Activity 2-unit 2-update 2024. English translation
Hypertensive Emergencies
1.
2. Dr Nahed Sherbini ,Consultant Internist ,Head of Internal Medicine Department
2010 KFH, Medina
3. ED
Medical & Surgical Wards
MICU
SICU
OR
Varon J, Fromm RE. Postgrad Med. 1996;99:189-203.
4. Hypertensive Emergencies
Hypertensive Urgencies
An Approach to Drug Treatment of HU and HE
5.
6. Affects at least 1 BILLION individuals
worldwide.
Most current (2003) evidence basis for
chronic management— (JNC 7)—lacks
guidance for acute management of patients
presenting with severe acute elevations of BP.
JNC 7, JAMA 2003; 289:2560-2572.
7. Data are largely lacking.
In a single-center Italian study, HU or HE
HU:HE ratio of 3:1 in that study
Zampaglione et al, Hypertension 1996;27:144.
8. Hypertensive emergencies and urgencies
Account for 3% of all ED visits1
An “Internal Medicine” ED
N=14,209
1634 had a medical urgency or emergency2
▪ 27.4% of these were hypertensive crises
1. Kitiyakara C, Guzman N. J Am Soc Nephrol. 1998;9:133-142.
2. Zampaglione B, et al. Hypertension. 1996;27:144-147.
9.
10. JNC7
BP Classification SBP mmHg DBP mmHg
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 Hypertension 140–159 or 90–99
Stage 2 Hypertension >160 or >100
11. Stage 3 hypertension (JNC 6):
Systolic > 180, Diastolic > 110
Functionally, this is “hypertensive urgency”
What about “crisis,” “emergency,” and
“urgency”?
JNC 7, JAMA 2003; 289:2560-2572.
12. “hypertensive crisis” is an acute, severe, stage
2 or 3 elevation BP.
Crisis is then differentiated into hypertensive
“emergencies” &“urgencies”.
JNC 7, JAMA 2003; 289:2560-2572.
13. Hypertensive Severe elevation in BP
emergency (>180/120 mmHg) Hypertensive Crisis
complicated by evidence of
impending or progressive
target organ dysfunction
Hypertensive Hypertensive Perioperative
Hypertensive Severe elevation in BP urgency emergency hypertension
urgency without progressive
target organ dysfunction
Emergency Intensive care Operating room
department unit post-anesthesia
care
Chobanian AV et al. Hypertension. 2003;42:1206-1252.
19. Four Categories of Presentation
1. Mild, uncomplicated
2. Transient
3. Emergencies
4. Urgencies
20. Mild, Uncomplicated HTN
Diastolic BP <115 mmHg without end organ
symptoms
Educate, do not treat, arrange follow up
Transient HTN
A reaction to some condition
▪ Pain, fright, epistaxis,
drug OD
Treat the condition
24. Goal in hypertensive urgency is to reduce
MAP (MAP= ( 2 Diastolic + systolic) / 3) by
10-15% and/or to a DBP of 110 . . . within
hours.
HU can generally be managed with oral
medications and requires BP lowering over
24-48 h.
JNC 7, JAMA 2003; 289:2560-2572.
25. Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling With Compelling
Indications Indications
Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling
(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications
Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs
May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB)
or combination. ACEI, or ARB, or BB, or CCB) as needed.
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
26. Compelling Indication Initial Therapy Options Clinical Trial Basis
ACC/AHA Heart Failure
Heart failure THIAZ, BB, ACEI, ARB, Guideline, MERIT-HF,
ALDO ANT COERNICUS, RALES
Post MI ACC/AHA Post-MI
BB, ACEI, ALDO ANT Guideline, BHAT,
SAVE, Capricorn,
ALLHAT, HOPE,
ANBP2, LIFE,
High CAD risk THIAZ, BB, ACE, CCB CONVINCE
28. Reduce MAP by ≤ 25% during the 1st minutes
to 1 h.
If stable, reduce BP to 160/100-110 mmHg in
next 2-6 h.
Conditions requiring special management
Aortic dissection
Stroke eligible for thrombolytic agents
Ischemic stroke
Chobanian AV et al. Hypertension. 2003;42:1206-1252.
29. Patients with chronic hypertension
Cerebral Blood Flow autoregulate cerebral blood flow
around higher set points
Patients with cerebral ischemia
Increasing risk of lose their ability to autoregulate
hypertensive Ischemia
encephalopathy Normotensive
Chronic hypertensive
Increasing risk
of ischemia
0 50 100 150 200 250
MAP (mm Hg)
Adapted with permission from Varon J, Marik PE. Chest. 2000;118:214-227.
30. NORMAL AUTOREGULATION AUTOREGULATION FAILURE
RISE IN BP RISE IN BP
ARTERIAL AND FAILURE OF
ARTERIOLAR VASOCONSTRICTION
CONSTRICTION
Normal flow.(flow=P/r) ENDOTHELIAL DAMAGE
(due to shear stress on the wall)
31. Patients with marked BP elevations and acute
target-organ damage
Admitted to an ICU for continuous monitoring of BP.
Should receive parenteral antihypertensive therapy with
an agent appropriate for the individual patient.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure. US Dept of HHS; NIH publication No. 04-5230; 2004:54.
45. The Eighth Report of the Joint National
Committee on
Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 8)
Update of the JNC 7 Report
Expected Availability for Public Review and
Comment: Spring 2011
Expected Release Date: Fall 2011