recent manag ement of hypertencive emergencies

7/27/2019 Recent Manag Ement of Hypertencive Emergencies

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Recent Management ofHypertensive Emergencies

Wiguno Prodjosudjadi

Division of Nephrology and Hypertension

Department of Internal Medicine, Faculty of MedicineUniversity of Indonesia

Dr. Ciptomangunkusumo General Hospital

Jakarta


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Hypertensive Emergencies

Acute Impairmentof Organ System

SevereHypertension

Hypertensive Urgencies

Potential Risk of

Acute Organ DamageSevere

Hypertension

Emergency

Unit

Severe

Hypertension

Severe hypertension without target organ damage


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Hypertensive encephalopathy

Intracranial bleeding

Left heart failure

Acute myocard infark

Acute dissecting aorta

Eclampsia

Malignant hypertension


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Clinical Manifestations of

Hypertensive Encephalopathy

Severe headache

Nausea and vomiting

Visual disturbances

Confusion

Focal and generalized weakness

Focal or generalized seizure

Focal neurological signs


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Intracerebral Bleeding


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Clinical Manifestations of

Aortic Dissection

Pain in the chest, back or abdomen

Abrupt, severe, persistent and may

migrate down-ward

Discrepancies between pulses

Murmur of aortic insufficiency

Neurological deficits

Mediastinal widening on chest X ray


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Type of Aortic Dissection

Chest 1991 ; 99 : 724-29

Type A Type B


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Pathophysiology of



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Acute Increase of BP on Target Organ

Acute BloodPressure

http://www.emedicine.com/emerg/topic267.htm

Blood

Pressure

Transudate leak

Arteriolar damage

Arteriolar

Vasoconstriction

Vasoconstriction

Autoregulation

Normal

CBF

Increase cardiac

workload

Renal system

impairment

& Failure of

Autoregulation

Acute BloodPressure CHF

Acute BloodPressure

Arteriosclerosis

Fibrinoid

necrosis


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Proposed Role of Passive Dilatation and

Disruption of the Blood Brain Barrier

Hypertension, 1988 ; 12 : 89-95


11/32Lancet 2000 ; 356 : 41117

Putative Vascular Pathophysiology

of Hypertensive Emergencies


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Fibrinoid Necrosis


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JASN, 1998 ; 9 :133

Mechanisms of Malignant HypertensionCritical degree of Hypertension

Increase in BP and Ischemia

Endothelial damage Increase in vasoconstrictors

(renin-angiotensin, vasopressin

Catecholamines)

Further blood

pressure increase

Pressure natriuresis

Hypovolemia

Further release of

vasoconstrictors

Platelet and fibrin

deposition

Fibronoid necrosis &

intimal proliferation

Intravascular

hemolysis


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Hyperplastic Arteriolitis

in Malignant Hypertension

Atlas of Heart Diseases, 1994 : Vol. 1

Silver Stain

Distal Renal Interlobular Artery in a 48 Years Old


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Management of



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Principles in the Management of


Minimizing TOD due to high blood pressure

Avoid deleterious effects of drug treatment

Purpose of treatment :

Over minutes to hours :

BP should be lowered by up to 25% MAP

or DBP should be lowered up to 100 -110 mmHg

Intravenous antihypertensive drugs is needed


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Parenteral Drugs for Treatment

of Hypertensive Emergencies

Sodium nitroprusside

Nicardipine HCl

Nitroglycerine

Enalaprilat

Hydralazine HCl Diazoxide

Labetalol HCl


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Treatment of Hypertensive

Emergencies

Type ofHypertensive

Drug of Choice Alternative orSecond line drug

Encephalopathy Nitroprusside Labetalol

Intracranial

hemorrhage Labetalol Nitroglycerin

Left ventricular failureNitroprusside, Diuretic,

ACE-INitroglycerin

Acute myocardial

infarction

Nitroglycerin, Beta-

blockers

Nitroprusside,

labetalol

Dissecting aortic

aneurysm

Beta-blockers,

NitroprussideLabetalol, Verapamil

Eclampsia Hydralazine, labetalol Nifedipine

JASN 1998;9(1):133-142


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Intravenous Antihypertensive Drugs

Available in Indonesia

Clonidine

Nicardipine HCl

Diltiazem HCl

Nitroglicerin

Diazoxide, Nitroprusside


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Available in 150 g per 2 ml ampul

Maximal dose was 900 g / 24 hours

Dilute 300 - 900 g in 5% Dextrose (250 cc)

given IV micro-drip infusion or syringe pump

Dose titration is based on the level of blood

pressure 24 Hours after BP target was reached, change

to oral antihypertensive therapy

Clonidine


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Clonidine

Nicardipine HCl

Diltiazem HCl

Nitroglicerin



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Available in 2 mg (2 ml) and 10 mg (10 ml) per ampul

Can be administered as bolus injection ( 10-30 g/Kg

BW), IV micro-drip infusion or by syringe-pump

IV micro-drip infusion with a starting dose 5 mg/hr; the

dose can be increased every 15 minutes by 2,5 mg/hr

up to 15 mg/hr (maximal dose)

After target of BP was reached, reduce the dose by

3 mg/hr and then change to oral antihypertensive

therapy

Nicardipine HCl


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Clonidine

Nicardipine HCl

Diltiazem HCl

Nitroglicerin



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Available in 10 mg and 50 mg per ampul

Can be administered as bolus injection (0,25 mg/kg

BW over period of 3 minutes, with maximal dose 20

mg)

Second bolus can repeated 15 minutes after first

bolus (0,35 mg/kgBW with maximal dose of 25 mg).

For IV drip infusion starting dose is 10 mg/hr which

can be increased up to 15 mg/hr (maximal)

Diltiazem HCl

B l I


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Target MBP

Level

Bolus I.v.

0.2 mg/kg

Drip infusion

50 mg/hour

Drip infusion30 mg/hour

Drip infusion

5-10 mg/hour

10% MBP reduction

From Baseline

20% MBP reduction

From Baseline

10

20

30

Switch to Oral

DILTIAZEM 180SR

Every 30-60 minutes observation


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Clonidine

Nicardipine HCl

Diltiazem HCl

Nitroglicerin



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Can be given by IV drip infusion with the rate of

5-100 gr/minutes

Dose titration is based on the level of BP

Onset of action is 2-5 minutes and the duration of

action is 3-5 minutes

Indication : hypertensive emergencies (with angina

pectoris or MCI) and lung edema

Nitroglycerin


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Clonidine

Nicardipine HCl

Diltiazem HCl

Nitroglicerin



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Diazoxide

Recommended dose 300 mg or 5 mg/Kg BW

IV bolus with small dose (75-150 mg) is safe and effective


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Untreated hypertensive emergencies : the 1 year

mortality rate is more than 90%

All patients presenting with hypertensive

emergencies in ER : the median survival duration

is 144 months

All presenting hypertensive emergencies : the 5-

year survival rate is 74%

Prognosis of Hypertensive Emergencies


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Conclusions

In hypertensive emergencies the blood pressure

should be lowered aggressively over minutes to hours

The purpose of antihypertensive treatment to prevent

target organ damage due to high blood pressure and

minimizing the risk of hypoperfusion

Various intravenous antihypertensive drugs can be

selected


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recent manag ement of hypertencive emergencies

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