Recent Manag Ement of Hypertencive Emergencies
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Transcript of Recent Manag Ement of Hypertencive Emergencies
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Recent Management ofHypertensive Emergencies
Wiguno Prodjosudjadi
Division of Nephrology and Hypertension
Department of Internal Medicine, Faculty of MedicineUniversity of Indonesia
Dr. Ciptomangunkusumo General Hospital
Jakarta
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Hypertensive Emergencies
Acute Impairmentof Organ System
SevereHypertension
Hypertensive Urgencies
Potential Risk of
Acute Organ DamageSevere
Hypertension
Emergency
Unit
Severe
Hypertension
Severe hypertension without target organ damage
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Hypertensive Emergencies
Hypertensive encephalopathy
Intracranial bleeding
Left heart failure
Acute myocard infark
Acute dissecting aorta
Eclampsia
Malignant hypertension
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Clinical Manifestations of
Hypertensive Encephalopathy
Severe headache
Nausea and vomiting
Visual disturbances
Confusion
Focal and generalized weakness
Focal or generalized seizure
Focal neurological signs
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Intracerebral Bleeding
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Clinical Manifestations of
Aortic Dissection
Pain in the chest, back or abdomen
Abrupt, severe, persistent and may
migrate down-ward
Discrepancies between pulses
Murmur of aortic insufficiency
Neurological deficits
Mediastinal widening on chest X ray
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Type of Aortic Dissection
Chest 1991 ; 99 : 724-29
Type A Type B
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Pathophysiology of
Hypertensive Emergencies
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Acute Increase of BP on Target Organ
Acute BloodPressure
http://www.emedicine.com/emerg/topic267.htm
Blood
Pressure
Transudate leak
Arteriolar damage
Arteriolar
Vasoconstriction
Vasoconstriction
Autoregulation
Normal
CBF
Increase cardiac
workload
Renal system
impairment
& Failure of
Autoregulation
Acute BloodPressure CHF
Acute BloodPressure
Arteriosclerosis
Fibrinoid
necrosis
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Proposed Role of Passive Dilatation and
Disruption of the Blood Brain Barrier
Hypertension, 1988 ; 12 : 89-95
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Putative Vascular Pathophysiology
of Hypertensive Emergencies
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Fibrinoid Necrosis
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JASN, 1998 ; 9 :133
Mechanisms of Malignant HypertensionCritical degree of Hypertension
Increase in BP and Ischemia
Endothelial damage Increase in vasoconstrictors
(renin-angiotensin, vasopressin
Catecholamines)
Further blood
pressure increase
Pressure natriuresis
Hypovolemia
Further release of
vasoconstrictors
Platelet and fibrin
deposition
Fibronoid necrosis &
intimal proliferation
Intravascular
hemolysis
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Hyperplastic Arteriolitis
in Malignant Hypertension
Atlas of Heart Diseases, 1994 : Vol. 1
Silver Stain
Distal Renal Interlobular Artery in a 48 Years Old
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Management of
Hypertensive Emergencies
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Principles in the Management of
Hypertensive Emergencies
Minimizing TOD due to high blood pressure
Avoid deleterious effects of drug treatment
Purpose of treatment :
Over minutes to hours :
BP should be lowered by up to 25% MAP
or DBP should be lowered up to 100 -110 mmHg
Intravenous antihypertensive drugs is needed
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Parenteral Drugs for Treatment
of Hypertensive Emergencies
Sodium nitroprusside
Nicardipine HCl
Nitroglycerine
Enalaprilat
Hydralazine HCl Diazoxide
Labetalol HCl
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Treatment of Hypertensive
Emergencies
Type ofHypertensive
Drug of Choice Alternative orSecond line drug
Encephalopathy Nitroprusside Labetalol
Intracranial
hemorrhage Labetalol Nitroglycerin
Left ventricular failureNitroprusside, Diuretic,
ACE-INitroglycerin
Acute myocardial
infarction
Nitroglycerin, Beta-
blockers
Nitroprusside,
labetalol
Dissecting aortic
aneurysm
Beta-blockers,
NitroprussideLabetalol, Verapamil
Eclampsia Hydralazine, labetalol Nifedipine
JASN 1998;9(1):133-142
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Intravenous Antihypertensive Drugs
Available in Indonesia
Clonidine
Nicardipine HCl
Diltiazem HCl
Nitroglicerin
Diazoxide, Nitroprusside
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Available in 150 g per 2 ml ampul
Maximal dose was 900 g / 24 hours
Dilute 300 - 900 g in 5% Dextrose (250 cc)
given IV micro-drip infusion or syringe pump
Dose titration is based on the level of blood
pressure 24 Hours after BP target was reached, change
to oral antihypertensive therapy
Clonidine
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Intravenous Antihypertensive Drugs
Available in Indonesia
Clonidine
Nicardipine HCl
Diltiazem HCl
Nitroglicerin
Diazoxide, Nitroprusside
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Available in 2 mg (2 ml) and 10 mg (10 ml) per ampul
Can be administered as bolus injection ( 10-30 g/Kg
BW), IV micro-drip infusion or by syringe-pump
IV micro-drip infusion with a starting dose 5 mg/hr; the
dose can be increased every 15 minutes by 2,5 mg/hr
up to 15 mg/hr (maximal dose)
After target of BP was reached, reduce the dose by
3 mg/hr and then change to oral antihypertensive
therapy
Nicardipine HCl
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Intravenous Antihypertensive Drugs
Available in Indonesia
Clonidine
Nicardipine HCl
Diltiazem HCl
Nitroglicerin
Diazoxide, Nitroprusside
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Available in 10 mg and 50 mg per ampul
Can be administered as bolus injection (0,25 mg/kg
BW over period of 3 minutes, with maximal dose 20
mg)
Second bolus can repeated 15 minutes after first
bolus (0,35 mg/kgBW with maximal dose of 25 mg).
For IV drip infusion starting dose is 10 mg/hr which
can be increased up to 15 mg/hr (maximal)
Diltiazem HCl
B l I
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Target MBP
Level
Bolus I.v.
0.2 mg/kg
Drip infusion
50 mg/hour
Drip infusion30 mg/hour
Drip infusion
5-10 mg/hour
10% MBP reduction
From Baseline
20% MBP reduction
From Baseline
10
20
30
Switch to Oral
DILTIAZEM 180SR
Every 30-60 minutes observation
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Intravenous Antihypertensive Drugs
Available in Indonesia
Clonidine
Nicardipine HCl
Diltiazem HCl
Nitroglicerin
Diazoxide, Nitroprusside
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Can be given by IV drip infusion with the rate of
5-100 gr/minutes
Dose titration is based on the level of BP
Onset of action is 2-5 minutes and the duration of
action is 3-5 minutes
Indication : hypertensive emergencies (with angina
pectoris or MCI) and lung edema
Nitroglycerin
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Intravenous Antihypertensive Drugs
Available in Indonesia
Clonidine
Nicardipine HCl
Diltiazem HCl
Nitroglicerin
Diazoxide, Nitroprusside
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Diazoxide
Recommended dose 300 mg or 5 mg/Kg BW
IV bolus with small dose (75-150 mg) is safe and effective
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Untreated hypertensive emergencies : the 1 year
mortality rate is more than 90%
All patients presenting with hypertensive
emergencies in ER : the median survival duration
is 144 months
All presenting hypertensive emergencies : the 5-
year survival rate is 74%
Prognosis of Hypertensive Emergencies
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Conclusions
In hypertensive emergencies the blood pressure
should be lowered aggressively over minutes to hours
The purpose of antihypertensive treatment to prevent
target organ damage due to high blood pressure and
minimizing the risk of hypoperfusion
Various intravenous antihypertensive drugs can be
selected
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