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1、Hypertensive Crisis,Sofiya Lypovetska MD PhDTernopil state medical university,SCOPE of the PROBLEM,Hypertension is an increasingly important medical and public health issue.The prevalence of hypertension increases with advancing age to the point where more than half of people aged 60 to 69 years old
2、 and approximately three-fourths of those aged 70 years and older are affectedData from observational studies involving more than 1 million individuals have indicated that death from both ischemic heart disease and stroke increases progressively and linearly from BP levels,Definitions and classifica
3、tion of blood pressure levels(mmHg),Factors influencing prognosis,Factors influencing prognosis,High/Very high risk subjects,Blood pressure measurement,Position statement:Ambulatory and home BP measurement,JNC VII Guidelines,Patient characteristics associated with resistant hypertension,Secondary ca
4、uses of resistant hypertension,Medication that can interfere with blood pressure control,Conditions favouring use of some antihypertensive drugs versus others,Compelling and possible contraindications to use of antihypertensive drugs,Hypertensive Crisis,Definitions-Is This:A Crisis?An Emergency?An U
5、rgency?Clinical PresentationsTreatments,Other Terminology,Severely elevated BP(JNC VII)Defined as BP 180/120“accelerated HPT”term used to describe individuals with chronic hypertension with associated group 3 Keith-Wagener-Baker retinopathy“malignant HPT”describe those individuals with group 4 KWB r
6、etinopathy changes+papilledema,DefinitionsHypertensive Crisis,Hypertensive Emergency1-2 hoursRapid/progressive end organ damageHypertensive Urgency.24-48 hrsInc.BP without evidence of end organ damageUncontrolled Hypertension.1 weekDo not require acute intervention,Shayne PH-Ann Emerg Med-01-APR-200
7、3;41(4):513-29,Hypertensive Emergency,Hypertensive encephalopathyIntracerebral bleedAcute MIAcute CHF with pulm edemaUnstable anginaAortic dissectionEclampsia,Tx:parenteral agent,BP 180/120 with evidence of target organ dysfunction,Cerebrovascular Hypertensive Emergencies,Cerebral Infarct,Intracereb
8、ral Hemorrhage,Cerebral Edema,Hypertensive Encephalopathy,Cerebral Perfusion Pressure,Cerebral blood flow a function of CPPAutoreg.Fails at 25%of MAP ICP CPP Vulnerable to MAP,CBF=blood flow;CPP=cerebral perfusion pressure;ICP=intracranial pressure;MAP=mean arterial pressure;TCA=total circulatory ar
9、rest.,Hypertensive Encephalopathy,Pathophysiology:-Loss of Cerebral Autoregulation of blood flow resulting in hyperperfusion of the brain,loss of integrity of the blood brain barrier,and vascular necrosis.Loss of Autoregulation occurs at a constant cerebral blood flow of above MAP 150 to 160 mmHg.Ac
10、ute OnsetReversible,Hypertensive Encephalopathy,Symptoms:Headache,Nausea/Vomiting,Lethargy,Confusion,Lateralizing neurological symptoms that are not often in an anatomical distribution.Signs:Papilledema,Retinal Hemorrhages Decreased level of consciousness,Coma Focal neurological findings,Hypertensiv
11、e encephalopathy,Clinical manifestation of cerebral edema and microhemorrhages seen with dysfunction of cerebral autoregulationDefined as an acute organic brain syndrome or delirium in the setting of severe hypertension,HPT Encephalopathy,Not adequately treated cerebral heamorrhage,coma and death.BU
12、T with proper treatment completely reversibleClinical diagnoses(exclusion),Management of Hypertensive Encephalopathy,Reduce Mean Arterial Pressure(MAP)by 20 to 25%(T.397)and do not exceed this within first 30 to 60 min.Rosen recommends reduction of 30 to 40%(R.1759)MAP=1/3(SBP-DBP)+DBPTreatment Redu
13、ces vasospasm that occurs at these high pressuresAvoid excessive BP reduction to prevent hypoperfusion of the brain and further cerebral ischemia,Hypertensive Encephalopathy,Cerebral overperfusionMAP overwhelms autoregulationVasodilation and Inc.Perm.Cerebral EdemaHemorrhage,Coma,DeathTx:Nipride,Fen
14、oldopam,Labatalol,Nicardipine,Hemorrhagic CVAcauses,Hypertensive Vascular DiseaseArteriovenous Anomalies(AVM)Arterial AneurysmsTumorsTrauma,Hemorrhagic CVA Management,Hemorrhagic CVAs commonly results in a profound reactive rise in blood pressureManagement is CONTROVERSIAL.Subarachnoid Hemorrhage:or
15、al nimodipine(nimotop)60mg po q 4 hours to reverse vasospasm.Nicardipine:2mg IV boluses followed by an IV infusion of 4 to 15 mg/hr is used by some to treat Subarachnoid Hemorrhage.,Ischemic CVA,Pathophysiology:Elevated Blood Pressure can be the cause of the central nervous system event,OR,it may be
16、 a normal physiologic response(Cushings Reflex),Ischemic CVA Management,Favors lowering MAP(mean arterial pressure)by 20%.Recommends IV Labetalol in small doses of 5mg increments IF Diastolic Blood Pressure is higher than 140 mmHg.(T.398),HPT Retinopathy,AV crossing changes,HPT retinopathy,HPT retin
17、opathy,Cardiovascular Hypertensive Emergencies,AorticDissection,CongestiveHeart Failure,Acute MI,Congestive Heart Failure,Pathophysiology:Increased Afterload with decreased Cardiac Output,CHF/Pulmonary Edema,Symptoms:Shortness of Breath,Cough,Chest Pain Lower Extremity SwellingSigns:Jugular Venous D
18、istension,Rales,S3 Gallop Hepatomegaly,Pedal Edema,CHF/Pulmonary Edema,Treatment:DiureticsNitroglycerinVasodilatorsDigitalisBeta-adrenoceptor agonistsOther positive inotropic agents,Acute Coronary Syndrome,Pathophysiology:-Increased afterload,cardiac workload,and myocardial oxygen demand-Decreased c
19、oronary artery blood flow,Acute Coronary Syndrome/Acute MI,Symptoms:Chest Pain,Nausea/Vomiting,Diaphoresis,Shortness of Breath Signs:Congestive Heart Failure Signs,S4 Gallop(due to decreased ventricular compliance)Few physical findings in many patients Clinical History is very Important,Acute Corona
20、ry Syndrome/Acute MI,Immediate Blood Pressure reduction is indicated to prevent Myocardial DamageNo specific Defined BP target Management:Nitroglycerin IV or Sublingual Beta Blockers(Esmolol,Lopressor)Nitroglycerin is Drug of Choice,Aortic Dissection,Pathophysiology:-Atherosclerotic Vascular Disease
21、,Chronic Hypertension,increased shearing force on the thoracic aorta,leading to intimal tear.-50%begin in ascending aorta-30%at aortic arch-20%in descending aorta,Dissection of Thoracic Aorta,Symptoms:Chest pain radiating to the back(classic presentation)Neurological Symptoms(carotid artery dissecti
22、on)Angina(coronary artery dissection)Shortness of breath(aortic insufficiency,cardiac tamponade)Signs:-Differential Blood Pressure(in UE)Bruit(interscapular)Neurological DeficitsAcute Cardiac Tamponade(rare),Dissection of Thoracic Aorta,Optimal Blood Pressure in these patients is undefined and must
23、be tailored for each patient,however,SBP of 120-130mmHg may be a intial starting point.(T.408),Acute Renal Failure,Pathophysiology:Hypertensive Glomerulonephropathy,Acute Tubular Necrosis-Worsening renal function in the setting of severe hypertension with elevation of BUN/CR,proteinuria,or the prese
24、nce of red cells and red cell casts in the urine.,Acute Renal Failure,Symptoms:-Many times there are few actual symptomsFacial or Peripheral Edema due to fluid overload or proteinuria may be present,shortness of breathSigns:Few findings unless edematousPulmonary Edema,Acute Renal Failure,Management:
25、Nitroprusside is agent of choice Dialysis(as needed)Lasix to enhance Sodium excretion;Also recommends Nitroprusside or Nifedipine Nitroglycerin is also a good agent in this setting since it is hepatically metabolized and gastrointestinally excreted.,Preeclampsia/Eclampsia,Pathophysiology:Systemic ar
26、terial vasoconstriction(including placental,leading to decreased uterine blood flow).Defined as SBP=140/90 mmHg or greater,OR a 20 mmHg rise in SBP or 10 mmHg rise in DBP from baseline and evidence of HELLP Syndrome,Preeclampsia/Eclampsia,Symptoms:lower extremity swelling,headache,confusion,seizures
27、,comaSigns:edema,hyperreflexia,elevation of blood pressure related to baseline BP prior to pregnancy(elevation may be mild 125/75)Management:IV Magnesium Sulfate,Hydralazine.May also use nifedipine or labetalol Delivery of Fetus is definitive treatment of pre-eclampsia,Treatment of acute severe hype
28、rtension in preeclampsia,Pheochromocytoma,Pathophysiology:-Alpha and Beta stimulation of the cardiovascular system due to adrenergic excess statesSymptoms:Episodic Headaches,flushing,tremor,diaphoresis,diarrhea,hyperactivity,and palpitationsSigns:Tachycardia,tachypnea,tremor,hyperdynamic state(high
29、output CHF),Pheochromocytoma,Management:Alpha Blocker FIRST,followed by a Beta BlockerPhentolamine(alpha)+Esmolol(beta)Labetalol IV(combined alpha and beta blockade),Pharmacologic AgentsHypertensive Emergencies,Rapid OnsetRapid Maximal effectRapid offsetEase of Titration,Parenteral Agents,Parenteral
30、 drugs for treatment of hypertensive emergencies,Oral Regimens for Treatment of Hypertensive Urgency in the ED,Clonidine:0.1 to 0.2mg PO,repeat 0.1mg q hour to desired BP reduction or max of 0.7mg.Labetalol:200 to 400mg PO,repeat every 2 to 3 hoursCaptopril:25mg POLosartan:50mg PO,Key Concepts,Acute
31、 End-organ damage determines hypertensive emergencyBe familiar with the agents of choice in specific emergenciesGoal for most is careful reduction of MAP by 20-25%over minutes to hoursDBP not less than 100 to 110Except:Pregnancy,Dissection,MI,Patients without acute end-organ ischemia rarely require urgent intervention,Thank You!,
