Indonesian Society of Hypertension

BP = CO x SVR

SBP + 2 DBP
MAP =
3
 Hypertensive emergencies

PATHOPHYSIOLOGY
abrupt SVR due to
humoral factors
?
BP
(de novo or chronic
hypertension)

Mechanical
stress

Release of
vasoactive
mediators

Vascular Endothelial
ischemia injury
Ault MJ, Ellrodt AG.
Am J Emerg Med 1985; 3:10–15
 Hypertensive emergency

 Hypertensive urgency
A number of different terms have been

applied to acute severe elevations in

blood pressure, and the current

terminology is somewhat confusing.

 HYPERTENSIVE EMERGENCY
Definition:
• BP >180/120 mm Hg (rapidity of the rise is more important)
• Impending or progressive target organ damage
- Cerebrovascular
- Cardiac
- Renal
- Surgical conditions
- Severe epistaxis
- Severe body burns
- Eclampsia
• Require immediate BP reduction with parenteral agents
Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252
Kaplan NM. Kaplan’s Clinical Hypertension. 2002
 Malignant hypertension

…embraces a syndrome of severe elevation of arterial blood

pressure (diastolic blood pressure usually but not always

>140mmHg) with vascular damage that can be manifest as

retinal haemorrhages, exudates and/or papilloedema;

hypertensive encephalopathy; and deterioration in renal

function. Malignant phase hypertension must be regarded as a

hypertension emergency.

2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007, 25:1105–1187
 HYPERTENSIVE URGENCY

Definition:

• Severe elevation in BP (in practice, DBP  130 mm Hg)

• Without progressive target organ dysfunction

• May be associated with headache, epistaxis, shortness of

breath, or severe anxiety (less severe than emergencies)

making the distinction with emergency become ambiguous

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

Kaplan NM. Kaplan’s Clinical Hypertension. 2002
 ACCELERATED HYPERTENSION

Severe elevation of arterial blood pressure

(diastolic blood pressure usually but not

always >140mmHg) without papilloedema.

2007 ESH/ESC Guidelines for the Management of Arterial Hypertension. J Hypertens 2007, 25:1105–1187
Most frequent presenting signs in patients with
hypertensive emergencies
% of patients

Chest pain Dyspnea Neurologic

deficit

Zampaglione B, et al. Hypertension 1996; 27:144–147

“………..it is estimated that 1 to 2% of

patients with hypertension will have a

hypertensive emergency at some time in

their life……….”

Vidt DG. Am Heart J 1986; 111:220–225

Bennett NM, Shea S. Am J Public Health 1988; 78:636–640
 Evaluation of patients with hypertensive
emergencies

• Presentation: new symptom related with elevated BP

• Medical history: organ damage, hypertension history and

medications, recreational drugs

• BP measured in both arms with appropriate BP cuff

• Physical examination:

- pulses in all extremities

- auscultation for pulmonary edema, heart murmurs, renal
artery bruits
- neurologic examination
- fundoscopic examination

• Laboratory test, Chest x ray, ECG, Echocardiography, and brain CT

scan
Patients with a hypertensive emergency

should be admitted to an Intensive Care

Unit for continuous monitoring of BP

and parenteral administration of an

appropriate agent.
 Initial Goal of Treatment in Hypertensive
Emergencies

Reduce MAP by no more than 25% in less than 1 hour.

Excessive fall may cause renal, cerebral, coronary ischemia

If stable, to 160/100-110 mm Hg within the next 2-6 hour

If stable, gradual reduction toward normal BP in the next

24 to 48 hours

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

 BLOOD PRESSURE CONTROL DURING ACUTE
ISCHEMIC STROKE

1. Remain controversial. It has been a common practice after

acute cerebral infarction to reduce or withhold BP treatment
until the clinical condition has stabilized 1)
2. Elevated BP during acute stroke is thought to be a
compensatory physiological response to improve cerebral
perfusion to the ischemic brain tissues
3. American Stroke Association Guidelines: patients with recent
ischemic stroke whose SBP is  220 mm Hg or DBP 120 to 140
mm Hg, cautious reduction of BP by 10% to 15% is suggested
(careful monitoring of neurological deterioration. Careful
infusion of sodium nitroprusside is indicated if DBP is  140
mm Hg2
1) Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252
2) Adams HP Jr et al. Stroke. 2003;34 :1056 –1083.
 ACUTE ISCHEMIC STROKE

“Pending more data, the consensus of the panel

is that emergency administration of
antihypertensive agents should be withheld
unless the DBP is 120 mm Hg or unless the SBP
is 220 mm Hg”

“A reasonable goal would be to lower blood

pressure by 15% to 25% within the first day”

Adams, Jr HP, et al. Stroke 2007;38;1655-1711

 ACUTE HEMORRHAGIC STROKE

Lowering of the BP is currently

recommended only when the SBP is 200

mm Hg, the DBP is 110 mm Hg, or the

MAP is 130 mm Hg.

Marik PE, Varon J. Chest 2007;131;1949-1962

 Drug Special indications Adverse efects
Sodium Most hypertensive emergencies Nausea, vomiting, muscle twitching,
nitroprusside Caution with high intracranial sweating, thiocynate and cyanide
pressure or azotemia intoxication
Nicardipine Most hypertensive emergencies Tachycardia, headache, flushing,
HCl except acute heart failure. local phlebitis
Caution with coronary ischemia

Fenoldopam Most hypertensive emergencies Tachycardia, headache, flushing, nausea

mesylate Caution with glaucoma
Nitroglycerin Coronary ischemia Headache, vomiting, methemo- globinemia,
tolerance with prolonged use
Enalaprilat Acute left heart failure. Avoid in Precipitous fall in pressure in high-renin
acute MI states; variable reponse
Hydralazine Eclampsia Tachycardia, flushing, headache, vomiting,
HCl aggravation of angina
Labetolol HCl Most hypertensive emergencies Vomiting, scalp tingling, broncho-
except acute heart failure constriction, dizziness, heart block,
orthostatic hypotension
Phentolamine Catecholamine excess Tachycardia, flushing, headache

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

Parenteral Drugs for the Treatment of Hypertensive Emergenies

Drug Dose Onset of action Duration of action

Sodium 0.25–10 g/kg/ min as IV Immediate 1–2 min

nitroprusside infusion
Nicardipine HCl 5–15 mg/h IV 5–10 min 15–30 min, may
exceed 4h
Fenoldopam 0.1–0.3  g/kg/ min IV 5 min 30 min
infusion
Nitroglycerin 5–100  g/min as IV 2–5 min 5–10 min
infusion
Enalaprilat 1.25–5 mg every 6 h IV 15–30 min 6–12 h
Hydralazine HCl 10–20 mg IV 10–20 min IV 1–4 h IV
10–40 mg IM 20–30 min IM 4–6 h IM
Labetolol HCl 20–80 mg IV bolus every 10 5–10 min 3–6 h
min
0.5–2.0 mg/min IV infusion
Phentolamine 5–15 mg IV bolus 1–2 min 10–30 min

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

Usual Adult Dose for Hypertensive Emergency
0.2 mg orally once. Additional doses of 0.1 mg may be given as
needed and tolerated every hour to control this patient's blood
pressure. The maximum recommended total daily dose in any
case of emergent hypertension is 0.8 mg.
Eleven severely hypertensive patients: severe left ventricular
failure, hypertensive encephalopathy, cerebral haemorrhage,
dissecting aortic aneurysm, renal failure, and severe epistaxis.
0-15 mg or 0-3 mg clonidine was given every 40 minutes. Doses of
clonidine required for control ranged from 0-15 mg (one ampoule)
to 09 mg (mean 0-56 mg).
It is concluded that clonidine is effective and safe in the treatment
of hypertensive emergencies.
Management of hypertension in patient undergoing surgery

1. Elective surgery:
Oral antihypertensive agents if BP  180/110 mm Hg.
2. Urgent surgery:
Rapidly acting parenteral agents: sodium nitropruside,
nicardipine, or labetolol.
3. Sudden intra-operative hypertension:
Parenteral antihypertensive agents as used in the
management of hypertensive emergencies.
4. Oral treatment must be interrupted postoperatively:
periodic dosing of iv enalaprilat or transdermal clonidine
hydrochloride may be useful.

Chobanian AV et al. The JNC 7 Complete Version. Circulation 2003;42:1206-52

Classification of hypertension during pregnancy

BP ≥140/90 mm Hg

Chronic < 20 weeks > 20 weeks

— proteinuria: chronic hypertension

+ proteinuria: chronic hypertension

with superimposed preeclampsia*
— proteinuria: gestational hypertension

*  2-3x
+ proteinuria: preeclampsia**
* * > 300 mg/24h

Chobanian AV et al. The JNC 7 Complete Version. Circulation 2003;42:1206-52

 Treatment of Acute Severe Hypertension in
Preeclampsia
5 mg iv bolus, then 10 mg every 20 to 30
Hydralazine minutes to a maximum of 25 mg, repeat
in several hours as necessary
20 mg iv bolus, then 40 mg 10 minutes
Labetolol (2nd line) later, 80 mg every 10 minutes for 2
additional doses to a maximum of 220 mg
10 mg per oral, repeat every 20 minutes
Nifedipine to a maximum of 30 mg. Caution when
(controversial) using nifedipine with magnesium sulfat,
can cause precipitous BP drop
Sodium nitroprusside 0.25 g/kg/min to a maximum of 5
( rarely when others g/kg/min. Fetal cyanide poisoning may
fail) occur if used for more than 4 hours

Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252

 Treatment of Chronic Hypertension in Pregnancy
Agent Comments
Preferred on the basis of long-term follow-
Methyldopa
up studies supporting safety
Reports of intrauterine growth retardation
Beta blockers
(atenolol). Generally safe
Increasingly preferred to methyldopa
Labetalol
because of reduced side effects
Clonidine Limited data
Limited data. No increase in major
Calcium antagonists
teratogenicity with exposure
Diuretics Not first-line agents. Probably safe
ACEIs, angiotensin II Contraindicated.
receptor antagonists Reported fetal toxicity and death
Treatment should be started if BP 150-160/100-110 mm Hg
Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252
 Antyhypertensive therapy of chronic hypertension in pregnancy
Drug Dosage Additional comments
Methyldopa 500-3000 mg in 2-4 Drug of choice due to extensive
divided dose experience
Labetolol 200-1200 mg in 2-3 Similar in efficacy and safety to
divided dose methyldopa
-blockers variable Possibility of fetal bradicardia, lower
birth weight (when used early in
pregnancy)
CCB variable Accumulating data support maternal
and fetal safety; may interact with
magnesium sulfate
-blockers variable Scant data for use in pregnancy
Clonidine 0.1-0.8 in 2-4 divided Limited data
dose
Thiazide diuretics Variable May be associated with diminished
volume expansion; may be necessary
in volume sensitive hypertension at
lower dose
ACE-inhibitors Contraindicated Neonatal anuric renal failure
ARB contraindicated Neonatal anuric renal failure

August P, Falkner B. 2001

 TREATING HYPERTENSION DURING LACTATION

1. All antihypertensive agents that have been studied are

excreted into human breast milk

2. Mothers who wish to breast-feed should withhold

antihypertensive treatment and reinstitute antihypertensive
therapy following discontinuation of nursing

3. No short-term adverse effects has been reported from

exposure to methyldopa or hydralazine

4. Propanolol and labetolol are preferred if beta blocker is

indicated.

5. ACE-Is and ARBs should be avoided in the basis of reported

fetal and neonatal renal effects.

6. Diuretics may reduce milk volume and thereby suppress

lactation
Chobanian AV et al. JNC 7-Complete Version. Hypertension. 2003;42:1206 –1252
1. Emergency

- Progressive or impending target organ damage

- Require immediate BP reduction with parenteral agent

2. Treatment

- Require close BP monitoring. Should not cause

hypotension

- Different BP goal in acute ischemic stroke

- Drug regimen without clear outcome studies