Hypertension Crisis

Dr Stella Palar, SpPD-KGHHYPERTENSION CRISIS & SPECIAL CONDITIONSHYPERTENSION CRISISDefinition: Condition with sudden increase of BP (SBP > 180mmHg, DBP > 120 mmHg) which need immediate intervention

Classification:Emergency Hypertension target organ damage, attempt to decrease BP in minutes/hoursUrgency Hypertension without target organ damage, attempt to decrease BP in 24-48 hoursClinical ManifestationNeurologyHeadache, blurry vision, seizures, focal neurological deficit, decrease of consciousnessOphthalmologyRetinal bleeding, exudates, papillae edemaCardiovascularChest pain, pulmonary edemaKidneyAzotemia, proteinuria, oliguriaObstetricPreeclampsia, eclampsiaHYPERTENSION CRISISManagementIdeally treatment be administered in the hospital, however it can be started in primary health care with oral anti hypertension

MedicineRoute PharmacologyDoseACE Inhibitor (Captopril)SublingualOral Start: SL: 10-15 min, O:15-30 minMax effect: SL:60 min, O:1-2 hDuration: 8 h

6,25-50 mg /xCentral alpha agonist (Clonidin)Oral Start: 30-60 minMax effect: 2-4 hDuration:3-12 h

75-150 ug/x/hourTotal 900 ugCalcium Channel blocker (Nifedipine)Oral Start: 5-20 minMax effect: 30-60 minDuration: 2-6 hAs alternative if other medicine not availableHYPERTENSION CRISISManagement

Target BP for Hypertension Emergency:First 5-120 minutes reduce MAP 20-25%Next 2-6 hours reduce to BP 160/100 mmHgNext 6-24 hours reduce to BP 140/90 mmHg if no sign of ischemic organ HYPERTENSION CRISISDrugsRouteClonidin (catapres)150 mcg/amp Clonidin 900 mcg in D5% 500 ml given by microdrips 12 drops/min, increase the dosage 4 drops every 15 minutes until target reached observed for 4 hours switched to oral clonidinDiltiazem (Herbesser)10 mg & 50 mg/amp Diltiazem 10 mg IV bolus in 1-3 minutes continued with 50 mg/hour for 20 minutes If BP >20% from initial BP, decrease dose to 30 mg/hour until target reached Continue with maintenance 5-10 mg/hour with 4 hour observation then switched to oral tabletNicardipine (Perdipine)2 & 10 mg/amp10-30 mcg /kgBW bolusWhen BP stable, continue with 0.5-6 mcg/kgBW/min until target BP reachedDrugsRouteLabetalol (Normodyn)IV Labetalol 20-80 mg IV bolus every 10 minutes or can be given in infusion drips 2 mg/minNitroprusside (Nitropress, Nipride)IV Nitroprusside given by infusion drips dosage 0.25-10 mcg/kg/minutesHYPERTENSION IN SPECIAL CONDITIONSHypertension in Heart and Vascular DiseaseHypertension in Kidney disorderHypertension in ElderlyHypertension in Neurological DisorderHypertension in DiabetesHypertension in PregnancyHypertension in Heart & Vascular DsIschemic Heart DiseaseTreatment started with B blokers & ACE-I then other can be added if neededHeart FailureDiuretics, B Blockers, ACE-I

Peripheral Arterial DiseaseB blockers, ACE-IHypertension in Kidney disorderTarget 1g/24h target 125/75 mmHgAttention to the alteration of renal function (creatinine should not 20%) & potassium level in the use of ACEI/ARB Hypertension in Elderly

Start anti hypertension if:SBP 160 mmHg if in good condition and life expectancySBP 140 mmHg if DM, smoker, or other risk factorsTarget65-79 yo : SBP 80 yo : SBP 140-145 mmHg

Principle: Start low go slowHypertension in Neurological DsIschemic strokeanti hypertension not recommended unless SBP>220 mmHg DBP>120 mmHg

Hemorrhagic strokeanti hypertension not recommended unless SBP >180 mmHg or MAP > 130 mmHgHypertension in DiabetesTarget BP: 20 weeks gestation.Systolic blood pressure 140 mmHg OR diastolic blood pressure 90 mmHgProteinuria of 0.3 g or greater in a 24-hour urine specimen Preeclampsia