The document discusses hypertensive emergencies, which are acute, severe elevations in blood pressure that can cause target organ damage. It notes key risk factors and various potential causes. It outlines goals for lowering blood pressure during hypertensive emergencies, which depend on the specific target organ(s) affected and time since presentation. Common medications used for treatment are discussed along with their indications and special considerations. Treatment goals differ for conditions like pregnancy, stroke, and aortic dissection. The importance of determining whether target organ damage is present and tailoring treatment accordingly is emphasized.
2. Introduction
Hypertensive crisis are acute, severe elevations in
blood pressure that may or may not be associated
with target-organ dysfunction.
Blood pressure > 180/110 mmHg
Hypertensive emergencies significant
morbidity and potentially fatal target-organ damage
1-3% of patients with HTN will have HTN emergency
during their lifetime.
3.
4. Risk factors
Female sex
Higher grades of obesity
Hypertensive or coronary heart disease
Mental illness
Non-adherence of anti-hypertensive medications.
10. BP Treatment goals for
Hypertensive Emergency
Goal Time BP Target
First hour Reduce MAP by 25% (maintain goal DBP>100mmHg)
Hours 2-6 SBP 160 mmHg and/or DBP 100-110 mmHg
Hours 6-24 Maintain goals for hours 2-6 during first 24 hrs
24-48 hrs Outpatient BP goals according to the 2017 Guidelines
for Management of High BP in adults.
11. Treatment Goals
Acute Aortic Dissection
Medical management should be considered first line
for most non-life threatening type B aortic
dissection.
Goal heart rate – 60 beats/min within minutes of
presentation.
Goal Blood Pressure – SBP < 120 mmHg and/or as
low as clnically tolerated.
12. Treatment Goals
Acute Ischemic Stroke
Adaptive response to maintain CPP to the brain.
Current Guidelines for BP reduction
Use of thrombolytic therapy
Other target organ damage ( aortic dissection, MI )
Severe elevated blood pressure SBP>220 mmHg &
DBP>110 mmHg
For thrombolytic therapy initiation BP goal is less than
185/110 mmHg
During therapy and subsequent 24 hrs BP goal is
<180/105 mmHg
Other circumstances – BP goal is 15% (10-20%)
reduction in MAP to allow maintainence of CPP
13.
14. Treatment Goals
Acute Hemorrhagic Stroke
Recent evidences suggest elevated BP during
acute ICH are associated with hematoma
expansion, neurologic deterioration and death.
BP goal – SBP < 160 mmHg over the first few
hours is relatively safe.
ATACH-2 trial, patients were randomised with
SBP target of < 140 mmHg or 140-180 mmHg
acutely after ICH hypertensive emergency.
Functional outcome did not differ.
15.
16. Acute Hypertensive Definations in
the Pregnant Patient
Name BP Criteria Additional Criteria
“Severe” acute
hypertension
SBP > 160 mmHg or
DBP > 110 mmHg
Preeclampsia SBP > 140 mmHg or
DBP > 90 mmHg
BP readings must occur on
>2 occasions, > 4 hrs apart
> 20 weeks gestation
Either :
Proteinuria
Severe features
Eclampsia Same as above New-onset grand mal
seizures in a woman with
no known seizure disorder
HELLP syndrome With or without
preeclampsia degree of BP
elevation
Evidence of the following
Hemolysis
Elevated lover enzymes
Low platelet
Hypertensive emergency BP > 240/140 mmHg
17. Treatment Goals
Treatment goals differ in pregnant patients
compared with general hypertensive crisis.
BP goal for Preeclampsia <160/110 mmHg –
avoid abrupt decrease in blood pressure.
MAP should be decreased by 20-25% over the
first few minutes to hours and blood pressure
further decreased to the target of 160/110 mmHg
or less over the subsequent hours.
18. Treatment of Hypertensive
Emergency
No drug of choice.
Choice of medication depends on a risk-benefit
analysis of each agent considering the.
Affected target organ on presentation
Pharmacokinetics & pharmacodynamics
Hemodynamic, adverse effect and BPV profile of
the medication profile.
Extreme caution should be used with acute and
profound lowering of BP Ischaemic
complications.
19. Medications
Agent Dosing range Onset Duration
Vasodilators
Hydralazine IV Bolus: 10-20 mg
IM : 10-40 mg q30 min
PRN
IV: 10 mins
IM: 20 mins
IV: 1-4 hours
IM: 2-6 hours
Nitroglycerine IV 5-200 mcg/min
Titrate by 5-25
mcg/min q5-10 mins
2-5 mins 5-10 mins
Sodium
nitroprusside
IV 0.25-10 mcg/kg/min
Titrate by 0.1-0.2
mcg/min q5min
seconds 1-2 mins
CCB
Clevidipine IV 1-6 mg/hr
Titrate by 1-2 mg/hr
q90s; max 32 mg/hr
1-4 min 5-15 min
Nicardipine IV 5-15 mg/hr
Titrate by 2.5 mg/hr
q5-10 min
5-10 min 2-6 hours
20. Agent Dosing range Onset Duration
Beta Blockers
Esmolol IV 25-300 mcg/kg/min
Titrate by 25 mcg/kg/min
q3-5 mins
1-2 mins 10-20 mins
Labetalol IV bolus: 20 mg; may repeat
doses of 20-80 mg q5-10
mins PRN
IV 0.5-10 mg/min
Titrate by 1-2 mg/min q2hr.
2-5 min; peak 5-15
mins
2-6 hr
Upto 18 hr
Metoprolol IV bolus: 5-15 mg q5-15
min PRN
5-20 min 2-6 hr
ACEI
Enalaprilat IV bolus: 1.25 mg q6hr
Titrate no more than q12-24
hr:
Max dose : 5 mg q6hr
15-30 min 12-24 hr
a-Antagonist
Phentolamine IV bolus: 1-5 mg PRN; Max
15 mg
Seconds 15 min
D1 Receptor Agonist
21. Indications and Special Considerations for
Medications Used for Hypertensive Emergency
Medication Indications Special Considerations
Hydralazine Pregnancy Prolonged hypotension
Risk of reflex tachycardia
Headaches, lupus like
syndrome
Nitroglycerin Coronary ischaemia or infarction
Acute LVF
Pulmonary edema
Tachyphylaxis
Flushing, headache, erythema
Venous greater than arterial
dilator
Sodium nitroprusside Most indications (excluding ICP
elevations and coronary
infarction/ischaemia)
Liver failure – cyanide
accumulation
Renal failure – thiocyanate
accumulation
Toxicity with prolonged
infusion
Increases ICP
Clevidipine Acute ischaemia or hemorrhagic Soy or egg allergy
22. Medication Indications Special Considerations
Esmolol Aortic dissection
Coronary
ischaemia/infarction
Contraindicated in acute
decompensated heart failure
Useful in tachyarrhythmias
Labetalol Acute ischaemic or hg stroke
Aortic dissection
Coronary
ischaemia/infarction
Pregnancy
Monotherapy in acute aortic
dissection
Contraindicated in acute
decompensated heart failure
Prolonged hypotension
Metoprolol Aortic dissection
Coronary
ischaemia/infarction
Contraindicated in acute
decompensated heart failure
Use in conjunction with arterial
vasodilator
Useful in tachyarrhythmias
Enalaprilat Acute LVF Contraindicated in pregnancy
Prolonged duration of action
Phentolamine Cetecholamine excess
e.g. pheochromocytoma
Use in catecholamine-inducd
HTN er
Used for cocaine induced HTN
crisis with BZDs
Fenoldopam Most indications Caution with increased ICP or
IOP
23.
24. Practice points
• Determine the presence or absence of target-
organ damage.
• Assessment
• Screen for exceptions – stroke, pregnancy
induced acute htn, aortic dissection- target goal
development.
• In general hypertensive emergencies the goal in
the first 60 mins of treatment is reduce the MAP
by25%.
• Patient with exceptions have unique treatment
goals leading to unique medication selection.
• Goal of medication selection is to provide
25. References
American college of cardiology – 2017 guideline
for detection, evaluation and management of high
blood pressure in adults.
American college of clinical pharmacology –
ccsap2018 – hypertensive emergencies.
American college of obs&gynae (ACOG) – task
force for htn in pregnancy.