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HYPERTENSIVE CRISIS

MD. Eloisa A. Rincón M


Médico Interno-HRRHL
BP Measurement Definitions

BP Measurement Definition

SBP First Korotkoff sound


DBP Fifth Korotkoff sound
Pulse pressure SBP minus DBP
Mean arterial pressure DBP plus one third pulse pressure†
Mid-BP Sum of SBP and DBP, divided by 2

†Calculation assumes normal heart rate .


BP indicates blood pressure; DBP, diastolic blood pressure; and SBP,
systolic blood pressure.
BP Measurement Definitions
2017 Hypertension Guideline
Classification of BP
Categories of BP in Adults*
BP Category SBP DBP

Normal <120 mm Hg and <80 mm Hg

Elevated 120–129 mm and <80 mm Hg


Hg
Hypertension
Stage 1 130–139 mm or 80–89 mm
Hg Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg

*Individuals with SBP and DBP in 2 categories should be


designated to the higher BP category.
BP indicates blood pressure (based on an average of ≥2
careful readings obtained on ≥2 occasions, as detailed in
DBP, diastolic blood pressure; and SBP systolic blood
pressure.
Definitions:
• Hypertension:
– Stage I: 130-139/80-89
– Stage II: >140/90

• Hypertensive Urgency:
– Systolic BP >180 or Diastolic BP >120 in the
absence of end-organ damage
Definitions Continued:
• Hypertensive Emergencies:
– SBP >180 OR DBP>120 in the presence of
end-organ damage
• Malignant Hypertension: End-organ damage--
eyes, kidneys, brain (hemorrhage/infarct) affected
• Hypertensive encephalopathy: Cerebral edema
leading to neurological symptoms
2017 Hypertension Clinical Practice Guidelines

BP and CVD Risk

Coexistence of Hypertension and Related Chronic


Conditions
Recommendation for Coexistence of
COR LOE
Hypertension and Related Chronic Conditions
Screening for and management of other modifiable
I B-NR CVD risk factors are recommended in adults with
hypertension.
CVD Risk Factors Common in Patients With
Hypertension
Modifiable Risk Factors* Relatively Fixed Risk Factors†
 Current cigarette smoking,  CKD
secondhand smoking  Family history
 Diabetes mellitus  Increased age
 Dyslipidemia/hypercholesterolemia  Low socioeconomic/educational
 Overweight/obesity status
 Physical inactivity/low fitness  Male sex
 Unhealthy diet  Obstructive sleep apnea
 Psychosocial stress

*Factors that can be changed and, if changed, may reduce CVD risk.
†Factors that are difficult to change (CKD, low socioeconomic/educational status,
obstructive sleep apnea, cannot be changed (family history, increased age, male sex), or,
if changed through the use of current intervention techniques, may not reduce CVD risk
(psychosocial stress).
CKD indicates chronic kidney disease; and CVD, cardiovascular disease.
2017 Hypertension Guideline

Measurement of BP

Accurate Measurement of BP in the Office

Recommendation for Accurate Measurement of


COR LOE
BP in the Office
For diagnosis and management of high BP, proper
I C-EO methods are recommended for accurate
measurement and documentation of BP.
Checklist for Accurate Measurement of BP

Key Steps for Proper BP Measurements

Step 1: Properly prepare the patient.

Step 2: Use proper technique for BP measurements.

Step 3: Take the proper measurements needed for diagnosis and


treatment of elevated BP/hypertension.

Step 4: Properly document accurate BP readings.

Step 5: Average the readings.

Step 6: Provide BP readings to patient.


Selection Criteria for BP Cuff Size for Measurement of
BP in Adults

Arm Usual Cuff Size


Circumference
22–26 cm Small adult

27–34 cm Adult

35–44 cm Large adult

45–52 cm Adult thigh


2017 Hypertension Guideline
2017 Hypertension Guideline
2017 Hypertension Guideline
Causes of Secondary Hypertension With Clinical
Indications
Common causes
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Uncommon causes
Pheochromocytoma/paraganglioma
Cushing’s syndrome
Hypothyroidism
Hyperthyroidism
Aortic coarctation (undiagnosed or repaired)
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary aldosteronism
Acromegaly
2017 Hypertension Guideline

Signs and Symptoms:


• Hypertensive Urgency:
– Can be completely asymptomatic
– Some symptoms include:
• Severe headache
• Shortness of breath
• Nosebleeds
• Severe anxiety
– Signs:
• Elevated BP on consecutive readings
S&S Continued
• Hypertensive Emergencies
– Symptoms:
• Nausea, vomiting (cerebral edema)
• Chest Pain
• SOB
• Blurry vision
• Confusion
• Loss of consciousness
S&S Continued
• Signs:
– Retinal hemorrhages, exudates, or papilledema
– Renal involvement (malignant nephrosclerosis) with
AKI, proteinuria, hematuria
– Cerebral edema  seizures and coma
– Pulmonary Edema
– Myocardial Infarction
– Hemorrhagic Stroke, lacunar infarcts
2017 Hypertension Guideline
Patient Evaluation
Basic and Optional Laboratory Tests for Primary
Hypertension
Basic testing Fasting blood glucose*
Complete blood count
Lipid profile
Serum creatinine with eGFR*
Serum sodium, potassium, calcium*
Thyroid-stimulating hormone
Urinalysis
Electrocardiogram
Optional testing Echocardiogram
Uric acid
Urinary albumin to creatinine ratio
*May be included in a comprehensive metabolic panel.
eGFR indicates estimated glomerular filtration rate.
2017 Hypertension Guideline

Evaluation for Target Organ Dysfunction

1. EKG: (Evaluation for ST elevation or depression, new T-wave inversions, LVH, or


new Left BBB)

2. CXR: (CHF/pulmonary edema, cardiomegaly, widened mediastinum)

3. UA or urine dip: (looking for proteinuria, red cells, or red cell casts)

4. Chem 8: (elevated BUN/CR indicating acute renal insufficiency or failure, look for
other etiologies causing mental status changes, like hypoglycemia)

5. Neurological Exam: (Evaluate for lateralizing signs and symptoms)

6. Funduscopic Exam: (looking for papilledema or hemorrhages)

7. CT Head: (only if neurological findings are suspicious for acute CVA)


2017 Hypertension Guideline

Diagnosis and Management


of
Hypertensive Emergency
Hypertensive Encephalopathy
Loss of cerebral
autorregulation of
blood flow

Above MAP 150-160

Hyperperfusion of Loss of integrity of


Vascular necrosis
brain blood brain barrier

Acute Onset
Reversible
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
Management of Hypertensive
Encephalopathy
• Reduce Mean Arterial Pressure (MAP) by 20 to 25% and
do not exceed this within first 30 to 60 min.

• Rosen recommends reduction of 30 to 40%.

• MAP= 1/3(SBP-DBP) + DBP

• Treatment reduces vasospasm that occurs at these high


pressures.

• Avoid excessive BP reduction to prevent hypoperfusion


of the brain and further cerebral ischemia.
Management of Hypertensive
Encephalopathy

- Nitroprusside is the agent of choice

- Nitroglycerin and Labetalol have


been used successfully, but have not
replaced Nitroprusside
Ischemic CVA

Pathophysiology:

Elevated Blood Pressure can be the cause


of the central nervous system event, OR, it
may be a normal physiologic response
(Cushing’s Reflex)
Ischemic CVA Management
• Elevated BP is usually a physiologic response to
the stroke itself and NOT the immediate cause
• This elevation of blood pressure maintains
cerebral perfusion to viable but edematous
tissue surrounding the ischemic area.
• Most embolic or thrombotic strokes do NOT
have substantial BP elevations and do not need
aggressive therapy
Ischemic CVA Management

Management: VERY CONTROVERSIAL!


Recent trends leans towards NOT treating
hypertension in the presence of a
cerebrovascular accident (thrombotic or
embolic) unless DBP exceeds 140mmHg.
Ischemic CVA Management

Tintinelli: Favors lowering MAP (mean


arterial pressure) by 20%.
Recommends IV Labetalol in small doses
of 5mg increments if DBP is higher than
140 mmHg.
Ischemic CVA Managment

Rosen: In most cases, recommends no


treatment of Hypertension in CVA patients.

- However, the author does recommend


treating HTN if diastolic blood pressure is
greater than 140 mmHg.
Management of Hypertension in Patients With Acute Ischemic Stroke
Acute (<72 h from symptom onset) ischemic
stroke and elevated BP

Patient
qualifies for IV
thrombolysis
therapy

Yes No

Lower SBP to <185 mm Hg and


DBP <110 mm Hg before
initiation of IV thrombolysis
BP ≤220/110 mm Hg BP >220/110 mm Hg
(Class I)

And

Maintain BP <180/105 mm Hg for Initiating or reinitiating treatment of Lower BP 15%


first 24 h after IV thrombosis hypertension within the first 48-72 during first 24 h
(Class I) hours after an acute ischemic stroke is (Class IIb)
ineffective to prevent death or
dependency
(Class III: No Benefit)

For preexisting hypertension,


reinitiate antihypertensive drugs
after neurological stability
(Class IIa)

Colors correspond to Class of Recommendation


BP indicates blood pressure; DBP, diastolic blood pressure; IV, intravenous; and SBP,
systolic blood pressure.
Management of Hypertension in Patients With a Previous History of
Stroke (Secondary Stroke Prevention)
Stroke ≥72 h from symptom onset and stable
neurological status or TIA

Previous
diagnosed or treated
hypertension

Yes No

Restart
antihypertensive
Established Established
treatment
SBP ≥140 mm Hg or SBP <140 mm Hg and
(Class I)
DBP ≥90 mm Hg DBP <90 mm Hg

Aim for
BP <140/90 mm Hg
(Class IIb) Initiate Usefulness of starting
antihypertensive antihypertensive
treatment treatment is not
(Class I) well established
(Class IIb)
Aim for
BP <130/80 mm Hg
(Class IIb)

Colors correspond to Class of Recommendation in Table 1.


DBP indicates diastolic blood pressure; SBP, systolic blood pressure; and TIA, transient
ischemic attack.
Causes of Hemorrhagic CVA

• Hypertensive Vascular Disease


• Arteriovenous Anomalies (AVM)
• Arterial Aneurysms
• Tumors
• Trauma
Hemorrhagic CVA Management

• Hypertension associated with


hemorrhagic stroke is usually
transitory and the result of
increased intracranial pressure
and irritation of the Autonomic
Nervous System
Hemorrhagic CVA Management
• Hemorrhagic CVA’s commonly results in a
profound reactive rise in blood pressure
• Management is CONTROVERSIAL.

• Subarachnoid Hemorrhage: oral 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.
Congestive Heart Failure /
Pulmonary Edema

Pathophysiology:
Increased Afterload with
decreased Cardiac Output
CHF / Pulmonary Edema

Symptoms:
Shortness of Breath, Cough, Chest Pain
Lower Extremity Swelling

Signs:
Jugular Venous Distension, Rales, S3 Gallop
Hepatomegaly, Pedal Edema
CHF / Pulmonary Edema Management
in the ED

- Nitroprusside or IV Nitroglycerin (T. 398)


- Rosen: May start with Nitroglycerin, but
Nitroprusside is agent of choice if Pulmonary
Edema is present. (R. 1760)
- Attempt treatment of CHF initially with standard
agents (Lasix,sublingual NTG, morphine), as
these often lower blood pressure, but resort to
Nitroprusside if necessary (R. 1761)
Acute Coronary Syndrome /
Acute MI
Pathophysiology:
- Increased afterload, cardiac
workload, and myocardial oxygen
demand
- Decreased coronary 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 Coronary Syndrome/
Acute MI
- Immediate Blood Pressure
reduction is indicated to prevent
myocardial damage.

- No specific defined BP target.

- Tailor treatment to symptom relief.


Acute Coronary Syndrome /
Acute MI

Management:
Nitroglycerin IV or Sublingual
Nitroprusside
Beta Blockers (Esmolol,Lopressor)

Nitroglycerin is Drug of Choice


Dissection of Thoracic Aorta

Pathophysiology:
- Atherosclerotic Vascular Disease, 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 dissection)
- Angina (coronary artery dissection)
- Shortness of breath (aortic insufficiency, cardiac tamponade)

Signs:
- Differential Blood Pressure (in UE)
- Bruit (interscapular)
- Neurological Deficits
- Acute Cardiac Tamponade (rare)
Dissection of Thoracic Aorta
Management:

- Medications with negative inotropic effects (beta-


blockers) MUST be given FIRST (reduces
shearing force)

- Vasodilators (nitroprusside) may be added for


further antihypertensive treatment after
administration of a negative inotropic agent.
Dissection of Thoracic Aorta

Optimal BP in these patients is


undefined and must be tailored
for each patient, however,
SBP of 120-130mmHg may be a
initial starting point.
Acute Renal Failure
Pathophysiology:

- Hypertensive Glomerulonephropathy, Acute


Tubular Necrosis (ATN)

- Worsening renal function in the setting of severe


hypertension with elevation of BUN/CR,
proteinuria, or the presence of red cells and red
cell casts in the urine.
Acute Renal Failure
Symptoms:
- Many times there are few actual symptoms
- Facial or Peripheral Edema due to fluid overload
or proteinuria may be present, shortness of
breath

Signs:
- Few findings unless edematous
- Pulmonary Edema
Acute Renal Failure
Management:

- Nitroprusside is agent of choice


- Dialysis (as needed)
- Rosen: 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.
Pheochromocytoma

Pathophysiology:

- Alpha and Beta stimulation of the


cardiovascular system due to adrenergic
excess states
Pheochromocytoma
Symptoms:
Episodic headaches, flushing, tremor,
diaphoresis, diarrhea, hyperactivity, and
palpitations.

Signs:
Tachycardia, tachypnea, tremor,
hyperdynamic state (high output CHF).
Pheochromocytoma
Management:

- Alpha Blocker FIRST, followed by a Beta


Blocker
- Phentolamine (alpha) + Esmolol (beta)
- Labetalol IV (combined alpha and beta
blockade)
Toxemia of Pregnancy
Pathophysiology:

- Systemic arterial 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
Toxemia of Pregnancy
Symptoms:
Lower extremity swelling, headache,
confusion, seizures, coma

Signs:
Edema, hyperreflexia, elevation of blood
pressure related to baseline BP prior to
pregnancy (elevation may be mild 125/75)
Toxemia of Pregnancy
Management:

- IV Magnesium Sulfate, Hydralazine.


- May also use nifedipine or labetalol
- Delivery of fetus is definitive treatment of
pre-eclampsia
Diagnosis and Management of a Hypertensive Crisis
SBP >180 mm Hg and/or
DBP >120 mm Hg

Target organ damage new/


progressive/worsening

Yes No

Hypertensive
Markedly elevated BP
emergency

Admit to ICU
(Class I) Reinstitute/intensify oral
antihypertensive drug therapy
and arrange follow-up

Conditions:
• Aortic dissection
• Severe preeclampsia or eclampsia
• Pheochromocytoma crisis

Yes No

Reduce SBP to <140 mm Hg Reduce BP by max 25% over first h†, then
during first h* and to <120 mm Hg to 160/100–110 mm Hg over next 2–6 h,
in aortic dissection† then to normal over next 24–48 h
(Class I) (Class I)

Colors correspond to Class of Recommendation in Table 1.


*Use drug(s) specified in Table 19.
†If other comorbidities are present, select a drug specified in Table 20.
BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care
unit; and SBP, systolic blood pressure.
2017 Hypertension Guideline
Summary of Medications used for
Hypertensive Emergencies
- Intravenous Nitroglycerin:
Start at 0.2 to 0.4 mcg/kg/min (10 to 30 mcg/min) and rapidly increase in 5
to10 mcg/min increments. Titrate to BP and symptomatic improvement.

- Nitroprusside:
Start 0.3 mcg/kg/min and titrate up every 5 to 10 minutes based on BP and
clinical response.

- Esmolol: 500 mcg/kg initial bolus over 1 minute, then start infusion at 50 to
150 mcg/kg/min

- Metoprolol (Lopressor): 5mg IV every 2 minutes for a total of 3 doses, then


start infusion at 2 to 5 mg/hr.
2017 Hypertension Guideline

Summary of Medications used for


Hypertensive Emergencies
- Labetalol: 20mg IV initial dose, with repeat doses of 40mg to 80mg
every 10 minutes to reach desired effect or max dose 300mg.

- Nicardipine: 2mg IV boluses followed by an IV infusion of 4 to 15


mg/hr

- Magnesium Sulfate IV: 4 to 6 grams over 15 minutes, followed by IV


infusion of 1 to 2 grams/hour

- Hydralazine: 10 to 20mg IV
2017 Hypertension Guideline
Best Proven Nonpharmacological Interventions for Prevention and
Treatment of Hypertension*
Nonpharmacologi Dose Approximate Impact on SBP
-cal Intervention Hypertension Normotension
Weight loss Weight/body fat Best goal is ideal body weight, but aim -5 mm Hg -2/3 mm Hg
for at least a 1-kg reduction in body
weight for most adults who are
overweight. Expect about 1 mm Hg for
every 1-kg reduction in body weight.
Healthy diet DASH dietary Consume a diet rich in fruits, -11 mm Hg -3 mm Hg
pattern vegetables, whole grains, and low-fat
dairy products, with reduced content
of saturated and total fat.
Reduced intake Dietary sodium Optimal goal is <1500 mg/d, but aim -5/6 mm Hg -2/3 mm Hg
of dietary for at least a 1000-mg/d reduction in
sodium most adults.
Enhanced Dietary Aim for 3500–5000 mg/d, preferably -4/5 mm Hg -2 mm Hg
intake of potassium by consumption of a diet rich in
dietary potassium.
potassium
Best Proven Nonpharmacological Interventions for Prevention and
Treatment of Hypertension* (cont.)
Nonpharmacologica Dose Approximate Impact on SBP
l Intervention Hypertension Normotension
Physical Aerobic ● 90–150 min/wk -5/8 mm Hg -2/4 mm Hg
activity ● 65%–75% heart rate reserve
Dynamic resistance ● 90–150 min/wk -4 mm Hg -2 mm Hg
● 50%–80% 1 rep maximum
● 6 exercises, 3 sets/exercise, 10
repetitions/set
Isometric resistance ● 4 × 2 min (hand grip), 1 min rest -5 mm Hg -4 mm Hg
between exercises, 30%–40%
maximum voluntary contraction, 3
sessions/wk
● 8–10 wk
Moderation Alcohol In individuals who drink alcohol, -4 mm Hg -3 mm
in alcohol consumption reduce alcohol† to:
intake ● Men: ≤2 drinks daily
● Women: ≤1 drink daily
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz
of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12%
alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).
BP Thresholds for and Goals of Pharmacological Therapy in Patients
With Hypertension According to Clinical Conditions
BP
BP Goal,
Clinical Condition(s) Threshold,
mm Hg
mm Hg
General
Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80
No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80
Older persons (≥65 years of age; noninstitutionalized, ≥130 (SBP) <130 (SBP)
ambulatory, community-living adults)
Specific comorbidities
Diabetes mellitus ≥130/80 <130/80
Chronic kidney disease ≥130/80 <130/80
Chronic kidney disease after renal transplantation ≥130/80 <130/80
Heart failure ≥130/80 <130/80
Stable ischemic heart disease ≥130/80 <130/80
Secondary stroke prevention ≥140/90 <130/80
Secondary stroke prevention (lacunar) ≥130/80 <130/80
Peripheral arterial disease ≥130/80 <130/80

ASCVD indicates atherosclerotic cardiovascular


disease; BP, blood pressure; CVD, cardiovascular
disease; and SBP, systolic blood pressure.
Referencias
• 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/
ASH/ASPC/NMA/PCNA . Guideline for the Prevention,
Detection, Evaluation, and Management of High Blood
Pressure in Adults. © American College of Cardiology
Foundation and American Heart Association, Inc.
Published on November 13, 2017, available at:
Hypertension and Journal of the American College of
Cardiology.