CRISIS HIPERTENSIVAS. CFEG. 2015 -...

Click here to load reader

  • date post

    17-Apr-2018
  • Category

    Documents

  • view

    214
  • download

    1

Embed Size (px)

Transcript of CRISIS HIPERTENSIVAS. CFEG. 2015 -...

  • Dr. Carlos Fernando Estrada GarzonaDepartamento de FarmacologaUniversidad de Costa Rica

    CRISIS HIPERTENSIVA

  • OBJETIVOS

    URGENCIA VS EMERGENCIA HIPERTENSIVA

    ABORDAJE TERAPEUTICO

    ANTIHIPERTENSIVOS IV

  • Franz Volhard (left) and Theodor Fahr (right)

    EMERGENCIA HIPERTENSIVA. 1914Hypertensive Crises*Challenges and Management

    Paul E. Marik, MD, FCCP; and Joseph Varon, MD, FCCP

    Hypertension affects > 65 million people in the United States and is one of the leading causes ofdeath. One to two percent of patients with hypertension have acute elevations of BP that requireurgent medical treatment. Depending on the degree of BP elevation and presence of end-organdamage, severe hypertension can be defined as either a hypertensive emergency or a hyperten-sive urgency. A hypertensive emergency is associated with acute end-organ damage and requiresimmediate treatment with a titratable short-acting IV antihypertensive agent. Severe hyperten-sion without acute end-organ damage is referred to as a hypertensive urgency and is usuallytreated with oral antihypertensive agents. This article reviews definitions, current concepts,common misconceptions, and pitfalls in the diagnosis and management of patients with acutelyelevated BP as well as special clinical situations in which BP must be controlled.

    (CHEST 2007; 131:19491962)

    Key words: aortic dissection; !-blockers; calcium-channel blockers; clevidipine; eclampsia; fenoldopam; hypertension;hypertensive crises; hypertensive encephalopathy; labetalol; nicardipine; nitroprusside; pre-eclampsia; pregnancy

    Abbreviations: ACE " angiotensin-converting enzyme; APH " acute postoperative hypertension; DBP " diastolicBP; FDA " Food and Drug Administration; JNC " Joint National Committee; MAP " mean arterial pressure;SBP " systolic BP

    H ypertension is one of the most common chronicmedical conditions in the United States, affect-ing close to 30% of the population # 20 years old.1While chronic hypertension is an established riskfactor for cardiovascular, cerebrovascular, and renaldisease, acute elevations in BP can result in acuteend-organ damage with significant morbidity. Hy-pertensive emergencies and hypertensive urgencies(see definitions below) are commonly encounteredby a wide variety of clinicians. Prompt recognition,evaluation, and appropriate treatment of these con-

    ditions are crucial to prevent permanent end-organdamage. This article reviews our current understand-ing of hypertensive crises, the common misconcep-tions and pitfalls in its diagnosis and management, aswell as pharmacotherapy and special situations thatclinicians may encounter.

    Definitions

    The classification and approach to hypertensionundergoes periodic review by the Joint NationalCommittee (JNC) on Prevention, Detection, Evalu-ation, and Treatment of High Blood Pressure, withthe most recent report (JNC 7) having been releasedin 2003 (Table 1).2 Although not specifically ad-dressed in the JNC 7 report, patients with a systolicBP (SBP) # 179 mm Hg or a diastolic BP (DBP)# 109 mm Hg are usually considered to be having ahypertensive crisis. The 1993 report3 of the JNCproposed an operational classification of hyperten-sive crisis as either hypertensive emergencies orhypertensive urgencies. This classification remainsuseful today. Severe elevations in BP were classified

    *From the Department of Pulmonary and Critical Care (Dr.Marik), Thomas Jefferson University, Philadelphia, PA; andDepartment of Acute and Continuing Care (Dr. Varon), TheUniversity of Texas Health Science Center at Houston, Houston,TX.The authors have no conflicts of interest to disclose.Manuscript received October 11, 2006; revision accepted January23, 2007.Reproduction of this article is prohibited without written permissionfrom the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).Correspondence to: Paul E. Marik, MD, FCCP, 834 Walnut St,Suite 650, Philadelphia, PA 19107; e-mail: paul.marik@jefferson.eduDOI: 10.1378/chest.06-2490

    CHEST Postgraduate Education CornerCONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE

    www.chestjournal.org CHEST / 131 / 6 / JUNE, 2007 1949

    Downloaded From: http://journal.publications.chestnet.org/ on 09/08/2013

  • PA> 180/120 DAO A ORGANO BLANCO

    PRESENTE

    REDUCCION INMEDIATA DE LA PA

    VIA ENDOVENOSA

    AUSENCIA DE DAO A ORGANO BLANCO

    REDUCCION DE PA 24-48 HORAS

    VIA ORAL

    CRISIS HIPERTENSIVAS. DEFINICION

    URGENCIA EMERGENCIA

    Drugs 2008; 68 (3): 283-297REVIEW ARTICLE 0012-6667/08/0003-0283/$53.45/0 2008 Adis Data Information BV. All rights reserved.

    Treatment of AcuteSevere HypertensionCurrent and Newer Agents

    Joseph Varon1,2,3

    1 The University of Texas Health Science Center at Houston, Houston, Texas, USA2 The University of Texas Medical Branch at Galveston, Galveston, Texas, USA3 St Lukes Episcopal Hospital/Texas Heart Institute, Houston, Texas, USA

    ContentsAbstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2831. Classification of Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2842. Hypertensive Crises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

    2.1 Hypertensive Urgencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2852.2 Hypertensive Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

    2.2.1 Operative and Postoperative Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2852.2.2 Hypertension in Acute Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

    2.3 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2863. Initial Management of Severe Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

    3.1 Pharmacological Agents Used in the Treatment of Hypertensive Crises . . . . . . . . . . . . . . . . . . . . 2873.1.1 Enalaprilat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2883.1.2 Labetalol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2893.1.3 Esmolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2893.1.4 Clevidipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2893.1.5 Nicardipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2903.1.6 Nifedipine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2903.1.7 Fenoldopam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2913.1.8 Hydralazine and Diuretics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2913.1.9 Nitroglycerin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2913.1.10 Sodium Nitroprusside . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292

    4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

    Approximately 72 million people in the US experience hypertension. World-Abstractwide, hypertension may affect as many as 1 billion people and be responsible for7.1 million deaths per year. It is estimated that 1% of patients with hypertensionwill, at some point, develop a hypertensive crisis. Hypertensive crises are furtherdefined as either hypertensive emergencies or urgencies, depending on the degreeof blood pressure elevation and presence of end-organ damage. Immediate reduc-tion in blood pressure is required only in patients with acute end-organ damage(i.e. hypertensive emergency) and requires treatment with a titratable, short-acting, intravenous antihypertensive agent, while severe hypertension withoutacute end-organ damage (i.e. hypertensive urgency) is usually treated with oralantihypertensive agents.

  • chest pain (27%) dyspnea (22%) neurologic deficits (21%)

    The absolute level of BP may not be as important as the .

    GENERALIDADES

    Hypertensive Crises*Challenges and Management

    Paul E. Marik, MD, FCCP; and Joseph Varon, MD, FCCP

    Hypertension affects > 65 million people in the United States and is one of the leading causes ofdeath. One to two percent of patients with hypertension have acute elevations of BP that requireurgent medical treatment. Depending on the degree of BP elevation and presence of end-organdamage, severe hypertension can be defined as either a hypertensive emergency or a hyperten-sive urgency. A hypertensive emergency is associated with acute end-organ damage and requiresimmediate treatment with a titratable short-acting IV antihypertensive agent. Severe hy