MAP by no more than 20-25% of initial) over first 2-6 hrs.

Careful monitoring for worsening of CNS status:

Rx choices: 1. Sodium nitroprusside (Nypride): Usual first line therapy. Can cause cyanate or thiocyanate

toxicity (after 24-48 hours of rx), which is more of a worry in patients with underlying renal or hepatic dysfunction. Onset immediate, duration of action 1-2 minutes.

2. Labetalol: Both alpha- and beta-blocking properties.

3. Fenoldopam: Peripheral D1-receptor agonist that causes direct vasodilation, renal-arterial dilation, and natriuresis.

4. Others: hydralazine, IV nitroglycerin, nicardipine iii. Special situations: 1. Eclampsia: Deliver the baby; MgSO4 2. CVA: More permissive HTN

Alternative drug(s

Drug(s) of choice Emergency

Nitroprusside, labetalol

Nitroglycerin, BB Acute coronary syndrome

Nitroprusside ; ACEinhibitors

furosemide Nitroglycerin ,

Acute pulmonary edema

Labetalol, nicardipin Nitroprusside, fenoldopam

Hypertensive encephalopathy

Nitroprussidenicardipin

Labetalol Intracranial hemorrhage

Labetalol, esmolol, trimethapha

followed by nitroprusside B.BLOCKER

Aortic dissection

LABRTOLOL Phentolamine; nitroprussid with B-blocker

Adrenergic crises

Nicardipine, labetalol

Hydralazine Pre-eclampsia/eclampsia

NOTROPRUSSIDE Arterio & venodilator Decreases preload & after load Potential as a general vasodilator to

increased ICP Dose 0.3–10mcg/kg/minute in D5WIncrease by 0.5mcg/kg/min and titrate.Onset –secondsDuration:1—2 min

Caution :>2mcg/kg/min may lead to CN toxicity

Avoid –renal /hepatic failure ,neurovascular emergrncies ,increased ICP

Recommended when all else fails

LABETALOL B blocker & weak alpha 1 effects without reflex tacchycardia Commonly used Broad applications Exceptios – cocaine intoxication ,CCF Bolus 10—20mg IV over 2min 40—80 mg –10min intervals upto 300mg

total Check BP 5 & 10 min after bolus

LABETOLOL Infusion –2mg /min and titrate to

response upto 300mg Effect—2—5min 15 min and lasts 2-4

hours

Avoid : CCF ,CHB ,Bronchspasm ,Bradycardia

coronary or cerebral arteriosclerosis, renal impairment, or documented hypersensitivity.

Captopril Sublingual use 25–50mg has

gainedpopularity in ED, Especially useful patients with HTN and CHF

Cautions include symptomatic hypotension increasing especially following the first dose.. in HTN crisis associated with CHF or myocardial ischemia.Adverse reactions include ACE inhibitor-induced cough, angioedema

METOPROLOL

Indicatio : Acute CS 5 mg q 5-15 min upto 15 min

NIFEDIPINE DISCOURAGED IN HYPERTENSIVE

EMERGENCIES AS IT CAN EXPAND THE INFARCTION ZONE

MAY BE USED IN PRE-ECLAMPSIA

CLEVIDIPINE 3rd generation CCB Ultra-short Arteriolar vasodilator Cardiac surgery T1/2 <1min May be beneficia in future

Hydralazine Dose 5–20mg IV q4–6hours prn

initial. dose;increase dose.Change to PO

as soon as possible. Used in the treatment of eclampsia

NICARDIPINE Initial infusion 5mg/hour, titrate

2.5mg/hou every 5–15 minutes.Maximum 15mg/hour

maintenance 3mg/hour

Contraindications include aortic stenosis, or previous hypersensitivity to calcium channel blockers. Pheochromocytoma 0.5–2mg boluses repeated as needed. Pre-eclampsia/eclampsia, initial dose 1mcg/kg/minute, titrate 0.5mg/hour (usual dose 0.7mcg/kg/minute)

Fenoldopam Dopamine 1 agonist Continuous infusion (inability to bolus

may preclude its use in the ED) Dose. 0.1–1.6mcg/kg/minute titrate every

15 min (usual dose 0.3mcg/kg/minute) Onset 5 min ,Peak 15 min Duration: 30—60 min Improves cr.clearance and urine flow PT with renal impairement

Application in Renal Neurologic HTN emergencies

SE---flushing ,dizziness ,vomiting

PHENTOLAMINE Alpha 1 & a 2 blocker Bolus : 5-20 mg IV / 5 min Infusion : 0.2-0.5 mg/min Indications :Cocaine

intoxication ,PheochromocytomaMay induce----MI ,CVA

Must protect from light by wrapping in aluminum foil.

Contraindications include documented hypersensitivity, idiopathic hypertrophic subaortic stenosis (IHSS), atrial fibrillation or flutter. Caution in renal or hepatic insufficiency, as levels may increase and can cause cyanide or thiocyanate toxicity, especially with prolonged use and with doses greater than 4mcg/kg/ minute.Arterial invasive monitoring recommended

NITROGLYCERIN Venodilator ,reduces

preload ,CO ,cardiacwork Dose 5–10mcg/minute IV titrating

upward by 5q 3-5min upto 20mcg/min THEN 10mcg/min q 3-5 min upto 299mcg/min to keep SBP > 90mmHg decrease MAP by 25%.

Continuous 0.1–1mcg/kg/minute IV infusion. Doses may reach over 100mcg/minute pending hemodynamic tolerance.

NITROGLYCERIN Onset : 2 min Duration : 1 hr Avoid :Renal /cerebral

hypoperfusiion ,ViagraSide effects include headache, or

hypotension, tachycardia.

ENALAPRILAT ACE I only IV Application CHF /ACS Test dose 0.625mg hypotension common with

first dose Bolus 1.25mg over 5 min q 4-6hr Onset within 15 min Max effect 1—4 hrs Avoid in pregnancy ,angiedema