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Crisis Hypertension
Crisis Hypertension
LV hypertrophy
Fibrosis Heart failure DEATH
Remodeling MI
Apoptosis
GFR
Proteinuria
Renal failure
Aldosterone release
Glomerular sclerosis
*preclinical data
LV = left ventricular; MI = myocardial infarction; GFR = glomerular filtration rate
Adapted from Willenheimer R et al Eur Heart J 1999; 20(14): 9971008, Dahlöf B J Hum Hypertens 1995; 9(suppl 5):
S37S44, Daugherty A et al J Clin Invest 2000; 105(11): 16051612, Fyhrquist F et al J Hum Hypertens 1995; 9(suppl 5):
S19S24, Booz GW, Baker KM Heart Fail Rev 1998; 3: 125130, Beers MH, Berkow R, eds. The Merck Manual of
Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories 1999: 16821704, Anderson S
Exp Nephrol 1996; 4(suppl 1): 3440, Fogo AB Am J Kidney Dis 2000; 35(2): 179188
Joint National Committee VII
Vasculature - aortic
Vasculature
dissection,
eclampsia
Hypertensive Emergencies
• CNS - Hypertensive encephalopathy
• CVS
– Acute myocardial ischemia
– Acute cardiogenic pulmonary edema
– Acute aortic dissection
– Post-op vascular surgery
• Renal - Acute renal failure
• Eclampsia
• Catechol excess- Pheochrom, Drugs
Pathophysiology
Sudden increase in
Systemic Vascular Mechanical Stress with endothelial
Resistance injury, increased permeability, Coag/Plt
activation, fibrin deposition
BP
1) Fibrinoid necrosis
2) Ischemia
3) Activation of RAA
4) Proinflammatory cytokines
Clinical Presentation
• Variable
• Zampaglione et al (Hypertension 27:144, 1996)
– 14, 209 ER visits in one year period
– 108 met definition of hypertensive
emergency (0.8%)
– Mean Systolic BP 210 + 32
– Mean Diastolic BP 130 + 15
Clinical Presentation
• Frequency of signs and symptoms
– Chest Pain 27%
– Dyspnea 22%
– Neuro defect 21%
– Interestingly….
• Headache was only 3% and epistaxis was 0%
in this study
Hypertensive emergency is
associated with a threshold BP of
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Threshold BP
• There is no specific BP where
hypertensive emergencies occur
• But, organ dysfunction is rare with
diastolic BPs < 130 mm Hg
– Rate of increase may be more important
– Hence, encephalopathy will occur at lower
BPs in pregnancy and in children
Initial Evaluation
• Focused history
– History of hypertension?
– How well is hypertension controlled?
– What antihypertensives?
– Adherence to antihypertensive regimen?
– Last dose of antihypertensive?
Initial Evaluation
• Social History
– Recreational Drugs
• Amphetamines
• Cocaine
• Phencyclidine
Initial Evaluation
• Confirm BP in both arms
• Use appropriate sized BP cuff
• Cuff that is too small
– BP cuffs that are too small falsely elevate
BP measurements in obese patients
Initial Evaluation
• Assess for end-organ damage
• Vascular Disease
– Assess pulses in all extremities
– Auscultate over renal arteries for bruits
• Cardiopulmonary
– Listen for rales (CHF)
– Murmurs or gallops
Initial Evaluation
• Neurologic Exam
– Hypertensive Encephalopathy - mental
status changes, nausea, vomiting, seizures
– Lateralizing signs uncommon and suggest
cerebrovascular accident
• Retinal Exam
– Lost art
– Keith-Wagener-Barker Classification
Lab Testing
• ECG
– LVH, look for signs of ischemia, injury, infarct
• Renal Function Tests (urine included)
– Elevated BUN, Creatinine, proteinuria, hematuria
• CBC
• CXR - pulmonary edema, aortic arch, cardiac
enlargement
Lab Testing
• Aortic Dissection?
– Suspect with severe tearing chest pain,
unequal pulses, widened mediastinum
– Contrast Chest CT Scan or MRI
• Pulmonary Edema/CHF
– Transthoracic Echocardiogram
– Differentiate between systolic dysfunction,
diastolic dysfunction, mitral regurgitation
Management
• Where?
– ICU with close monitoring
– Severe requires intra-arterial BP
monitoring
• Which Parenteral meds?
• Depends on the situation
Preferred Agents
• Beta blockers
– Labetolol
– Esmolol
• Calcium Entry blocker
– Nicardipine
• Dopamine-1 receptor agonist
– Fenoldapam
• Vasodilators - nitroprusside/nitroglucerin
Concept of Hypertensive
Urgencies
• Potentially dangerous BP elevation
without acute, life-threatening end-organ
damage
• Examples (controversial!)
– Retinal changes without
encephalopathy or acute visual
symptoms
– High BP with nonspecific Sx (headache,
dizziness, weakness)
– Very high BP without symptoms
Hypertensive Urgencies
• Severe elevation of BP ( DBP > 115)
• No progressive end-organ disease
• Joint National Committee on Detection,
Evaluation, and Treatment of HBP
– 1984 - lower BP within 24 hours
– 1988 - urgent therapy rarely required
– 1993 - Gradual lowering of BP
• Risks of rapid reduction (cerebral and myocardial
ischemia)