Ht emergency 2011 v2003

1

6 กพ. 2554พญ.เสาวนนิทร์ อินทรภักดี

โรงพยาบาลเลิดสิน

Hypertensive Crisis: Hypertensive Emergencies and Urgencies

2

Definitions and classification of blood pressure levels (mmHg)

Category ESC 2007 JNC VII 2003

Optimal < 120 and < 80 Normal < 120 and < 80

Normal 120–129 and/or 80–84 Pre HT 120-139 or 80-99

High normal 130–139 and/or 85–89

Grade 1 HT 140–159 and/or 90–99 stage 1 HT 140-159 or 90-99

Grade 2 HT 160–179 and/or 100–109 stage 2 HT > 160 or > 100

Grade 3 HT > 180 and/or > 110

Acute target organ damage

3

Brain :

Hypertensive encephalopathy

Cerebral infarction

Cerebral hemorrhage

Advanced retinopathy

Heart :

Acute coronary syndromes

Acute heart failure

Aorta :

Aortic dissection

Kidney:

Acute renal failure

Placenta :

Eclampsia

4

BP > 180/120 mmHg

a) hypertensive emergencies, often with BP >220/140

life-threatening organ dysfunction.

b) hypertensive urgencies

symptoms or modest organ damage,

c) severe HT

without symptoms or acute signs of organ damage

Triage of Pts with Severe HT

Hypertensive Urgencies or Emergencies

Hypertensive Emergencies

Severe elevations in BP

(>180/120 mmHg)

Complicated by evidence of

impending or progressive

target organ dysfunction.

Require immediate BP

reduction (not necessarily to

normal) to prevent or limit

target organ damage.

•

Examples

hypertensive encephalopathy

Intracerebral hemorrhage,

acute MI

acute left ventricular failure

with pulmonary edema

unstable angina

dissecting aortic aneurysm,

eclampsia

JNC VII 2003

6

Hypertensive Emergencies

Catecholamine excess states

Pheochromocytoma crisis

Overdose with sympathomimetics or drugs with similar action

(phencyclidine, cocaine, phenylpropanolamine)

Hypertension associated with acute renal failure

Microangiopathic anemia

Manual of Hypertension of the European Society of Hypertension 2008

Initial Evaluation of Patients with a

Hypertensive Emergency

History

Prior diagnosis and treatment of

hypertension

Intake of pressor agents: street

drugs, sympathomimetics

7



History

Symptoms suggesting an acute

end-organ involvement

chest pain – myocardial infarction,

thoracic aortic dissection

back pain – thoracic aortic

dissection

dyspnea – acute pulmonary edema

neurological symptoms-

hypertensive encephalopathy,

stroke

8



Physical examination

Blood pressure – both upper limbs

Funduscopy

Cardiopulmonary status

AR, MR , signs of CHF

Neurologic status

level of consciousness, focal sigh

of ischemia

Body fluid volume assessment

Peripheral pulses

9

Initial Evaluation of Pt with a Hypertensive

Emergency

Laboratory evaluation

Hematocrit and blood smear (microangiopathic hemolysis)

Urine analysis

Automated chemistry: creatinine, glucose, electrolytes

Electrocardiogram

Chest radiograph (if heart failure or aortic dissection is suspected)

CT brain in patients with neurological symptoms

CT chest or MRI in patients with unequal pulses/ an enlarged

mediasternum

10

Initial Evaluation of Pt with a Hypertensive

Emergency

Laboratory evaluation

Plasma renin activity and aldosterone (if primary aldosteronism is

suspected)

Plasma renin activity before and 1 h after 25 mg captopril (if renovascular

hypertension is suspected)

Spot urine or plasma for metanephrine (if pheochromocytoma is

suspected)

12

13

Further rise in blood pressure and

vascular damage

Tissue ischemia

Local effects (prostaglandins, free

radicals)

Endothelial damage

Platelet deposit

Mitogenic and migration factors

Myointimal proliferation

Systemic effects (Renin-angiotensin,

catechol, vasopressin)

Pressure natriuresis

Hypovolemic

Further increase in vasopressors

Critical Degree of Hypertension

initiation and progression

of

accelerated-malignant HT

Clinical Characteristics of Accelerated-

Malignant Hypertension

Blood pressure: usually >140 mm Hg diastolic

Funduscopic findings :

accelerated HT - grade 3 retinopathy ( hemorrhages,

exudates)

malignant HT - grade 4 retinopathy (papilledema)

Neurologic status: headache, confusion, somnolence,

stupor, vision loss, focal deficits, seizures, coma

Renal status: oliguria, azotemia

Gastrointestinal status: nausea, vomiting14

When mean arterial pressures > 180 mm Hg,

vessels are stretched and dilated— producing

generalized vasodilation

Breakthrough of cerebral blood flow ,

hyperperfuses the brain under high pressure,

with leakage of fluid into the perivascular

tissue, leading to cerebral edema

15


Pathophysiology


A sudden, marked elevation

of BP

Severe headache and

altered mental status,

reversible by reduction of BP

Encephalopathy is more

common in previously

normotensive individuals

whose pressures rise

suddenly 16

MRI hypertensive encephalopathy

T 1-weighted images

Posterior reversible

leukoencephalopathy

syndrome

finding : edema of the white

matter of the parieto-occipital

regions

17

hypertensive brainstem encephalopathy

finding : pontine abnormalities

Almost all hypertensive emergencies are caused or

exacerbated by intense systemic vasoconstriction, often

with profound blood volume reduction

goal of therapy is to reduce vasoconstriction while

maintaining adequate perfusion of target organs

18

Goal of Hypertensive Emergencies Rx

LIMIT ORGAN DAMAGE

Admitted to an ICU for continuous monitoring of BP and iv

administration of an appropriate agent

The initial goal of therapy in hypertensive emergencies is to

reduce mean arterial BP by no more than 25 percent (within

minutes to 1 hour)

If clinical is stable, reduce BP to 160/100–110 mmHg within

the next 2–6 hours

Further gradual reductions toward a normal BP can be

implemented in the next 24–48 hours.

JNC VII 200319

Treatment of Hypertensive Emergencies

Exceptions

acute aortic dissection

acute stroke in evolution (for which no BP

lowering is generally recommended)

20

JNC VII 2003

Acute aortic dissection

Initial management of thoracic aortic dissection should be

directed at decreasing aortic wall stress by controlling HR and

BP :

In the absence of contraindications, Iv beta blockade should

be initiated and titrated to a target heart rate < 60 /min

If systolic blood pressures > 120 mm Hg after adequate heart

rate control has been obtained, then iv angiotensin-converting

enzyme inhibitors and/or other vasodilators should be

administered .

21

2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM

Guidelines for the Diagnosis and Management of Patients With

Thoracic Aortic Disease. Circulation. 2010;121:1544-1579.

Acute Ischemic Stroke

The American Heart Association recommends

Treatment with intravenous labetalol or nicardipine

Started when BP values are above 220/120mmHg

The target BP should be a 10–15% lowering of BP

In patients candidates to treatment with intravenous

tissue plasminogen activator BP should be

maintained below 185/110mmHg.

22

Guidelines for the early management of patients with ischemic stroke.

A Scientific Statement from the Stroke Council of the American Stroke Association.

Stroke 2003; 34:1056–83.

Acute STEMI

Relative contraindications for thrombolytics

History of chronic, severe, poorly controlled hypertension

Severe uncontrolled hypertension on presentation (SBP

> 180 mm Hg or DBP >110 mmHg)

23

ACC/AHA Guidelines for the Management of Patients With

ST-Elevation Myocardial Infarction 2004

Management of ICH

Emergency diagnosis and assessment of ICH

and its cause

Medical RX – correct coagulopathy

Inpatient management and prevent of

secondary brain injury

General monitoring

Management of glucose

Seizures

Procedures /surgery – clot removal

Prevent of recurrent – Rx hypertension24

25

HYPERTENSION could contribute to hydrostatic

expansion of the hematoma, peri-hematoma edema, and

rebleeding

26

1. If SBP is 200 mm Hg or MAP is 150 mm Hg

aggressive reduction of BP with continuous intravenous infusion, with

frequent BP monitoring every 5 min.

2. If SBP is 180 mm Hg or MAP is 130 mm Hg and there is the

possibility of elevated ICP, then consider monitoring ICP and reducing BP

using intermittent or continuous intravenous medications while

maintaining a cerebral perfusion pressure 60 mm Hg.

3. If SBP is 180 mm Hg or MAP is 130 mm Hg and there is not

evidence of elevated ICP, then consider a modest reduction of BP

(MAP of 110 mm Hg or target BP of 160/90 mm Hg) using intermittent or

continuous intravenous medications to control BP and clinically

reexamine the patient every 15 min

Guidelines for the Management of Spontaneous ICH

A Guideline for Healthcare Professionals

From the American Heart Association/American Stroke Association 2010

Guidelines for Treating Elevated BP in Spontaneous ICH

27

Drug Useful for Hypertensive Emergencies

Agent

vasodilators

Dose Onset/

of action

Duration of

action

Precautions Special indication

Sodium

nitroprusside 0.25–10.00

µg/kg/min as

i.v. infusiona;

maximal

dose for 10

min only

Immediate/ 1-2 min Nausea, vomiting,

muscle twitching;

thiocyanate

intoxication,

methemoglobinemia

acidosis, cyanide

poisoning;

bags, bottles, and

delivery sets must be

light resistant

Most hypertensive

emergencies ,

caution with high

ICP or azotemia

Glyceryl

trinitrate 5–100 µg as

i.v. infusion 2-5 min 5-10 min Headache,

tachycardia, vomiting,

flushing,

methemoglobinemia;

requires special

delivery systems due

to the drug's binding to

polyvinyl chloride

tubing

Coronary ischemia

28

Agent

vasodilators

Dose Onset/ of

action

Duration of action Precautions Special indication

Nicardipine

Calcium

channel

blocker

5–15 mg/h

i.v. infusion 5-10 min/ 15–30 min, but may

exceed 4h after

prolonged infusion

Tachycardia,

nausea, vomiting,

headache, possible

protracted

hypotension after

prolonged infusions ,

Most hypertensive

emergencies ,

except in acute

heart failure ;

caution with

coronary ischemia

Fenoldopam

dopamine

agonist (D1-

receptors)

0.1–0.3

mg/kg/min

i.v. infusion

< 5min 30 min Headache,

tachycardia,

flushing, local

phlebitis

Most hypertensive

emergencies ,

caution with

glaucoma


JNC VII 2003

29

Agent vasodilators

Dose Onset/ of

action

Duration of

action

Precautions Special

indication

Hydralazine 10–20 mg as i.v.

bolus

10–40 mg i.m.; repeat every 4–6 h

10 -20 min iv

20-30 min im

1-4 h iv

4-6 h im

Tachycardia,

headache,

vomiting,

aggravation of

angina pectoris

Eclampsia

Enalaprilat 1.25 – 5 mg every 6

h i.v. 15–30 min

/

6-12 hr Renal failure in

patients with

bilateral artery

stenosis,

hypotension

Acute LV

failure; avoid

in acute MI


JNC VII 2003

30

Agent

Adrenergic

inhibitors

Dose Onset of

action

Duration

of action

Precautions Special indication

Labetalol

Alpha1, beta 1

and beta 2

receptor

antggonist

10–80 mg as i.v.

bolus every 10

min; up to 2

mg/min as i.v.

infusion

5–10 min 3–6 h Bronchoconstriction

, heart block,

orthostatic

hypotension,

vomiting, scalp

tingling

Most hypertensive

emergencies ,

except acute heart

failure

Esmolol

Beta 1receptor

antagonist

500 µg/kg bolus

injection i.v. or

50 –100

µg/kg/min by

infusion ; may

repeat bolus after

5 min or increase

infusion rate to

300 µg/ kg/min

1-2 min 10–30 min First-degree heart

block, congestive

heart failure,

asthma

Aortic dissection,

perioperative

Phentolamine 5–15 mg as i.v.

bolus

1–2 min 10-30 min Tachycardia,

orthostatic

hypotension,

flushing

Catecholamine

excess

JNC VII 2003


31

Agent

vasodilators

Dose Onset/ of

action

Duration of action Precautions Special indication

Urapidil

Alpha blocker

,central

sympatholytic

effect via

stimulation of

serotonin

5HT(1A)

receptors

20 -60

mg iv

bolus

3-4 min/ 6-10 h Sedation

Clevidipine

Calcium

channel

clocker

0.1–0.3

mg/kg/mi

n i.v.

infusion

< 5min 30 min Headache,

tachycardia,

flushing, local

phlebitis

Most hypertensive

emergencies ,

caution with

glaucoma


JNC VII 2003

32

Condition Drug(s) of choice Relative

contraindications/cautions

Acute pulmonary

edema

Nitroglycerin + loop diuretic

Nitroprusside + loop diuretic

Beta-blockers, verapamil

Acute coronary

syndromes

Nitroglycerin + beta-blocker

Nitroprusside + beta-blocker

Hydralazine

Hypertensive

encephalopathy

Nitroprusside, labetalol,

nicardipine

Centrally acting sympatholytic

agents

Dissecting aortic

aneurysm

Nitroprusside + beta-blocker Isolated use of pure vasodilators

Intracranial

hemorrhage

Labetalol, nicardipine Nitroprusside with caution,

nifedipine

Drugs of choice and relative contraindications

for hypertensive emergencies


33

Condition Drug(s) of choice Relative

contraindications/cautions

Ischemic stroke Nitroprusside, labetalol,

nitroglycerin

Nifedipine

Adrenergic crisis Labetalol, phentolamine +

beta-blocker

Beta-blocker monotherapy

Acute renal

impairment

Fenoldopam, nicardipine Diuretics with caution

Eclampsia MgSO4, hydralazine,

methyldopa

Nitroprusside

Subarachnoid

hemorrhage

Nimodipine Nitroprusside with caution

Drugs of choice and relative contraindications

for hypertensive emergencies


Hypertensive Urgencies

severe elevations in BP

without progressive target

organ dysfunction

Examples include

upper levels of stage II HT

associated with

severe headache

shortness of breath

Epistaxis

severe anxiety

34

JNC VII 2003

35

Hypertensive Urgencies

Severe uncomplicated essential hypertension

Severe uncomplicated secondary hypertension

Postoperative hypertension

Hypertension associated with severe epistaxis

Drug-induced hypertension

Rebound hypertension (i.e., sudden withdrawal of clonidine)

Cessation of prior antihypertensive therapy

Severe hypertensive crises related to anxiety, panic attacks or pain


Treatment of Hypertensive Urgencies

Agents that reliably cause an immediate fall in BP

include captopril (25-50 mg), central sympatholytics

(clonidine 0.1–0.2 mg), labetalol (200–400 mg), and

amlodipine (2.5–5 mg)

initiation of therapy with two oral agents is appropriate to

lower BP to an intermediate target over 24 to 72 hours

Appropriate follow-up within 3 days.

36

37

Drug Initial dose Onset Duration Adverse effects

Captopril 25–50 mg 15–45 min 6–8 h Renal failure in bilateral artery

stenosis

Labetalol 200–400 mg 30–120 min 2–12 h Orthostatic hypotension,

bronchoconstriction

Clonidine 0.150–0.300 mg 30–60 min 8–16 h Hypotension, dry mouth

Prazosin 1–2 mg 60–120 min 8–12 h Syncope (first dose), orthostatic

hypotension, tachycardia

Nicardipine 20–40 mg 30–60 min 8–12 h Headache, tachycardia, flushing

Amlodipine 5–10 mg 60–120 min 12–18 h Headache, tachycardia, flushing

Oral Drugs for Hypertensive Urgencies


Treatment of Severe HT (asymptomatic)

immediate normalization of the BP is not necessary

it is usually appropriate to prescribe a two-drug therapy

identify individuals at risk for secondary hypertension

counsel the patient on the importance of long-term BP

control

schedule follow-up within 1 week or less.

38

39

ALGORITHM FOR TRIAGE AND MANAGEMENT

Severe hypertension Hypertensive urgency Hypertensive emergency

BP >180/120 mm Hg >180/120 mm Hg Often >220/140 mm Hg

Symptoms Often asymptomatic

HeadacheAnxiety

Severe headache

Shortness of breathEdema

Prolonged chest pain/unstable angina

Motor impairment/neurologic

deficitAltered mental status

Uncontrollable bleeding

Workup results No target organ damage/clinical

cardiovascular disease

Target organ damage/clinical

cardiovascular disease may be present

Pulmonary edema/heart

failure

Acute MICerebrovascular accident

EncephalopathyRenal insufficiency

PreeclampsiaRenal failure

Aneurysm

40

ALGORITHM FOR TRIAGE AND MANAGEMENT

Severe hypertension Hypertensive urgency Hypertensive emergency

BP >180/120 mm Hg >180/120 mm Hg Often >220/140 mm Hg

Acute management Initiate/resume

medication(s)

Increase dosage of

inadequate agentObserve for 1–3 h

Lower BP with oral or

parenteral agents as

underlying conditions warrant

Adjust current therapyObserve for 3–6 h

Order baseline laboratories

Initiate intravenous lineMonitor vital signs

May initiate disease-a

appropriate parenteral

therapy in the emergency room

Plan Arrange follow-up >72 h

If no prior evaluation, schedule appointment

Arrange follow-up

evaluation (24–72 h) Immediate admission to intensive care unit

Treat to appropriate goal BP

Additional diagnostic studies as warranted

A 44 –year –old Thai male

Chief compliant : Dyspnea, cyanosis

Present illness : Underlying disease HT, CKD, Irregular RX

3 hr prior to admission : chest pain with dyspnea

Physical exam

General appearance : Dyspnea and cyanosis

Vital sign : BP 220/120 mmHg HR 120/min regular RR 28/min

T 37 C O2 sat room air 85%

HEENT : Unremarkable

Neck : Jugular distension

41

Cardiovascular : heart PMI at 5 th ICS mid clavicular line

normal S1S2 no murmur no gallop

Lung : rales both lungs

Abdomen : No hepatosplenomegaly not tender

Extremities : N edema

Neurologic : Normal

Lab :

Hb 14 wbc 3220/mm3 platelet 329,000 /mm3

BUN 39.7 ng/dL Creatinine 3.44 ng/mL

Troponin I 4.6

42

Problem list

1. NSTEMI with CHF

2. CKD

3. Hypertensive emergency 43

First Rx

a. O2 therapy

b. IV Furosemide

c. IV Morphine

d. IV Nitroglycerine

Which antihypertensive drug ?

a. IV Nitroglycerine

b. IV Beta blocker

c. IV Nicardipine

d. IV Nitroprusside

44

Ht emergency 2011 v2003

Health & Medicine

Transcript of Ht emergency 2011 v2003