1. HYPERTENSIVE CRISIS
SYED RAZA

2. OBJECTIVES
• 1. What is Hypertensive Crisis ?
• 2. Size of the problem
• 3. Clinical presentation
• 4. Management

3. CASE SCENARIO
• 69/M
• Chest tightness and shortness of breath
• Diabetes – 10 years. Chronic smoker
• Not known hypertensive
• BP 230/120 mmHg HR 110/mt
• CVS – S3 gallop, No murmur.
• Chest – Bi-basal fine inspiratory crackles
• P/A – Kidneys not ballotable. No RA bruit.
• Neuro – fully consciouss , No neuro deficits.

6. Lab
• Hb – 9.4
• MCV- 84
• Creatinine : 2.1 mg/dl
• Urine : 3 + protein
• Cardiac markers - Normal

7. What would you do next?
• 1. 24 hour urinary protein.
• 2. 24 hour ambulatory BP
• 3. Renal Ultrasound
• 4. Fundoscopy

9. What targets organs are Involved?
• 1. Brain
• 2. Heart
• 3.Retina
• 4. Kidneys

10. What targets organs are Involved?
• 1. Brain
• 2. Heart
• 3.Retina
• 4. Kidneys

11. What is the diagnosis?
• 1. Accelerated Hypertension
• 2.Malignant Hypertension
• 3. Hypertensive Urgency
• 4. Hypertensive Emergency

12. Answer
Hypertensive Emergency
Severe Hypertension where BP is > 180/110
mmHg with evidence of target organ damage.
1.Retinopathy / Retinal hemorrhage
2.Encephalopathy/I.C hemorrhage/ IC tension
3.Acute Pulm. Oedema, Myocardial
ischaemia/Aortic dissection.
4. Acute Renal Failure

13. HYPERTENSIVE CRISIS
• Approximately 25% of emergency room visits
are due to hypertensive crisis.
• BP > 180/110 mmHg
• Emergency : Target organ damage.
• Urgency : No target organ damage.

16. Common precipitating factors
• 1. No regular health checks
• 2. Age - elderly
• 3.Sub therapeutic treatment
• 4. Non adherence to medication.
• 5. Lack of family care physician.

17. Signs and Symptoms
Symptoms specific to target organ damage
• Headache
• Neck pain
• Blurring of vision
• Chest tightness
• Shortness of breath
• Anuria

18. Lab Work Up
• 1.CBC
• 2. KFT
• 3.Urine Analysis
• 4. CXR – Heart/aorta size/ LVF
• 5. ECG
• 6.Fundoscopy
• 7.CT/MRI Brain

20. Management : Basic Principle
Urgency : Out-patient
Oral medication
BP reduction 24-48 hours
Emergency : Inpatient
Intravenous
Immediate BP reduction < 25% within
minutes – 1 Hour
160/100 : 2-6 hours

21. Intravenous Antihypertensive
• Nitroglycerine (5-100 mic/mt)
• Sodium Nitroprusside (0.25-10 mic/kg/mt)
• Enalaprilat (only ACEI in I/V form, 1.25-5mg)
• Nicardipine (2nd
generation) 5-15 mg/hr
• Clevidipine (3rd
generation)
• Esmelol (250-500 mic/kg/mt)
• Labetalol (20-80 mg bolus)

22. Oral Drugs for Hypertensive
Urgency
• Amlodipine 5-10 mg OD – 12 hrly
• Captopril 12.5 – 25 mg 6 hrly
• Nicardipine 20-30 mg 6-8 hrly
• Clonidine 0.2 mg 12 hrly
• Labetalol 200-400 mg 8-12 hrly
• Lasix 20-40 mg 8-12 hrly

23. Medication of choice
• Myocardial Ischemia/ LVF : NTG, Esmolol
• Aortic Dissection : Labetalol
• Acute Renal Failure : Fenoldopam /
Nicardipine
• Hyper-adrenergic states : due to sympatho-
mimetic drugs : Benzodiazepines.
Pheo chromocytoma : Phentolamine

24. • Eclampsia : Labetalol /Magnesium
ACEI and ARB contra-indicated
Intracranial Heamorrhage: Aim MAP 130
mmHg
First : Labetolol
Second : Sodium Nitroprusside if no raised ICP
If ICP raised : Use Nicardipine.

25. • Labetalol : Alpha selective, Beta non selective
• oral/ intravenous
• Nicardipine : second generation
dihydropyridine.Onset of action 5-20 minutes
• Nitroglycerine :
• More of Venodilator than arterial dilator.
• SE: Headache, Flushing, Tachycardia
•

26. • Nitro prussside :
Strong veno and arterial vasodilator.
rapid onset of action.
Risk of thiocyanide toxicity : Hyperreflexia
delerium , psychosis

27. Fenoldopam
• Selective dopamine 1 receptor Agonist
• Onset of action < 1 minute
• Useful in patients with acute renal failure.
• Fenoldopam improves urinary output,
• Creatine clearance , sodium excretion

28. Use of Captopril
• Short acting ACEI
• Hypertensive Urgency
• Oral and sublingual : 6.25-50 mg
• Effect seen within 5-15 minutes
• Max reduction of BP in 30 mins
• Duration of effect 2-6 hours
• S/E : Hyperkalaemia / Angio-edema/dry cough

29. Captopril vs Nifedipine

31. Case
• 72/m
• Annual physical check-up
• Asymptomatic
• BP 210/100-110 mmHg

32. What would you examine next?
• 1. Fundoscopy
• 2. CVS
• 3.Neurology examination.
• 4. Peripheral pulses

33. ANSWER
• 1. Fundoscopy
• 2. CVS
• 3.Neurology examination.
• 4. Peripheral pulses

34. Physical Examination
• Fundoscopy – Normal
• Systemic Physical Examination – Normal
• Lab- Normal
• ECG and CXR - NAD

35. What is the diagnosis?
• 1. Malignant Hypertension.
• 2. Hypertensive Urgency
• 3. Hypertensive Emergency
• 4. Severe Acute Hypertension.

36. ANSWER
• 1. Malignant Hypertension.
• 2. Hypertensive Urgency
• 3. Hypertensive Emergency
• 4. Severe Acute Hypertension.

37. How will you manage the patient?
• 1.Admit and start intravenous
antihypertensive medication
• 2. Treat as OP clinic with orally
antihypertensive
• 3. Treat if patient is symptomatic
• 4. Just Observe

38. How will you manage the patient?
• 1.Admit and start intravenous
antihypertensive medication
• 2. Treat as OP clinic with orally
antihypertensive
• 3. Treat if patient is symptomatic
• 4. Just Observe

40. What do the guidelines say?
Joint National Committee
•Seventh report on Prevention, Detection,
Evaluation and Treatment of Hypertension
states ‘’ Initial goal of therapy in hypertensive
emergencies is to reduce MAP by no more than
25% - minutes to 1 hour
160/100-110 - 2 to 6 hours
<140/90 - 24 to 48 hours

41. Exceptions
• Patients with ischemic stroke
• Patients with Aortic Dissection
• Patients requiring urgent thrombolytic
therapy (BP < 180/100 mmHg)

42. Acute Ischemic Stroke
• If BP < 220/120 mmHg – only observe
Unless end organ damage
concurrent hemorrhage
If SBP > 220 and DBP 120-140 : Labetalol
/Nicardipine
If DBP > 140 : Nitroprusside
Aim for 10 – 15% reduction over 24 hours

43. Aortic Dissection
• BP should be lowered quite aggressively
• Goal : systolic BP 100-120 mmHg within 20
minutes
• Aim
a. lower BP
b. decrease LV contraction so as to decrease
Aortic shear stress
DOC : labetalol or Esmolol