HYPERTENSIVE

CRISES and
HYPETENSIVE
ENCEPHALOPATH
Y
:Objectives


Define hypertension and stages of

hypertension. Define the various types

of hypertensive crises
Recognize signs and symptoms

associated with hypertensive crises


Hypertensive encephalopathy
defenision and pathophysiology
Treatment options
 Case Scenario

A 50-year-old man with a long history of hypertension presents to

the ED with the complaints of headache for 2 days. He has
not taken his antihypertensive medications in more than a year
and does not remember their names. His physical
examination is remarkable only for a persistent blood pressure of
210/ 120 mm Hg and grade I retinopathy.
Background knowledge
 Mean arterial blood pressure

MAP= DIASTOLIC BP+1/3pulse 

pressure

O
r 
MAP=
SBP+(2XDBP)/3
Da m a ga f r o m h ig h b lomd p r a ssur e

B lindnes s

Hea rt
attac
k

Ki d n
ey
f a I re
 ESC- Definit ions a nd cla ssif
icatio n o off ice blood 1

c gory Sys on
pressure levels (mmHg)
Optimal <120 I ndfor <80
·. onm I ll l0-11 80-84
29 85-89
nd/or
1

Hig n or al
1130._ll3
Grad yper te1 9 90-99
sio
II 0-159
G d 2 yp r te1 •

10 1160-11 nd lo 1100---
Grad e 3 ype te 79 -
•O
09
SI _ 180
nd
:Definitions

 Hypertension:
 Stage I: 140-
159/90-99
 Stage II:
 >160/100
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
Hyperten sive Crisis
-

-
- - - - - -- -- -------- ----------- --------- ---- - ----- --------------
..,,
----- - ----- ---------- -------
$ 16/21
(END ORGAN DAMAGE (EOD
:Signs and Symptoms

 Hypertensive
Urgency:
 Can be completely
asymptomatic
 Some symptoms
include:
 Severe headache
 Shortness of breath
 Nosebleeds
 Severe anxiety
S&S Continued

 Hypertensive Emergencies
 Symptoms:
 nausea, vomiting (cerebral edema)
 Chest Pain
 SOB
 Blurry vision
 Confusion
 Loss of consciousness
..CONT

 Signs:
 Retinal hemorrhages,
exudates, or papilledema
 Renal involvement (malignant
nephrosclerosis) with AKI,
proteinuria, hematuria
 Cerebral edema  seizures and
coma
 Pulmonary Edema
 Myocardial Infarction
Definition of hypertensive
encephalopathy

 Abrupt, sustained increased BP exceeds limits of

cerebral autoregulation
 MAP 150 -200
 Variable vasospasm, edema, hemorrhages
 Headaches, nausea, vomiting, confusion
 Patchy focal neuro deficits
 Papilledema, retinopathy
 Signs + symptoms resolve with reduction
of BP
? What's the
problem
Physiology of cerebral
flow
..regulation
In summary
?How its rise to cause damage
 Artery V e in

••
" li u - n ic . a i
,_-..;, .• E n d o 1 1 he'ltium
••
- - ..
a
- - _

- - - - - - - - - - - - ·• S u b e n d o t h e lilam
,........, 1111'1tftenial e a s t ic
la m 1 n a
- - - - - - - - - -- -- -- - - E Tx tuenorncaal m e d i a
- -e{la
- -s t ic la m in a
- - - - - - - - - "liu - n i c .a - - - - - - - -
e x te m a

Capillary
ne
pathophysiology

 Acute rise in
BP

1-Failure of autoregulation

vasoconstriction 2- damage

Endothelial

3- Activates coagn and Depsn. of

proteins 4-inflammation fibrinogen
in vessel wall
5-FIBRINOID NECROSIS
Nlecrotizing arteriole: Malignant
HPTN

•
•
• • JI
 pathophysiology

 The pathophysiology of hypertensive

crises is not completely understood.
 With mild-to-moderate elevations in blood
pressure, arterial and arteriolar
vasoconstriction initially maintains tissue
perfusion while preventing increased
pressure from being transmitted to more

distal vessels.
With severe elevations in blood pressure
(i.e.,
>180/110 mm Hg), this autoregulation fails,
and increased pressure in capillaries leads
to endothelial damage of the vascular wall,
causing fibrinoid necrosis and perivascular
edema.
MRI of Acute hypertensive
encephalopathy
?How to deal with it
Treatment Options

 Hypertensive Urgency:
 Goal: Reduce BP to <160/100 over
several hours to day
 Elderly at high risk of ischemia
from rapid reduction of BP,
therefore slower reduction in BP in
this patient population
Treatment continued

 Hypertensive Urgency continued:

 Previously untreated
hypertension:
 Slow reduction of BP (one to two
days): Amlodipine, Metoprolol XL,
lisinopril (po anti-hypertensives
usually enough)
Treatment Continued

 Hypertensive Emergency:
 Goal: Lower Diastolic BP to approximately
100-105 over 2-6 hours; max initial fall not
to exceed 25%
 More aggressive decrease can lead to
ischemic stroke and myocardial
ischemia
 If focal neurological sx present obtain
MRI to r/o acute stroke (rapid BP correction
contraindicated)
 Parenteral antihypertensives (IV
Drip) recommended over oral agents
Treatment

 Recommended parenteral
antihypertensive agents (IV drip) for
Hypertensive Emergencies and
admission to ICU
 Nitroprusside (cautious about

cyanide toxicity), Nicardipine,
and Labetalol.
Once BP controlled, switch to
oral anti- hypertensives and
follow-up closely
P a r e n te r a l d r u g s f o r il:r e a il:m e n t o f h y p e r i l : e n s i v e e n r 11 e r g en o e s *
Drug Onset: Duration of Adverse effects• Special
Dose of action iindicat.ions
.act on

Sodium nitroprusside
v .a s odil a t lo r s
I
0.25 - 10Immediate - Nausea, vomitrng, muscle
µg/kg/min as V twitching, sweating, t:hiocynate and -
1-2 min cyanide intoxication Most hypertens ive
infusion emergencies; caution
with high intracranial
pressure or azotemia

Nicardipine
hydrochlorideI 5-15 mg/h 5-10 min V
I Tachyca rdia,
headache, flushing, local phlebrtis
Most hypertensive
emergencies except
acute heart failure;
cautiion with coronary
15-30 min1 may ische mia
exceed 4 h
All
hypertensive
Atr ial fibrillabion, nausea emergencies

Clevidipine 1-2 m/h 1-2 min

!l!V with
rrapid 5-l.5 nnin
ttwit:rat: on itto Most:
nnax of 16 Tachycardia, hypertensive
nng/h emergencies ; ca ution
headache, nausea , flushing wi·tih
0. 1 0.3 glaucoma
Fenoldopani
mesylat:e
<:5 min 30 min Coronary
Headache, vo m1t1ng, ischemia
µo/kg per min methemoglobinemia,
V infusion ·tolerance with prolonged
use
Nitroglyce rin
5-100 Precipito us fall in pressure in hio;;ih- Acute left
I 5- 10 min renin st:at:es; variable response ventricular
failure; avoid in
2-5 min
acute myocardial
Enalaprilat µg/min as V infarction
infusion
Tachyca rdia,flushing , headache,
I 6- 12 h vomiting, aggravation of angina Ec:lamps ia
1.25-5 mg

15-30 min
Hydra lazine every 6 h V
hydrochlorideI
1-4 h V
I
4-6 h M
V

I IV

- T h e s e d o s e s m a y v a r y f r o m t h o s e · i n t h e P h y s ic i a n s ' D e s k R e f e r e n c e ( 6 4 t h e d it io n ) .
• · H y p o t e n s i o n m a y oMc c u r w it h a l l a g e n t s .
L!.. R e q u i r e s s p e c i a l d e li v e r y s y s t e m .
A d a p t :e d w i t :h p e r m i s s i o n f r o m : C ho b a n i a n A V ,. B a k r i s GL.,. B la c k H R , . e t : a l . S e v e n t:h r e p o r t : o f t:h e
J o i n t : N a t : J on a l C om m i t t e e o n p r e v e n t :i o n ,. d e t :e c J :i o n , . e v a l u a t : J o n , . a n d t :r e a t : r n e n t : o f h i g h b lo o d
pressure . I M
.N y p e r t :.e n s i o n 2 0 0 3 ; 4 2 : 1 . 2 0 6 . C o p y r ig h t : © 2 0 0 3 L J p p i n c o t : t : W J / f l a r n s & W J / ki n s .
P a r e n t e r a l d r u g s f o r ·t r e a t : m e n t : o f h y p e r t e n s i v e e m e r g e n c ie s , c o n tJin u e -d
1

* Drug Dose Onset of Duration Adverse effects• Speci\al

action of ,actiion indications

Andr,enell'lg ic inhibitors
Labetalol 20-80 mg 5-10 3 6 h Vo miting, scall!Jl Most
hydroclnloriide [V !bolus min ting'ling, hypert:ensive
every 10 bro nohoco nstridtion, emergeno1es
min dizziness, nausea, exc ept aoute,
he·art blodk, heart failure
0.5-2.0 orthostatic
mg/min V hypotension
inf1U1 sio n
Esmo lol 250-500 1-2 min 10-30 min Hypotension, nause·a, Aortic
hydirocln loride-8 µg/kg/ min by asthma, first-degree he·art: dissection,
infiusio n; blodk, HF perio1pe11ative
may repeat
bolus after
5 min or
1nore·ase
infusio n to
300 µg/min
Phentolamine 5-15 mg [V 1-2 min 10-30 min Tachycardia, fluslning, Catedholamine
bolus headaohe exc ess

"" T h e ·s e d o s e s m a y v a r y f r o m t h o s e i n t h e P h y s ioia n s ' D e s k R ef e r e n c e ( 6 4 t h e·d it io n ) .

• Hy p o t e n s i o n m a y o o ou r w it h a l l a g e n t s .
l!J. Re q u ir e s s p e oia l d e liv e r y s y s t e m .
A d a p te d w it h p er m is s io n f r o m ': C h ob a n i a n A V , B a k r is GL , B l a ck H R,, ie t a l .. S e v 1en th 11e p o r t o f th e
J oi n t
N a t io n a l C om m i t te e o n p Fe v e n t i o n .... d e t e c t i o n ., ,e v a lu a t io n .... a n d t r e a t:Fnen r o f h ig h blo o d p rie ss u r ;e .
H y p e rt"e n s io n 2 0 0 3 ; 4 2 : 1 2 0 6 . C o p y r ig h t © 2 0 0 3 Li p p i n c o t t Wil l ia m s .& Wilk in s .
 Summary

Hypertensive Crises are common

Differentiate Hypertensive Urgency from
Emergency on the basis of end-organ damage
Know main pathophysiology of
hypertensive encephalopathy
Can treat hypertensive urgency with
oral
antihypertensives, but parenteral medications
required for hypertensive emergencies

25% reduction in diastolic BP over 2-6 hours for

hypertensive emergencies
 Thank you for
your attention
? Any questions