Management of

hypertensive emergency
and urgency
Daly p mbunda
 Introduction
• Normal blood pressure is 120/80mmHg
• Why we care about hypertension?
• one of the most common chronic disease of medical concern.
• Affects >30% of population > age 20
• 30% of the population is unaware they have hypertension.
Risk factor for
• Cardiovascular disease and mortality
• Cerebrovascular disease and mortality
• End stage renal diseases
• Other end organ damage
Hypertensive emergency
• Estimates about 1% of those with hypertension will present with
hypertensive emergency each year.
• Mortality rate up to 90%
• Diastolic blood pressure>120
• Evolving end-organ damage and treated under ICU
Hypertensive urgency
• SDP>180 and DPB>120 that requires control in BP over 24 to 48 hours
• No end organ damages
• Not emergence
• No admission to ICU
Sign and symptoms
• Headache, vomiting and nausea
• Chest pain
• Acute kidney failure
• Abnormal heart rhythms
• Cerebral infarction
• Pulmonary edema
• Hypertensive encephalopathy
• Congestive heart failure
Pre disposing factors
• Withdraw of anti hypertensive medication
• Pheochromocytoma
• Collagen-vascular diseases
• Stimulants drug use ( cocaine and amphetamines)
• MAOIs ( selegiline and phenelzine)
 Treatment
Medication options
• Iv antihypertensive
Hypertensive emergency

• Oral antihypertensive
Hypertensive urgency
Treatment
• Goals is to reduce MAP by 25% to 160/100mmHg within 2-6 hours
using injectable then 12-24 hours later start oral agents.

labetalol
• MoA will reduce vascular smooth muscle resistance
• dose 20-80mg
• Onset of action 5-10 minutes
• Duration of action3-6hours
• ADR heart block and orthostatic hypotension
• Contraindicated in asthma
Nicardipine

• MoA calcium channel blocker- selective arterial vasodilator

• Dose 5-15mg
• Onset of action 5-10 min
• Duration of action 1-4 hours
• ADR flushing and headache
• Contraindicated in acute heart failure
Hydralazine

• MoA decrease systemic resistance by direct vasodilation of arterioles

• Dose 10-20mg
• Onset of action 10-20 minutes
• Duration of action 1-14 hours
• ADR headache and reflex tachycardia
• Contraindicated in aortic dissection
Sodium nitroprusside

• MoA direct smooth muscle dilator(arterial and venous)

• Dose 0.25-8mcg
• Onset of action 20 seconds
• Duration of action 1-2 minutes
• ADR nausea, vomiting and muscle spasm
Nitroglycerin
• MoA potent vasodilator – decrease coronary vasospasm
• Dose 5-100mcg
• Onset of action 2-5 minutes
• Duration of action 5-10 minutes
• ADR mathemoglobinemia and coronary ischemia
Esmolol
• High selective beta blocker vasodilator
• Dose 250-500mcg
• Onset of action 1-2 minutes
• Duration of action 10-30 minutes
• ADR bradycardia and aortic dissection
Oral agents for hypertensive
urgency
• Short acting hypertensive drugs
drug Mode of action dose Onset of action Duration of Side effects
action
captopril ACE inhibitor 12.5-25mg BID 15-30 min 4-6hrs Cough

clonidine Alpha2 agonist 0.1-0.2mgBID 30-60min 6-8hrs Rebound

hypertension
after
withdrawal

furosemide Loop diuretics 20-80mg OD 30-60min 8-12hrs Hypokalemia

and
hyponatremia
labetalol Alpha and beta 200-400mg 30-120min 6-8hrs bronchoconstri
blocker ction
ADR treatment
• Heart block by artificial pacemaker
• Orthostatic hypotension- erythropoietin working by increasing blood
volume
• Congestive heart failure- captopril, digoxin and spironolactone
• Reflex tachycardia- propranolol and Esmolol
• Muscle spasm- diazepam
• Mathemoglobinemia- oxygen therapy and methylene blue
Special situation

1. Hypertensive encephalopathy
• Reduce MAP by 25% or diastole to 100mmHg over 8 hours
• Drug of choice
• Labetalol
• Sodium nitroprusside
 2.Acute ischemic stroke
• Often loss of cerebral auto regulation
• Ischemic region more prone to hypo perfusion
• Drug of choice.
• Labetalol
• Nicardipine
• Sodium nitroprusside
3.Acute intracerebral
hemorrhage
• Treatment based on radiograph evidence of raised ICP
• No raised ICP –MAP<110
• Drug of choice
• Nicardipine
• Labetalol
• Sodium nitroprusside
 4.Acute coronary syndrome
• Treat if SBP>160 and /or DBP>100
• Drug of choice
• Nitroglycerin
• Labetalol
• Nicardipine
5.Acute pulmonary edema
• Treat with vasodilator addition to diuretics
• Drug of choice
• Enalapril, oxygen and loop diuretic
6. Pheochromocytoma
Drug of choice
• Diazepam
• Labetalol
7.Pre-eclampsia/Eclampsia
• Goal SBP<160 and DBP<110.
• IV magnesium sulfate to prevent seizures
• Drug of choice
• Methyldopa
• Hydralazine
• Labetalol