23.07.

2009

Hypertensive Emergencies

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Definition
Hypertensive Urgency: Severe hypertension (>220/120 mmHg) with no target organ damage Hypertensive Emergency: Severe hypertension (DBP > 130 mm Hg) and the presence of Target organ damage

Acute end-organ damage

Neurological Hypertensive encephalopathy Cerebral vascular accident/cerebral infarction Subarachnoid hemorrhage Intracranial hemorrhage Cardiovascular Myocardial ischemia/infarction Acute left ventricular dysfunction Acute pulmonary edema Aortic dissection Other Acute renal failure/insufficiency Retinopathy Eclampsia Microangiopathic hemolytic anemia

Pathophysiology
Failure of normal autoregulation and an abrupt rise in systemic vascular resistance (SVR) Increases in SVR are thought to occur from the release of humoral vasoconstrictors from the wall of a stressed vessel The increased pressure within the vessel then starts a cycle of endothelial damage, local intravascular activation of the clotting cascade, fibrinoid necrosis of small blood vessels, and the release of more vasoconstrictors If the process is not stopped, a cycle of further vascular injury, tissue ischemia, and autoregulatory dysfunction ensues

Common clinical presentations

Cerebral infarction (24.5%) Pulmonary edema (22.5%) Hypertensive encephalopathy (16.3%) Congestive heart failure (12%). Less common presentations
Intracranial hemorrhage, Aortic dissection, Eclampsia

History
Medications Details of antihypertensive drug therapy and compliance Intake of over-the-counter preparations such as sympathomimetic agents Use of illicit drugs such as cocaine, amphetamines Duration and severity of preexisting hypertension Degree of BP control Presence of previous EOD, particularly renal and cerebrovascular disease Date of last menstrual period Other medical problems (eg, prior hypertension, thyroid disease, Cushing disease, systemic lupus, renal disease)

History
Assess whether specific symptoms suggesting EOD are present.
Chest pain - Myocardial ischemia or infarction Back pain - Aortic dissection Dyspnea - Pulmonary edema, congestive heart failure Neurologic symptoms - Seizures, Headache,visual disturbances, altered level of consciousness (hypertensive encephalopathy)

Physical Examination
(assess whether EOD is present)

Vital signs
BP should be measured in both the supine position and the standing position (assess volume depletion). BP should also be measured in both arms (a significant difference may suggest aortic dissection)

Eye: The presence of new retinal hemorrhages, exudates, or papilledema suggests a hypertensive emergency. Cardiovascular - Evaluate for the presence of heart failure.
Jugular venous distension Crackles Peripheral edema

Abdomen - Abdominal masses or bruits CNS

Level of consciousness Visual fields and fundoscopic examination Focal neurological signs

Causes
The most common cause is history of inadequate hypertensive treatment or an abrupt discontinuation of their medications in a patient with essential hypertension Other causes
Renal parenchymal disease - Chronic pyelonephritis, primary glomerulonephritis, tubulointerstitial nephritis (accounts for 80% of all secondary causes) Systemic disorders with renal involvement - Systemic lupus erythematosus, syssclerosis, vasculitides Renovascular disease - Athtemic erosclerotic disease, fibromuscular dysplasia, polyarteritis nodosa Endocrine - Pheochromocytoma, Cushing syndrome, primary hyperaldosteronism Drugs - Cocaine, amphetamines, cyclosporin, clonidine withdrawal, phencyclidine, diet pills, oral contraceptive pills Drug interactions - Monoamine oxidase inhibitors with tricyclic antidepressants, antihistamines, or tyramine-containing food CNS - CNS trauma or spinal cord disorders, such as Guillain-Barr syndrome Coarctation of the aorta Preeclampsia/eclampsia Postoperative hypertension

Investigations
Electrolytes, BUN, and creatinine levels to evaluate for renal impairment FBC and smear to exclude microangiopathic anemia Urinalysis Dipstick urinalysis (UA) to detect hematuria or proteinuria (renal impairment) Microscopic UA to detect RBCs or RBC casts (renal impairment) Optional studies Toxicology screen Pregnancy test Endocrine testing

Imaging
Imaging Studies Chest radiography is indicated in patients with chest pain or shortness of breath. Cardiac enlargement Pulmonary edema Widened mediastinum Head CT and/or brain MRI are indicated in patients with abnormal neurologic examinations or clinical concern for the following: Intracranial bleeding Cerebral edema Cerebral infarction Chest CT scan, echocardiography, or aortic angiography is indicated in cases where aortic dissection is suspected. Other Tests Electrocardiography (ECG) to assess for evidence of myocardial ischemia or left ventricular hypertrophy

Management
Parenteral antihypertensive therapy is indicated most hypertensive emergencies, especially if encephalopathy is present. The initial goal in hypertensive emergencies is to reduce the pressure by no more than 25% (within minutes to 1 or 2 hours) and then toward a level of 160/100 mm Hg within 26 hours Excessive reductions in pressure may precipitate coronary, cerebral, or renal ischemia

Cerebral Autoregulation

Sodium nitroprusside
Sodium nitroprusside is an arterial and venous vasodilator that decreases both afterload and preload. Nitroprusside decreases cerebral blood flow while increasing intracranial pressure It is particularly disadvantageous inpatients with hypertensive encephalopathy or following a cerebrovascular accident In patients with coronary artery disease, a significant reduction in regional blood flow (coronary steal) can occur Cyanide toxicity Requires special handling to prevent its degradation by light.

Labetalol
Labetalol is a combined selective alpha1-adrenergic and nonselective Beta-adrenergic receptor blocker with an alpha- to-Beta blocking ratio of 1:7 Unlike pure adrenergic blocking agents that decrease cardiac output, labetalol maintains cardiac output. Labetalol reduces the systemic vascular resistance without reducing total peripheral blood flow. In addition, the cerebral, renal, and coronary blood flow are maintained This agent has been used in the setting of pregnancy induced hypertensive crisis because little placental transfer occurs mainly due to the negligible lipid solubility of the drug.

Nicardipine
Nicardipine is a second-generation dihydropyridine derivative calcium-channel blocker with high vascular selectivity and strong cerebral and coronary vasodilatory activity. IV nicardipine has been shown to reduce both cardiac and cerebral ischemia. A useful therapeutic benefit of nicardipine is that the agent has been demonstrated to increase both stroke volume and coronary blood flow with a favorable effect on myocardial oxygen balance. This property is useful in patients with angina and systolic heart failure.

Hydralazine
Hydralazine is a direct-acting vasodilator Indications: pre-eclampsia.eclampsia High incidence of hypotension in slow acetylators Reflex tachycardia Should not be used in aortic dissection and Coronary artery disease

Nitroglycerin
Nitroglycerin is a potent venodilator and only at high doses affects arterial tone. It causes hypotension and reflex tachycardia, which are exacerbated by the volume depletion characteristic of hypertensive emergencies. Nitroglycerin reduces BP by reducing preload and cardiac output Indications: Agent of choice for moderate hypertension complicating unstable angina, MI or pulmonary edema undesirable effects in patients with compromised cerebral and renal perfusion.

Other Drugs
Fenoldopam
Fenoldopam mediates peripheral vasodilation by acting on peripheral dopamine-1 receptors. Fenoldopam improves creatinine clearance, urine flow rates, and sodium excretion in severely hypertensive patients with both normal and impaired renal function.

Neurological emergencies
Hypertensive encephalopathy
Clinical features: headache, irritability, confusion, and altered mental status Preferred medications Labetalol Nicardipine Esmolol Medications to avoid Nitroprusside Hydralazine Treatment guidelines: Reduce mean arterial pressure (MAP) 25% over 8 hours.

Neurological emergencies
Acute ischemic stroke
Preferred medications Labetalol Nicardipine
American Heart Association/ASA guidelines(2005)

Withhold antihypertensive medications unless the systolic blood pressure (SBP) is >220 mm Hg or the diastolic blood pressure (DBP) is >120 mm Hg UNLESS patient is receiving IV fibrinolysis, then goal BP: SBP <185 mm Hg and DBP <110 mm Hg. After treatment with fibrinolysis, the SBP should be maintained <180 mm Hg and DBP <105 mm Hg for 24 hours

Neurological emergencies
Acute ischemic stroke
American Heart Association/ASA guidelines(2005) recommend the use of labetalol or nicardipine if the SBP is > 220 mm Hg or the DBP is from 121 to 140 mm Hg, and nitroprusside for a DBP >140 mm Hg Aim for a 10%15% reduction in blood pressure

Neurological emergencies
Acute intracerebral hemorrhage
Preferred medications :Labetalol,Nicardipine,Esmolol Medications to avoid : Nitroprusside

American Stroke Association guidelines(2007)

(Class IIb, Level of Evidence C).

If SBP is 200 mm Hg or MAP is 150 mm Hg, then consider aggressive reduction of blood pressure with continuous intravenous infusion, with frequent blood pressure monitoring every 5 minutes If SBP is 180 mm Hg or MAP is 130 mm Hg and there is evidence of or suspicion of elevated ICP, then consider monitoring ICP and reducing blood pressure using intermittent or continuous intravenous medications to keep cerebral perfusion pressure 60 to 80 mm Hg

Neurological emergencies
Acute intracerebral hemorrhage
American Stroke Association guidelines(2007) (Class IIb, Level of Evidence C). If SBP is 180 mm Hg or MAP is 130 mm Hg and there is not evidence of or suspicion of elevated ICP, then consider a modest reduction of blood pressure (eg, MAP of 110 mm Hg or target blood pressure of 160/90 mm Hg) using intermittent or continuous intravenous medications to control blood pressure clinically reexamine the patient every 15 minutes.

 American Stroke Association guidelines(2007) (Class IIb, Level of Evidence C).

Neurological emergencies
Subarachnoid hemorrhage
Preferred medications Nicardipine Labetalol Esmolol Medications to avoid Nitroprusside Hydralazine Treatment guidelines: Maintain SBP <160 mm Hg until the aneurysm is treated or cerebral vasospasm occurs. Oral nimodipine is used to prevent delayed ischemic neurological deficits, but it is NOT indicated for treating acute hypertension.

Cardiovascular emergencies
Aortic dissection
Preferred medications : Labetalol, Esmolol,Nicardipine, Nitroprusside (with beta-blocker) Medications to avoid Avoid beta-blockers if there is aortic valvular regurgitation or suspected cardiac tamponade.

Treatment guidelines:
Maintain SBP <110 mm Hg, unless signs of end-organ hypoperfusion are present. Preferred treatment includes a combination of narcotic analgesics (morphine sulfate), beta-blockers (labetalol, esmolol), and vasodilators (nicardipine, nitroprusside) A vasodilator alone is not ideal because this can promote reflex tachycardia, increase aortic ejection velocity, and promote dissection propagation. Calcium channel blockers (verapamil, diltiazem) are an alternative to beta-blockers

Cardiovascular emergencies
Acute coronary syndrome
Preferred medications

Beta-blockers Nitroglycerin Avoid; Nicardipine, Hydralazine(reflex tachycardia)

Treatment guidelines: Treat if SBP >160 mm Hg and/or DBP >100 mm Hg. Reduce BP by 20-30% of baseline. Thrombolytics are contraindicated if BP is >185/100 mm Hg

Acute heart failure

Preferred medications :Nitroglycerin,Enalaprilat Nitroprusside Avoid: Hydralazine, labetalol Treatment guidelines: Treatment with vasodilators (in addition to diuretics) for SBP 140 mm Hg. IV or sublingual nitroglycerin is the preferred agent.

Other
Sympathetic Crises (Cocaine toxicity/pheochromocytoma )
Preferred medications Phentolamine Nitroglycerin/nitroprusside Medications to avoid Beta-adrenergic antagonists prior to phentolamine administration Treatment guidelines: Hypertension and tachycardia from cocaine toxicity rarely require specific treatment. Alpha-adrenergic antagonists (phentolamine) are the preferred agents for cocaine-associated acute coronary syndromes. Pheochromocytoma treatment guidelines are similar to that of cocaine toxicity. Beta-blockers can be added for BP control only after alpha-blockade.

Other
Preeclampsia/eclampsia
Preferred medications Hydralazine Labetalol Nicardipine Medications to avoid Nitroprusside Angiotensin-converting enzyme inhibitors Treatment guidelines: In women with eclampsia or preeclampsia, SBP should be <160 mm Hg and DBP <110 mm Hg in the prepartum and intrapartum periods. If the platelet count is <100,000 cells mm3 BP should be maintained below 150/100 mm Hg. Patients with eclampsia should also be treated with IV magnesium sulfate

Acute Postoperative Hypertension

Definition:Significant elevation in BP during the immediate postoperative period that may lead to serious neurological, cardiovascular, or surgical-site complications Activation of the sympathetic nervous system and increase afterload Treatment in cardiac surgery patients, treatment is recommended for a BP 140/90 or a MAP of at least 105 mm Hg. Treat Pain and anxiety before BP lowering Preffered drugs:Labetalol, esmolol, nicardipine

Thank you