Edward P. Sloan, MD, MPH, FACEP

Emergency Department Emergency Department Patient Hypertensive Patient Hypertensive

Emergencies: Emergencies: Published Guidelines, Published Guidelines,

Articles, & Their FindingsArticles, & Their Findings

Edward P. Sloan, MD, MPH, FACEP

2007 EMA Advanced Emergency & Acute Care

Medicine Conference

Atlantic City, NJAtlantic City, NJSeptember 24, 2007September 24, 2007

Edward P. Sloan, MD, MPH, FACEP

Edward P. Sloan, MD, MPH FACEP

Professor

Department of Emergency MedicineUniversity of Illinois College of Medicine

Chicago, IL

Edward P. Sloan, MD, MPH, FACEP

Attending PhysicianEmergency Medicine

University of Illinois HospitalOur Lady of the Resurrection Hospital

Chicago, IL

Edward P. Sloan, MD, MPH, FACEP

DisclosuresDisclosures• FERNE Chairman and PresidentFERNE Chairman and President• FERNE advisory board for The Medicine FERNE advisory board for The Medicine

Company in May 2007Company in May 2007• FERNE grant by The Medicines Company to FERNE grant by The Medicines Company to

support this programsupport this program

• No individual financial disclosuresNo individual financial disclosures

Edward P. Sloan, MD, MPH, FACEP

Hypertensive CrisisHypertensive Crisis• Hypertensive urgency:Hypertensive urgency:

• elevation of blood pressure elevation of blood pressure without acute end organ damagewithout acute end organ damage

• Hypertensive emergencyHypertensive emergency• elevation of blood pressure with elevation of blood pressure with

acute end organ damageacute end organ damage• Diastolic BP usually >120 in both Diastolic BP usually >120 in both

instancesinstances

Edward P. Sloan, MD, MPH, FACEP

Guideline SourcesGuideline Sources

• www.Guidelines.govwww.Guidelines.gov • Published guidelinesPublished guidelines• Pivotal clinical trialsPivotal clinical trials• Clinical practiceClinical practice

Edward P. Sloan, MD, MPH, FACEP

Edward P. Sloan, MD, MPH, FACEP

ACEP Clinical PolicyACEP Clinical Policy

• Are ED BP readings accurate and reliable for screening asymptomatic patients for hypertension?

• Level B: If ED BP persistently > 140/90, refer for possible HTN.

• Level C: A single elevate reading suggests possible need for outpt screening.

Edward P. Sloan, MD, MPH, FACEP

ACEP Clinical PolicyACEP Clinical Policy

• Do asymptomatic patients with elevated BP benefit from rapid lowering of their BP?

• Level B: Initiating Rx not needed if there is scheduled follow-up.

• Level B: Rapidly lowering BP notnecessary and may be harmful.

• Level B: If Rx started, expect gradual improvement, not in ED.

Edward P. Sloan, MD, MPH, FACEP

Edward P. Sloan, MD, MPH, FACEP

JNC7 ReportJNC7 Report

• Age > 50, SBP > 140 mm Hg is risk

• After 115/75, CVD risk doubles as BP increases 20/10 mm Hg

• 102-139 / 80-89 pre-hypertensive

• Start with thiazide-type diuretics

Edward P. Sloan, MD, MPH, FACEP

JNC7 ReportJNC7 Report

• Most pts will require two drugs

• If BP 20/10 mm Hg high, consider two drug therapy

• Patients must be motivated for successful intervention on BP

Edward P. Sloan, MD, MPH, FACEP

Edward P. Sloan, MD, MPH, FACEP

ASA Ischemic Stroke PolicyASA Ischemic Stroke Policy

• Treat BP > 185 / 110 mm Hg

• Labetalol 10 – 20 mg IV, repeat x 1

• Nitropaste 1 - 2 inches

• Nicardipine infusion 5 mg/hr, titrate up by 2.5 mg/hr at 5 – 15 intervals• Reduce infusion to 3 mg/hr when desired BP attained

• Consider sodium nitroprusside

Edward P. Sloan, MD, MPH, FACEP

Edward P. Sloan, MD, MPH, FACEP

ASA ICH Guideline ASA ICH Guideline

• Therapy must be individualized

• In general, be more aggressive than with ischemic stroke

• Goals for BP control critical

• Reduce BP in order to minimize ongoing bleeding

• Caution with CPP decreases in setting of increased ICP

Edward P. Sloan, MD, MPH, FACEP

ASA ICH Guideline ASA ICH Guideline • Hx HTN: maintain MAP < 130 mm Hg

• Labetalol, esmolol, nitroprusside, hydralazine, enalapril

• BP > 230/140 x 5 min, nitroprusside

• BP 180-230/105-140 x 20 min, start labetalol, esmolol, or enalapril

Edward P. Sloan, MD, MPH, FACEP

ASA ICH Guideline ASA ICH Guideline

• If more Rx needed, consider diltiazem, lisinopril, verapamil

• Use easy to titrate drugs

• If BP < 180 / 105, defer and BP Rx

• Keep CPP > 70 mm Hg

Edward P. Sloan, MD, MPH, FACEP

Edward P. Sloan, MD, MPH, FACEP

NINDS tPA Clinical TrialNINDS tPA Clinical Trial

• Hypertension common in study

• Modest BP effects observed by design, with little overshoot

• tPA patients who were hypertensive after randomization and received Rx were less likely to have a favorable outcome

• Significance of observation unclear

Edward P. Sloan, MD, MPH, FACEP

Edward P. Sloan, MD, MPH, FACEP

ED Clinical StudyED Clinical Study

• “Screening tests of urban ED patients with asymptomatic severely elevated blood pressure infrequently detect unanticipated hypertension-related abnormalities that alter ED management.”

Edward P. Sloan, MD, MPH, FACEP

Edward P. Sloan, MD, MPH, FACEP

Marik, Varon Review Marik, Varon Review

• Good epidemiology and pathophysiology information

• Drug information and table

• Special considerations, populations

• Titratable medications might best be utilized in the ICU setting

Edward P. Sloan, MD, MPH, FACEP

ConclusionsConclusions• Guidelines, clinical studies, and

review articles do provide guidance

• Treatment options must be individualized for each patient

• Specific strategies are defined

• It is possible to practice within a reasonable standard of care

• Pt outcomes can be optimized

Edward P. Sloan, MD, MPH, FACEP

Questions?Questions?edsloan@uic.edu312 317 4996

www.ferne.org

ferne_ema_2007_htn_emergencies_sloan_guidelines_findings_092407_finalcd04/19/23 03:51