Hypertension and

hypertensive emergencies
Introduction
 Hypertension:
 The elevation of blood pressure on at least 3 separate
occasions
 Asociated w/ high arterial pressure
 In malawi, there is a high prevalence of
hypertension in rural and urban areas of malawi, with
low levels of detection, treatment and control.
 The need for cost-effective strategies for primary
prevention, detection and treatment of hypertension
 The growing public health challenge of non-communicable
diseases in Sub-Saharan Africa.

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Introduction

 Consequences of the actual blood

pressure will depend:
 Measured level
 Age / Race / Sex
 Glucose intolerance
 Cholesterol
 Smoking habit

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Introduction
 Hypertension can be
secondary due to conditions:
 Coarctation of the aorta
 Renal disease
 Endocrine disease
 Contraceptive pill.  

 It is symptomless in the vast

majority of patients

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The basics
 Mild HTN is considered a diastolic BP of 90-
104mmHg & a systolic BP of 140-159
 Moderate HTN is diastolic 105-114 and
systolic of 160-179 mmHg
 Severe HTN is diastolic 115 or higher, and
systolic 180-209 mmHg
 Malignant HTN demonstrates exudates,
hemorrhages or papilloedema

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Key Points
 Patients with hypertension can be grouped
into the following categories:
 Emergency: Presents with hypertension &
evidence of end organ damage (chest pain,
mental status changes, renal failure, or ocular
findings)
 Urgency: Diastolic over 130 and or impending end
organ damage
 Chronic: Diastolic under 130 with no specific
symptoms

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• Key Points
 Diagnosis should not
be based on a single
measurement
 If the initial reading
is elevated, it should
be repeated
 Wait till the patient
has been resting
quietly on their back
for 5 min. & then
check both arms

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• Key Points
 When therapy is begun it must continue for
life
 Compliance - important determinant of
blood pressure control
 Explanation, education & minimizing side
effects are key

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Evidence of end organ
damage
 Cardiomegaly
 Proteinuria
 Uremia
 Retinopathy
 Evidence of stroke

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  Urgent blood pressure reduction may
precipitate stroke or blindness.
 Aim of treatment is to bring the diastolic
BP below 90 mmHg w/out unacceptable
side effects

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Hypertensive Emergency
 Diagnosed not by a specific blood
pressure
 Defined as an increased blood pressure
that causes acute end-organ (brain,
heart, kidneys, and eyes) damage 

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Hypertensive Emergencies
 AMI/chest pain
 CVA/SAH
 Hypertensive
encephalopathy
 CHF/Pulmonary
edema
 Aortic dissection

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Hypertensive Emergencies
 Take patients history:
 Prior diagnosis of HTN?
 Cessation of BP medications?
 Cardiovascular/Renal/Cerebrovascular disease
 Diabetes
 Chronic obstructive pulmonary disease (COPD)
 Asthma

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Hypertensive Emergencies
 Precipitating causes include:
 Pregnancy
 Illict drug use (e.g. cocaine)
 Monoamine oxidase inhibitor or decongestants

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Hypertensive Urgencies
 Diastolic blood pressure over 115-130 mm
Hg.
 Patients may have chronic end organ damage
 No evidence of acute, life-threatening
dysfunction
 No signs of acute organ dysfunction
 ↓ The BP over 24-48 hours
 Follow-up the next day is recommended.

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Acute Hypertensive
Emergency
 A systolic BP >180 and DBP > 110
 No signs or symptoms
 Usually no immediate treatment is
required but the patients should have
follow-up the next day

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Transient Hypertension
 Normotensive once the precipitating
event is resolved
 Examples include:
 Pregnancy
 Severe anxiety
 Alcohol withdrawal
 Cocaine/drug use

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Clinical Findings
 These constitute a
Hypertensive
Emergency:
 Papilledema
 Retinal exudates
 Neurological deficits
 Seizures
 Meningismus or
encephalopathy

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Clinical Findings
 Assess for:
 Carotid bruits
 Heart murmurs
 Gallops
 Symmetric pulses
 Abdominal masses
 Pulmonary rales

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Diagnosis
 Clinical
 Don’t wait for lab test to start therapy
 Laboratory tests show end organ damage
 Electrolytes show kidney damage or
associated electrolyte abnormalities
 U/A shows kidney damage

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Diagnosis

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Treatment
 Reduce blood pressure rapidly to slightly
above normal level
 Don’t reduce blood pressure too quickly in
stroke patients or patients with cerebral
vascular disease
 Avoid SL nifedipine to treat HTN urgently
 Treat w/ IV medications

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Treatment for Specific
Hypertensive Emergencies
 Hypertensive encephalopathy
 Decrease blood pressure by < 20% in the first
hour
 Don’t decrease the BP >30% over the next 48-
72 h
 IV Nitroprusside infusion requires blood
pressure checks

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Treatment for Specific
Hypertensive Emergencies
 CVA, subarachnoid or intra-cerebral
hemorrhage:
 If the diastolic BP is persistently >140 mm Hg
then slowly reduced the BP by 20-30% over
12-24 hours
 Nitroprusside or labetalol can be use

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Treatment for Specific
Hypertensive Emergencies
 AMI/Chest pain:
 Myocardial infarction is imp
 Nitroglycerine SL or preferably IV is the best
drug
 Titrate the infusion to reduce the BP to ‘normal’
levels
 Beta blockers useful for patients w/ cardiac
ischemia.

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Treatment for Specific
Hypertensive Emergencies

 CHF/Pulmonary edema
 Use a nitroglycerine IV infusion to reduce the
BP to normal
 Do not use beta blockers w/ CHF

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Treatment for Specific
Hypertensive Emergencies
 Chronic Hypertension
 Educate patient about the importance of:
 Weight loss
 Exercise
 Salt restriction
 Chronic therapy & ongoing care.

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Treatment
 Chronic Hypertension include:
 Drugs
 Diuretics
 Beta blockers
 Calcium channel antagonists
 Angiotension-converting enzyme (ACE)
inhibitors
 Alpha adrenergic antagonists

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Recommended Set up Care
 Step One: hydrochlorothiazide (O) 12.5-25 mg
once daily
 Step Two: hydrochlorothiazide (O) 25 mg once
daily PLUS
 Methyldopa (O) 250 mg two to three times a day
OR
 Propranolol (O) 160-320 mg once daily
 Step Three: Captopril (O) 12.5-25 mg 3 times
per day

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 Recommended Hypertensive Medications
Based on Patient Variables
Patient Demographics Diuretic Beta blocker Calcium ACE Alpha blocker
channel  Inhibitor
blocker

Elderly ++ +/- + + +

Black Race ++ +/- + + +/-

Patient Medical
Condition
Angina +/- ++ + ++ +

Post AMI + ++ + +/- ++

CHF ++ ? + - ++

CVA + + +/- ++ +

Renal insufficiency ++ +/- + ++ ++

Diabetes - - ++ + ++

Dyslipidemia - - ++ + +

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 Common Anti-hypertension
Medications
Beta blockers  

Atenolol 50mg daily 25 - 100mg

Metoprolol 50mg bid 50 - 450 mg

Propanolol 40mg bid 40 - 240mg

Proponolol LA 80mg daily 60 - 240 mg

Labetalol 100mg bid 200 - 1200 mg

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Common Anti-hypertension
Medications
Calcium channel blockers  

Diltiazem 5 mg daily 2.5 - 10 mg

Diltiazem SR 60 - 120 mg bid 120 - 360 mg

Diltiazem CD 180 mg bid 180 - 360 mg

Nicardipine 20mg tid 60 - 120 mg

Nicardipine SR 30 mg bid 60 - 120 mg

Nifedipine XL 30 mg daily 30 - 90 mg

Verapamil SR   120 - 140 mg daily 120 - 480 mg

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Common Anti-hypertension
Medications
 Drug Starting dose Usual dose

Diuretics
Furosemide 20 mg daily 20 - 320 mg
Hydrochlorthiazide 25 mg daily 12.5 - 50 mg

ACE inhibitors 

Captopril 25 mg bid 50 - 450 mg

Enalapril 5 mg daily 2.5 - 40 mg

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 Disposition & Referral

Controlled Blood
Pressure/no signs High Blood
of end organ Pressure/signs of
damage end organ damage

Send home Hospitalize

& follow up

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Case 1
 A 48 year old man presents with pitting
edema of the lower extremities which has
slowly developed over the past six months.
 He also has chronic(> one year) dyspnea on
exertion which he has attributed to his long-
term cigarette smoking of 1.5 packs per day.
 On review of systems, he has vague right
upper quadrant pain of several months'
duration.
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Case 1
 Dyspneic with moving about the exam room; was
noted to be cyanotic upon arrival to office after
climbing a flight of stairs
 Blood Pressure110/60 upright and supine
 Pulse100 and regular and Respirations20 at rest
 Pursed lip respirations and accessory muscle use
Elevated jugular venous pressure
 Apical impulse is not palpable; prominent pulsations
felt in epigastric area. Right ventricular heave present
 S3 gallop on auscultation in the epigastric area; I-
II/VI systolic murmur along the left sternal border
which intensifies with inspiration. Loud P2

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Case 1

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Case 1

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Case 1
 What is the most likely cause of this patient's
illness?
 What are the clinical presentations of right
ventricular failure?
 What is the most common cause of right
heart failure?
 What are other causes of right heart failure?

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Case 2

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Case 3
 A young man presents with pale, oedematous
face.
 He is complaining of headache and dizziness;
is seemed to be a bit confused.
 He is speaking slowly and his answers are
simple, short and partly inadequate.
 He is saying that he has some visual
disturbances and some slight pressure in his
chest.

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Case 3
 The relatives are saying that he turned pale and
oedematous several days ago and his condition has
worsened since then.
 The present day he has constant nausea and vomited
once.
 In the last few hours after an anxious period he
turned somnolent: he did not or hardly reacted and
answered any questions.
 He could barely walk and after having been put into
bed by his relatives he fell down from it.
 So they decided to bring him to the hospital

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Case 3
 Have you had fever, shivers or sweating
lately?
 Has your urine changed lately?
 Has your bowel habit changed lately
(constipation, diarrhoea)?
 Have you had some (or more than usual)
alcohol lately?
 Have you got any wound on your body?
 What have you eaten recently?
 Do you feel pain in your back (waist)? 
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Case 3
 The family is showing you a previous medical note about acute
gastro-enteritis. That time his BP was 145/95mmHg.
 During a thorough physical examination you are finding pale
skin, periorbital and facial oedema, minimal abdominal
sensitivity and several signs of neurologic abnormalities in
several potential areas referring to different localisation.
 These signs are increasing in intensity (but not equally) and
changing their localisation during the prolonged examination.
 You are also detecting some uncertain clonus. He’s complaining
of retching without vomiting. His BP is 190/136mmHg,
HR=62/min.
 What is your preliminary diagnosis?

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Case 3
 Would you do some further examination
at the bedside to make a decision about
the need and kind of the therapy?
 What acute therapy would be optimal
for the Patient in this situation?

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Case 4
 A 72 year old black male presents with
chest pain and headache for last two
hours
 Vital signs
 HR 110
 Respiration 14
 BP 210/125
 Temperature 370C

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Case 4
 What are some other questions you
want to ask?
 What might be some physical exam
findings you may want to look for?
 What diagnostic tests would you order?
 What is the differential diagnosis?
 How would you manage this patient?
 What would his disposition be?
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Case 5

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Case 6

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