HYPERTENSION

DR ABDELMONIEM SAEED
ER SPECIALIST
Hypertension
 defined as a systolic blood pressure of 140 mm
Hg or a diastolic blood pressure of 90 mm Hg
measured on two occasions at least 6 hours
apart.

 Adverse outcomes are unlikely as long as

blood pressure remains <140/90 mm Hg
 JNC-7 Classification of Hypertension

Class Systolic BP (mm Diastolic BP (mm

Hg) Hg)

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 140–159 or 90–99

Stage 2 160 or 100

Hypertensive crisis
 Hypertensive emergency
 is an acute elevation of blood pressure (180/120 mm Hg)
associated with end-organ damage, specifically, acute effects on
the brain, heart, aorta, kidneys, and/or eyes

 Hypertensive urgency
 is a clinical presentation associated with severe elevations in
blood pressure(>180/120 mm Hg) without progressive target
organ dysfunction

 Sever hypertensive episode

 Rapid Increase in the blood pressure without impending end
organ damage and usually asymptomatic
Pathophysiology
 poorly understood

 sudden increase in systemic vascular resistance secondary to

circulating humoral vasoconstrictors.

 These initial events trigger mechanical wall stress and endothelial

injury, leading to increased permeability, activation of the
coagulation cascade and platelets, and deposition of fibrin.

 fibrinoid necrosis of the arterioles ensues

 The rate of blood pressure elevation is an important determinate

of end-organ injury
Clinical presentation

History
 Asymtomatic accidental finding on v/s assessment

 Symptoms of target organ damage

 Headache
 visual disturbance and decreased LOC
 Chest pain and SOB
 Nausea and vomiting
 epistaxis
Physical examination
 High BP Sys >180 or Dys > 110
 Finding of target organ damage
TREATMENT
Important points

 no evidence that antihypertensive drugs reduced mortality or

morbidity in patients with hypertensive emergencies

 insufficient trial evidence to recommend one agent over another

 the treatment recommendations in this section are largely

consensus based

 Patient safety and physician familiarity with specific drugs are

important concerns

 physicians should carefully consider target range for blood

pressure reduction to avoid overtreatment
BETA-BLOCKERS
Labetalol

 is the most commonly used parenteral antihypertensive agent in the

ED.
 Labetalol is unique among commonly used ß-blockers because it also
has selective alpha1 inhibitory effects.
 Used for most hypertensive emergencies with the exception
 of cocaine intoxication and
 systolic dysfunction in association with decompensated heart failure,
 Dose
 Bolus:
 10–20 mg (0.25 mg/kg for an 80-kg patient) IV over 2 min;
 may administer 40–80 mg at 10-min intervals, up to 300 mg total dose.
 Continuous infusion:
 initially, 2 mg/min; titrate to response up to 300 milligrams total dose, if
needed.
Metoprolol
 indicated in acute coronary syndromes, and 5
mg IV every 5 to 15 minutes up to 15 mg can be
given

 oral metoprolol is preferred because it is less

likely to be associated with hypotension, unless
hypertension and tachycardia

.
Esmolol
 it has a safety advantage in patients at risk for the adverse
effects of ß-blockers, such as patients with severe asthma.

 dose
 Loading dose: 250–500 mg/kg infused over 1–3 min IV, follow
with:

 Maintenance infusion:
 50 mg/kg/min IV over 4 min; increase infusion rate using increments
of 50 micrograms/kg/min IV (for 4 min). If no improvement observed

 This regimen can be repeated x4 bolus doses and to an infusion

rate of 200 micrograms/kg/min
CALCIUM CHANNEL
BLOCKERS
Nicardipine
 has an onset of action of 5 to 10 minutes, and can be titrated
at 15-minute intervals.

 It is safe and effective in neurologic hypertensive

emergencies, and has a favorable effect on myocardial
oxygen balance increasing both stroke index and coronary
blood flow.

 Continuous infusion:
 start at rate of 5 mg/h.
 If target BP not achieved in 15 min, increase dose by 2.5 mg/h
every 15 min until target pressure or the maximum dose of 15
mg/h is reached.
Clevidipine
 is a third-generation dihydropyridine calcium channel
blocker with ultra-short-acting selective arteriolar
vasodilator

 has recently been approved for the treatment of

hypertensive emergencies, excluding aortic dissection.

 Its advantage is its ability to be titrated with a half-life

less than a minute.

 Continuous infusion: initiate IV infusion at 1–2 mg/h.

Nifedipine
 discouraged in hypertensive emergencies
except in patients with preeclampsia.

 Dose 10mgPO.
VASODILATORS
 Nitroglycerin
 Is a weak arterial dilator (requiring high doses)

 Recommended as a first-line agent in the

treatment of heart failure and acute coronary
syndromes

 Its hypotensive effects are due to its reduction

of preload and cardiac output, which makes it
a poor choice in other hypertensive
emergencies.
 Nitroprusside

 was the most commonly used drug for

hypertensive emergencies because of its rapid
onset and almost universal efficiency.

 its use decreased because of awareness of its

toxicity and the need for invasive monitoring.

 should be considered when other agents fail

Chest Pain and Severe Hypertension
Aortic dissection

 Acute aortic dissection presents with abrupt, severe onset of pain (90%
of cases)

 described as tearing or ripping, and radiating to the interscapular

region 78% of cases)

 Chest radiograph is abnormal in 90%

 31% have pulse deficits 28% have a diastolic murmur and 17% have
neurologic deficits.

 Up to 25% of patients with aortic dissection have ECG changes.

 Four percent have ST elevation in two or more contiguous leads,
 whereas an additional 9% have ST depression,
 the remaining 13% have new T-wave changes
 Aortic dissection
 Use Labetalol IV, Esmolol, IV Nicardipine Iv
or Nitroprusside

 Target SBP 100–120 mm Hg,

 Reduce shear forces by reducting of BP and

HR.

 The treatment of pain with morphine is an

important part of the management
 Acute myocardial infarction
 Medication
 Nitroglycerin SL, or IV continuous
 metoprolol or labetalol bolus therapy

 No more than 20%–30% , reduction for SBP

>160 mm Hg.

 Anticoagulation indicated to reduction of

ischemia
Acute hypertensive pulmonary edema
 Medication
 Nitroglycerin SL, or IV
 Enalaprilat IV
 Nicardipine IV
 Nitroprusside IV
 Reduction of BP by 20%–30%.

 Promotion of diuresis after vasodilation.

Hypertensive encephalopathy
 Is characterized by ,altered mental status, headache, vomiting, seizures, or
visual disturbances and, in certain patients, papilledema, retinal hemorrhages or
exudates

 Cerebral hemorrhage or infarct is identified by head CT scan.

 Focal neurologic deficits are more commonly associated with stroke

 Medication
 Nicardipine IV
 Labetalol IV
 Fenoldopam

 Decrease MAP 15%–20%.

 aggressive lowering may lead to ischemic infarction

Subarachnoid hemorrhage & Intracranial
hemorrhage
 Medications
 Labetalol IVI
 Nicardipine IVI
 Esmolol IV, bolus, then continuous drip

 Aim SBP <160 mm Hg or MAP <130 mm Hg to prevent

rebleeding.

 Some neurosurgeons may prefer therapeutic hypertension

to treat vasospasm

 Hypotension should be avoided and BP monitored carefully

to maintain SBP 120 to preserve cerebral perfusion.
Acute ischemic stroke
 Medication
 Labetalol IV
 Nitroglycerin.
 Nicardipine IV

 If fibrinolytic therapy planned, treat if >185/110 mm

Hg.
 Treat if >220/120 mm Hg on third of three
measurements, spaced 15 min apart.72
 Lowering of BP may significantly worsen ischemia and
deficit.
 Lowering of BP by >10%–15% in first 24 h should be avoided.
Peripheral Edema and Severe Hypertension

 New onset renal failure

 Eclampsia
Acute renal failure

 new-onset renal failure may have peripheral

edema, oliguria, loss of appetite, nausea and
vomiting, orthostatic changes, or confusion.
 Medication
 Labetalol bolus
 Nicardipine IV
 Fenoldopam IV

 Dialysis
 Reduction of BP by no more than 20% acutely
Severe preeclampsia, HELLP syndrome,
eclampsia
 Patients with preeclampsia present later in pregnancy with edema and
proteinuria, but may develop hemolysis, elevated liver enzyme levels, and
low platelet counts

 Medication
 Labetalol
 Nifedipine PO (nicardipine may be better tolerated)

 Aim Bp of <160/110 mm Hg

 Hydralazine yields an unpredictable therapeutic response and therefore is

not recommended

 Angiotensin-converting enzyme inhibitors are contraindicated in

pregnancy due to their effects on the fetus
Sympathetic Crisis and Severe Hypertension

 Pheochromocytoma
 Signs include headache, alternating periods of
normal and elevated blood pressure,
tachycardia, and flushed skin, punctuated by
asymptomatic periods.

 recreational use of cocaine, amphetamines,

or phencyclidine
 signs include tachycardia, diaphoresis, and
hypertension, with or without mental status
changes.
Sympathetic Crisis and Severe Hypertension

 Medication
 Benzodiazepine IV bolus first line if failed
 Nitroglycerin SL, IV
 Phentolamine
 Nicardipine IV

 Aim to reduce excessive sympathetic drive and Symptoms

relief

 The use of -blockers is not recommended because unopposed

-blockade can cause storm and increase cocaine.

 Labetalol has been used in this setting, but is not

recommended.
Common presenting scenarios of hypertensive emergency
 HYPERTENSIVE URGENCIES
AND ASYMPTOMATIC SEVERE
HYPERTENSION
Hypertensive Urgencies and Asymptomatic
Severe Hypertension
 Repeat measurement

 Reduce precipitating factors such as anxiety and

pain

 Use oral medications

 Aim to reduce BP in days

 Arrange for OPD visit

Hypertensive Urgencies and Asymptomatic Severe Hypertension
DISPOSITION AND FOLLOW-UP
Recommended Treatment Protocol for ED Patients
with Increased Blood Pressure (BP)
Indications for Specific Antihypertensive
Therapy
Common Adverse Effects of Antihypertensive
Drugs
THANK YOU