HYPERTENSION CHRO

1. Evidence Based management of
Hypertension
Case 6

2.  A 52-year-old man presented to the
emergency department with
 worsening occipital headache
 Confusion
12 hours
 numbness and weakness involving the right
side of his body
 blurry vision.
 Past medical history
 Hypertension
 hyperlipidemia..

3. On physical examination
 Blood pressure was 213/134 mm Hg.
 Confused.
 Papilledema was seen on fundoscopic examination.
 motor weakness (4/5) in the right upper extremity.

4. Laboratory studies revealed
following:
 serum potassium, 3.1 mEq/L;
 blood urea nitrogen, 36 mg/dL; and
 serum creatinine, 2.5 mg/dL (baseline creatinine, 1.5
mg/dL).
 Electrocardiogram revealed left ventricular hypertrophy by
voltage criteria and nonspecific ST-T wave abnormalities in
the lateral leads.
 Computed tomography scan of the head without contrast
revealed diffuse bilateral white matter changes consistent
with hypertensive encephalopathy

5.  Although not specifically addressed in the JNC 7
report, patients with a systolic BP > 179 mm Hg or a
diastolic BP > 109 mm Hg are usually considered to be
having a “hypertensive crisis”.
Crises
Emergency Urgency

6.  The term malignant hypertension has been used to
describe a syndrome characterized by elevated BP
accompanied by encephalopathy or acute
nephropathy. This term, however, has been removed
from National and International Blood Pressure
Control guidelines and is best referred to as a
hypertensive emergency.
CHEST / 13 1/6/ JUNE, 2007

7. Left with 2 terms
 Hypertensive Emergency
 Hypertensive Urgency

8.  Hypertensive emergency (crisis)
 severe elevation in blood pressure (> 180/120 mm Hg)
 complicated by evidence of impending or progressive target organ
dysfunction.
 Target organ dysfunction (Acute) include Emergency not defined
by a
 coronary ischemia,
specific number, but
 disordered cerebral function,
rather by evidence of
 cerebrovascular events,
acute dysfunction in
 intracerebral or subarachnoid hemorrhage or
 hypertensive encephalopathy. (cerebral edema)
cardiovascular,
 pulmonary edema, and
neurologic, or renal
systems
 renal failure.
 The rate of change in blood pressure
Dept. of Health and Human Services, National Institutes of Health,
Can Fam Physician 2011;57:1137-41 National Heart, Lung, and Blood Institute; 2004. NIH Publication No.
04–5230.

9. Examples of Hypertensive
emergency
 hypertensive encephalopathy,
 Intracerebral hemorrhage,
 acute MI,
 acute left ventricular failure with pulmonary edema,
 unstable angina pectoris,
 dissecting aortic aneurysm,
 Eclampsia, HELLP Syndrome
 Acute renal failure
 Microangiopathic hemolytic anemia
 Acute Postoperative Hypertension

11.  Hypertensive urgency,
 severe elevation in blood pressure without progressive
target organ dysfunction (>160/110)
 Examples
 upper levels of stage II hypertension associated with
 severe headache,
 shortness of breath,
 epistaxis, or
 severe anxiety.
The Seventh Report of the Joint National Committee on
Prevention,Detection,Evaluation, and Treatment of High Blood

12. Pathophysiology
Check
Activation of Coagulation cascade and
standing
pro-inflammatory mediators BP
Underlying Precipitating
Hypertension Factor

13. Index case
 The patient was admitted to the intensive care unit
and started on intravenous nitroprusside.
 Blood pressure decreased to 190/100 mm Hg over the
first 3 hours and neurologic symptoms resolved within
5 hours.
 He was switched to his usual oral regimen on the third
day of hospital admission and was discharged home on
the fifth day with controlled blood pressure

14. Management of Urgency
 Oral antihypertensive agents in an outpatient or
observational setting
 low doses
 incremental doses
 Avoid excessive reduction in elderly, patients with
PAD/CVD/intracranial disease
 The initial goal is to reduce blood pressure to 160/110 mm Hg
over several hours to days using conventional oral therapy
(24-48 hrs)
 Mean arterial pressure should be reduced by no more
than 25% within the first 24 hours using conventional oral
therapy.

15.  Captopril
 ACE inhibitor
 onset of action 15 to 30 minutes
 maximum drop in blood pressure 30 and 90 minutes
 25-mg oral dose initially, followed by incremental doses of 50 to 100
mg 90 to 120 minutes later
 Significant adverse effects include cough, hypotension,
hyperkalemia, angioedema, and renal failure (especially in
patients with bilateral renal artery stenosis, in whom it should be
avoided).

18.  Nicardipine
 Calcium channel blocker
 oral dose is 30 mg,
 Repeated every 8 hours until the target blood pressure is
achieved.
 Onset of action is ½ to 2 hours.
 Common adverse reactions include palpitations, flushing,
headache, and dizziness
Am Heart J 1995;129:917–23

19.  Labetalol
 has mixed α1- and β-adrenergic blocking
properties(1:7)
 onset of action within 1 to 2 hours
 Starting dose is 200 mg orally, which can be
repeated every 3 to 4 hours
 Common side effects include nausea and dizziness.

20.  Clonidine
 central sympatholytic (α2-adrenergic receptor agonist) agent
 onset of action within 15 to 30 minutes
 peak effect within 2 to 4 hours
 oral regimen is a 0.1 to 0.2 mg loading dose followed by 0.05 to 0.1
mg every hour until target blood pressure is achieved, up to a
maximum dose of 0.7 mg.
 Common side effects include sedation, dry mouth, and orthostatic
hypotension.
 Beware of “withdrawl”

21.  calcium channel blocker
 Peak effect within 10 to 20 minutes.
 Short-acting nifedipine is not approved by the US FDA
(unpredictable drops in blood pressure and associated risk
of stroke)
 In 1995, an ad hoc panel convened by the National
Heart,Lung, and Blood Institute concluded that “short-
acting nifedipine should be used with great caution (if at all),
especially at higher doses, in the treatment of hypertension.”

22. Treatment of hypertensive
emergency
 Use parenteral drugs
 Continuous monitoring of blood pressure.
 Reduce the mean arterial pressure by 10% during the first hour and an additional 15% within the
next 2 to 3 hours
 JNC VII
 Reduce mean arterial BP by no more than 25 per-cent (within minutes to 1 hour),
 then if stable, to 160/100–110 mmHg within the next 2–6 hours.
 If tolerated further gradual reductions toward a normal BP can be implemented in the next 24–48 hours
 More rapid reduction in blood pressure may result in cardiac or renal or cerebrovascular hypo-
perfusion.
 altered autoregulation curve
 Pressure natriuresis may cause volume depletion in patients with hypertensive emergency, and
administering vasodilator medications to these patients can lead to precipitous drops in blood
pressure. Patients with volume depletion should receive intravenous (IV) saline to restore
intravascular volume and shut off the renin-angiotensin-aldosterone system.
Elliot WJ. Clinical features and management of selected hypertensive
emergencies. J Clin Hypertens (Greenwich)
2004;6:587–92

23. Exceptions to treatment of
Emergency
 Aortic dissection
 Pulmonary edema
 Stroke
 Patient requiring thrombolysis

24.  Hypertension in the setting of an intracerebral bleed
 Treat only when blood pressure is more than 180/ 105
mm Hg.(or 200/110)
 MBP should be maintained <130 mm Hg
 Ischemic stroke,
 Observe first 1 to 2 hours to determine if it spontaneously
decrease s
 Only a persistently MAP>130 mm Hg or a SBP> 220 mm Hg
or DBP >120, should be carefully treated.
 Mean arterial pressure should be lowered by 15% to 20% (10-
15% JNC VII) over 24 hrs
 Bring BP <185/110 for thrombolysis. Maintain at <180/105
 Labetelol,Sodium Nitroprusside , nicardipine, enalipritat
used
American Heart association recommendation
Adams HP Jr, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scien-tific
statement from the Stroke Council of the American Stroke Association. Stroke 2003; 34:1056 –1083
The European Stroke Initiative Executive Committee andthe EUSI Writing Committee. European Stroke
Initiativerecommendations for stroke management: update 2003.Cerebrovasc Dis 2003; 16:311–337

25.  Acute aortic dissection,
 IV β-blocker (eg, labetalol or esmolol) followed by a
vasodilating agent, classically IV nitroprusside.
 lower the SBP to a goal of < 120 mm Hg within 20
minutes (MAP <80).

26.  Acute stroke with accelerated htn well within accepted
range but with concomitant noncerebral acute
organ damage .
 What next?
 Blood pressure should be reduced carefully
beyound the accepted values using emergency
guidelines, with careful monitoring of
neurological status

27. Acute Postoperative Hypertension
 early onset, (within 2 h after surgery)
 Typically of short duration, (treatment for ≤ 6 hrs)
 Complications of APH may include hemorrhagic stroke, cerebral
ischemia,encephalopathy, myocardial ischemia, myocardial
infarction, cardiac arrhythmia, CCF with pulmonary edema,
failure of vascular anastomoses, and bleeding at the surgical site
 Most commonly associated with cardiothoracic, vascular, head
and neck, and neurosurgical procedures.
 Activation of the sympathetic nervous system, increase in
afterload, increase in SBP and DBP with or without tachycardia

28.  Post cardiac surgery, treatment is recommended for a
BP > 140/90 or a MAP of > 105 mm Hg. Other
conditions the goal may vary
 Rule out Pain,anxiety, hypothermia with shivering,
hypoxemia, hypercarbia, and bladder distension
 Labetalol, esmolol, nicardipine, and clevidipine have
proven effective

29. Emergencies and urgencies. The
Cleveland Clinic disease
management project. 12 Jan
2006.

30. The Seventh Report of the Joint National Committee
on Prevention,Detection,Evaluation, and Treatment
of High Blood Pressure

31. The current AHA
guidelines recommend the
use of Labetalol or
nicardipine if the SBP is
>220 mm Hg or the DBP is
from 121 to 140
mm Hg, and nitroprusside
for a DBP > 140 mm Hg
The diagnosis and management of hypertensive crises.
Chest 2000

32. Take Home Message

33. 5 patients arrive with identical vital signs: heart rate of 100 beats/min, blood pressure
(BP) of 209/105 mm Hg, respiration rate of 20 breaths/min, and temperature of 36.9oC
 Patient A is a 65-year-old man with nausea,  Intravenous labetalol, bolus or infusion.Target:
vomiting, and confusion and papilledema Reduce MAP by 20% to 25% over 2 to 8 hours
 Nitroglycerin infusion; intravenous
 Patient B is a 73-year-old woman with sudden enalaprilat or sublingual captopril.
shortness of breath, pink sputum, and heavy Furosemide will work only after adequate
chest pain and LVH decrease in preload and afterload
 Urgent imaging with simultaneous decrease in
 Patient C is a 56-year-old man with sharp, BP. Nitroprusside and esmolol infusion;
tearing chest and back pain and diastolic labetalol boluses or infusion.Target: Rapidly
murmer reduce systolic BP to 110 mm Hg if there is
no evidence of hypoperfusion
 No treatment.Reduce BP only if it is greater
 Patient D is a 64-year-old woman with a 6- than 220/120 mm Hg (embolic) or greater
hour history of right-sided weakness. NCCT than 180/105 mm Hg (hemorrhagic)
no hemorrage. Thrombolysis not
contemplated
 Restart the medications she was on (Diuretic
 Patient E is a 51-year-old woman with a mild
headache, concerned about her history of and ARB). Ask her to follow up in OPD
hypertension.Poorly compliant. LVH +

34. Thank You