‫بسم الله الرحمن‬ ‫الرحيم‬

• A 50 year man presented to ED with headache and BP 210/115 • What is the diagnosis?

• A 25 year pregnant lady, presented to ED with one attack of fits, and BP 160/90 • What is the diagnosis?

• A 60 year old man presented to ED, with weakness of his upper limb, and BP 200/100, with evidence of infarction on CT. • What is the management?

HYPERTENSIVE CRISES

HYPERTENSIVE CRISES

• Hypertensive Emergency • Hypertensive Urgency

HYPERTENSIVE CRISES
• Accounted for more than 25% of all patient visits to an ED • The correct differentiation of these two forms, presents the greatest challenge to the physician.

Why this is a difficult topic
• Blood pressure alone is a poor indicator of an emergency • Failing to treat an emergency and treating a non-emergency can have serious consequences for the patient

Why this is a difficult topic
• Different emergencies have different goals in BP reduction • The first line agent for one emergency may be contraindicated for another

General Management Goals
• Reduce BP so autoregulation can be re-established
• Typically, this is a 25% reduction in MAP Or, reduce MAP to 110-115

• Avoid
• Lowering the BP too much or too fast.

Exceptions:
• Aortic dissection and eclampsia
• In aortic dissection and eclampsia, BP should be lowered to normal levels

HYPERTENSIVE EMERGENCIES

HYPERTENSIVE EMERGENCIES
• (Severe) elevations in BP with evidence of progressive target organ dysfunction • Urgent lowering in minutes to hours.

Examples include:
 Hypertensive encephalopathy and CVA • Unstable angina, or AMI • Acute LVF with pulmonary edema • Dissecting aortic aneurysm • Eclampsia.

HE result from either:
• An exacerbation of essential hypertension • A secondary cause: Renal, Vascular, Endocrine, Neurologic, and,…

The most associated complications:
• Acute pulmonary edema 36% and ACS in 12% • Cerebral infarction (25%), encephalopathy (16%), and cerebral or subarachnoid hge (5%). • Eclampsia in 4%. • Aortic dissection in 2%.

Diagnosis of HE
• Keep in mind that it is not the degree of BP elevation, but rather the clinical status of the patient that defines a hypertensive emergency. • For example, a BP of 160/100 mm Hg in a A 25 year pregnant lady, presented to ED with one attack of fits represents a true hypertensive emergency.

ED Evaluation
• History

 Headache, vomiting and blurry vision
• Headache alone not sufficient to diagnose HE

• Clinical presentation • History of HTN  Chest pain, severe • Prescribed medicationsshortness of breath • Compliance • Past medical history • Illicit drug use

 Fits, confusion, and altered consciousness.

ED Evaluation
• Physical Exam
• Appropriate sized cuff • Measure both arms and legs • Focus on areas of potential targetorgan damage:

-CNS -Heart -Pulses -Kidney

-Retina

Laboratory evaluation:
 Initial

tests should be limited and

rapid:
A renal function An immediate chemistry panel An electrocardiogram. When suggests Cerebral ischemia or hemorrhage, or if the patient is comatose, CT scan immediately obtained.

TREATMET
• The initial goal for BP reduction is not to obtain a normal BP, But rather to achieve a gradual reduction in BP

TREATMET
• Excessively rapid reductions in BP have been associated with:
• Acute deterioration in renal function • Ischemic cardiac or cerebral events • Occasional retinal arterial occlusion and acute blindness.

TREATMET
• Initial reduction in MAP should not exceed 20% to 25% below the pretreatment BP. As an alternative, MAP can be reduced within the first 30 to 60 minutes to 110 to 115 mm Hg. • Further gradual reductions toward a normal BP can be implemented over the next 24 hours.

A significant exception to the above recommendations should be recognized (Cerebral ischemic stroke)

What is the management of Patients presenting to the ED with severe hypertension?

The first step is to establish the presence of Hypertensive emergencies with initiation of therapy with parenteral drugs

SUMMARY OF TREATMENT

Summary – Cardiovascular emergency
• Acute LV failure
• NTG, ACEI, Furosemide
• ~10-15% reduction of MAP

• Acute coronary syndrome • Aortic dissection

• NTG, beta-blocker
• ~10-15% reduction of MAP

• Nitroprusside + I.V. betablocker
• SBP ~100

Summary – Neurologic emergencies
• Hypertensive encephalopathy

• Nitroprusside,
• ~25 reduction of MAP

• Embolic CVA

• Only if >220/120 • Labetalol for

• Hemorrhagic CVA

• ~15-20% reduction of MAP

Summary – Other emergencies
• Eclampsia
• magnesium, hydralazine, labetalol, delivery
• Goal DBP ~90

• Catecholamine excess

• Phentolamine +/-beta blocker
• ~25% reduction of MAP

HYPERTENSIVE Urgency

HYPERTENSION Urgency
• Severe elevations in BP without acute, ongoing progressive target organ damage.
• Evidence of chronic organ damage may be present

• Lower in days to weeks.

The important caveat is that • {Elevated BP alone - even if severe
- rarely requires emergency therapy}

TREATMENT • Initial assessment should identify patients who have an elevated BP without any evidence of progressive TOD for oral medications

In which of the following would a SBP of 100-120 be appropriate?
• Aortic dissection • Thrombo-embolic CVA • Hemorrhagic CVA • Hypertensive encephalopathy

A. Aortic dissection
• In all the other scenarios, such a rapid drop in BP is likely to worsen outcome

All the following regarding CVAs are true EXCEPT:
• Hemorrhagic CVAs tend to have higher BP than embolic • Lowering the BP in the acute setting may worsen outcome • If BP needs lowering in hemorrhagic CVA, Nipride is the agent of choice

• Nitroprusside and other vasodilators are relatively contraindicated in hemorrhagic CVA as they may worsen ICP.

Labetalol is the agent of choice IF BP needs to be lowered

In HTN with pregnancy, all the following are true EXCEPT:
• At a BP of 160/90, a patient may experience a HTN emergency • Definitive therapy for eclampsia is magnesium • Definitive therapy for eclampsia is delivery

• Definitive therapy for eclampsia is delivery of the fetus and placenta

Questions and Comments

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