Hypertensive Urgency

January 2-3, 2023

CC Arimao, CC Parojinog, PGI Sialongo, PGINuñez

M.B.
● 52 years old
● Female, Married, Filipino, Roman Catholic
● Birthdate: January 03, 1971
● Public school teacher
● Tablon, Cagayan de Oro City
● Reliability: 90%
Chief
Complaint
● “Nalipong ko”
History of Present
Illness
● 1 day PTC
○ patient experienced onset of dizziness associated with headache with a pain
score of 5/10, located around the back of the head, the temples and the forehead
characterized as squeezing. Relieved by rest and exacerbated by movement.
○ 1 episode of epistaxis which spontaneously stopped after 1 minute.
○ Ear discomfort
○ Not associated with vomiting, fever, cough, and SOB.
○ Self medicate with betahistine 24mg, 1 tab twice a day which offers temporary
relief
○ No changes in the appetite and activity
History of Present
Illness
● 1 hour PTC
○ Had one episode of vomiting of previously ingested food.
Persistence of symptoms prompted consultation in the OPD,
upon assessment patient had a BP of 240/100 and was then
subsequently referred to ER .
Past History
● (+) Hypertension,
○ 2006 - patient was started on Losartan 100mg PO BID, non-adherent
● (-) DM
● (-) Asthma
● (-) Tuberculosis
● (-) Stroke
● (-) Cancer
● (-) Previous hospitalization
● (-) Previous surgery
Past History
● Obstetrical History
○ G4P4 (4004)
■ G1 (1999) term, boy, born via NSD in NMMC. no complication.
■ G2 (2000) term, boy, NSD in Tagoloan Lying in, no complication.
■ G3 (2004) term, boy, via NSD. patient was diagnosed with gestational
hypertension and was on methyldopa
■ G4 (2011) term, boy, via NSD in NMMC, no complication. Gestational
hypertension
● Gynecologic History
○ M: 12 years old
○ I: regular, 28 days interval
○ D: 3 days
○ A: 4 pads per day
○ S: (-) pain
Family
History
● (+) Hypertension- both paternal and maternal side
● (-) DM
● (-) Asthma
● (-) Tuberculosis
● (-) Stroke
● (-) Cancer
Personal-Social
History
● (-) Smoker
● (-) Alcoholic drinker
● (-) Illicit drug user
● Educational attainment: College graduate
● Public school teacher
● Married to a 62 yo, unemployed.
 Genogram
I BACONGA-GULLANA
FAMILY
Informant: Patient
Address: NMMC-ER
Date: JAN 1,2023

RED: htn + II
₱: breadwinner
: primary
caregiver ₱

III
 Review of Systems
● General: ● Gastrointestinal:
○ (-) weight loss ○ (-) change in bowel habits, hemorrhoids
● Skin: ● Genitourinary:
○ (-) rashes, lesions, jaundice ○ (-) frequency of urination
● HEENT: ○ (-) flank pain, hematuria
○ (-) blurred vision, glaucoma, cataracts, hearing ● Musculoskeletal:
problems, ear infection, nasal discharge, ○ (-) joint/muscle pain, weakness
nosebleed, bleeding gums ● Neurologic:
● Neck: ○ (-) altered sensorium
○ (-) goiter, lumps
● Endocrine:
● Breast:
○ (-) excessive thirst
○ (-) lumps, pain, nasal discharges
○ (-) excessive hunger
● Respiratory:
○ (-) heat/cold intolerance
○ (-) shortness of breath
● Cardiovascular:
○ (-) peripheral edema, chest pain
Physical
Exam
Vital Signs
BP 200/100 mmHg
HR 90 bpm
RR 20 cpm
T 36.8 C
O2 99% at room air

height : 154 cm weight: 53.5 kg BMI: 22.6 kg/m2

Physical
Exam
● General: Awake, coherent, not in respiratory distress
● HEENT: Anicteric sclerae, pink palpebral conjunctivae, pupils
equally round and briskly reactive to light, intact EOM, no nasal
discharges, moist lips and oral mucosa, no neck masses
● C/L: Equal chest expansion, no retractions, clear breath sounds
● CVS: Adynamic precordium, distinct heart sounds, regular rate
and rhythm, no murmur
● ABD: Flat, non distended, normoactive bowel sounds, (-)
tenderness
Physical
Exam
● MUSCULOSKELETAL: no joint deformities, good range of motion in hands, wrists, elbows, shoulders hips,
knees and ankles
● NEUROLOGIC MENTAL STATUS: Tense, but alert and cooperative. Oriented to person, place and time
● CRANIAL NERVES
○ CN I: able to smell
○ CNII: visual acuity intact
○ CN III, IV, VI:Extraocular movements intact
○ CN V: temporal and masseter strength intact
○ CN VII: no facial asymmetry, intact facial movements
○ CN VIII: hearing intact bilaterally to whispered voice. Rinne test: AC>BC Weber: vibration heard in
midline
○ CN IX & X: gag intact
○ CN XI: strength of the sternocleidomastoid and trapezius muscle 5/5
○ CN XII: tongue midline
Physical
Exam
● MOTOR: Good muscle bulk and tone. No weakness. Strength
5/5 throughout
● Cerebellar: point to point movement intact, gait stable
● SENSORY: light touch intact
● (-) romberg, no pronator drift
● REFLEXES: brisk response, 2+ all throughout
Primary Working
Impression
● Hypertensive urgency
DIFFERENTIAL
DIAGNOSIS
Hypothesis What information fits
the hypothesis?
What does not
fit?
What did I expect
but not find?
What additional
information do I
need?

Hypertensive History of dizziness, none none none

urgency headache, epistaxis,
vomiting,along with
>180/100 bp

Hypertensive History of dizziness, No altered mental Specific organ Any instance

emergency headache, epistaxis, status blurring of involvement for history of organ
vomiting,along with vision or other dizziness and dysfunction during
>180/100 bp neurological headache previous episodes
deficits (unrecalled)

BPPV History of dizziness, High blood History of trauma, none

female gender pressure, other episodes of
presence of dizziness
epistaxis
Working Impression
● HYPERTENSIVE URGENCY
HYPERTENSION
 Regulation of Blood Pressure
1. Increase in Intravascular Volume
● Sodium, an extracellular ion. Primary determinant of the ECF volume.
● Excessive sodium intake → expansion of intravascular volume → inc.
Cardiac output → inc. blood pressure

1. Autonomic Nervous System

● a1 receptors → vasoconstriction (smooth muscle); increase renal
sodium tubular reabsorption
● a2 receptors → inhibit release of norepinephrine
● β1 receptors → inc. rate and strength of cardiac contraction and
cardiac output; stimulates renin release in kidneys
● β2 receptors → vasodilation.
 Regulation of Blood Pressure
3. RAAS system
Stimuli for Renin secretion
a. Reduced NaCl transport in Thick ascending Loop of Loop of Henle
b. Less pressure or stretch in renal afferent arterioles
c. B1 receptor stimulation/ sympathetic NS stimulation
d. Pharma Blockade of ACE or Angiotension II receptors
4. Vascular Mechanisms
Radius and compliance are important determinants of Blood Pressure
Small reduction in radius can affect compliance.
 Complications of Hypertension

● Heart
● Brain
● Kidneys
● Peripheral Arteries
● Eyes
Pertinent History and PE
 Diagnosis
● NOT on a single visit
○ Exception: BP >180/110 mmHg PLUS evidence of
cardiovascular disease

● Two to three office visits at one to four weeks interval

● Can be confirmed by out-of office BP measurements

MANAGEMENT OF HYPERTENSION

Lifestyle Modifications:

● Weight reduction
○ Attain and maintain BMI <25 kg/m2
● Dietary salt restriction
○ <6 g NaCl/day
○ Sodium restriction to as low as 1500 mg/day
● Adapt DASH-type dietary plan
● Moderate alcohol consumption
● Physical activity
○ Regular aerobic activity like brisk walking for 30 mins/day
● Smoking cessation
MANAGEMENT OF HYPERTENSION

Pharmacological Treatment

FIRST LINE ANTIHYPERTENSIVE DRUGS

● angiotensin-converting enzyme (ACE) inhibitors
● angiotensin-receptor blockers (ARBs)
● calcium channel blockers
● thiazide/thiazide-like diuretics

Beta blockers- initial therapy in HPN patients with CAD, ACS, high
sympathetic drive and pregnant women
 Pharmacological Treatment

DRUG ACTION EXAMPLE

Thiazide Diuretics Inhibits Na/Cl symporter pump Hydrochlorothiazide (25–50

in distal convoluted tubule mg)

ACE inhibitors Inhibits ACE, blocks the Captopril (12.5-150 mg/d)

conversion of Angiotensin I to Enalapril 95-40 mg/d)
Angiotensin II

ARBs Competitive antagonism with Losartan (50-100 mg/d)

angiotensin II Valsartan (80-320 mg/d)

Beta blockers Inhibits B1 and B2 receptors Propanolol (40-180 mg/d)

Atenolol (25-100 mg/d)

Calcium channel Blocks L-type calcium Amlodipine (2.5- 10mg/d)

blockers channels Nifedipine (30-120 mg/d)
 Pharmacological Treatment

DRUG ACTION EXAMPLE

Loop diuretics Inhibtis Na–K-2Cl Furosemide

contransporter in the thick Ethacrynic Acid
ascending loop of Henle

Aldosterone antagonist Blocks the effects of Spironolactone

aldosterone, preventing the Eplerenone
reabsorption of sodium

Sympatolytics Centrally acting α2 Clonidine

sympathetic agonists Methyldopa
decrease peripheral Reserpine
resistance by inhibiting
sympathetic outflow
 MANAGEMENT OF HYPERTENSION

Aim for Blood Pressure control within 3 months

Target BP:
● Reduction by at least 20/10 mmHg, ideally to <140/90 mmHg
● <65 years: BP target <130/80 mmHg if tolerated (but >120/70 mmHg)
● >65 years: <140/90 mmHg
IDEAL cOMBINATION THERAPY
● ACEi/ARBs+ CCB
● ACEi/ARBs+ thiazide/thiazide-like diuretics

NOT RECOMMENDED COMBINATION THERAPY

● ACEi+ ARBs= Hyperkalemia/Renal Failure

BP >150/100 mm Hg (or >160/100 mm Hg in the elderly):

a combination of 2 agents, preferably combination of a RAAS inhibitor (ARB/ACE-is) and
CCB or diuretic, should be given initially since it is unlikely that any single agent would be
sufficient to achieve the BP target.
Source: Executive Summary of the 2020 Clinical Practice Guidelines for the Management of Hypertension in the Philippines
 HYPERTENSIVE CRISIS

➢ Refers to an acute severe hypertension (systolic blood pressure of >180

mmHg and/or diastolic blood pressure of 120 mmHg) that cause or
increase the risk of end-organ damage.
➢ They can be due to a primary hypertension or precipitated by
underlying conditions.
 HYPERTENSIVE URGENCY VS.
EMERGENCY
➢ HYPERTENSIVE URGENCY: SBP ≥180 mmHg or DBP ≥120 mmHg

➢ HYPERTENSIVE EMERGENCY: SBP ≥180 mmHg or DBP ≥120 mmHg +

Hypertension-mediated Organ Damage (HMOD)
 HYPERTENSIVE URGENCY

➢ Is defined as severe increase in BP which is not associated with an end

organ damage/complication.
➢ Possible precipitating factors include: Non-adherence to anti-hypertensive
medications, less effective outpatient blood pressure control, acite pain,
herbal supplement and emotional stress.
Management
● Blood pressure measurement should be repeated after 30 mins. of bed rest.
● Initial treatment should aim for about 25% reduction in BP over 24 hours
but not lower than 160/100 mmHg.
● Oral drugs

● Combination therapy may be necessary.

● Importantly, there is no role for IV BP lowering drugs.
Management at the ER
● Monitor BP
● Diagnostics: Cbc, Crea, 12LECG
● Antihypertensives and Pain medications started: Losartan 100 mg OD now then
repeat BP after 30 mins and Orphinadine Citrate + PCM 35/450 mg/tab now
● Home meds:
○ Losartan 100 mg/tab OD
○ Amlodipine 10 mg/tab OD
● To follow up w/ other Labs: CBC w/ PC, Urinalysis, FBS, Hba1c, Crea, Bun,
Lipid profile, SGPT, and SGOT
● Follow up
○ At NMMC OPD once with lab results
CASE SUMMARY
● Patient M.B. came in with a chief complaint of “Nalipong ko”.
● Patient was noted with a sudden onset of dizziness associated with headache and
vomiting.
● Patient sought consult in our institution as OPD and upon assessment BP was
elevated at 240/100 and was then referred to ER.
● Patient was managed as a case of Hypertensive Urgency.
● Patient was started on Losartan 100 mg tab OD and Amlodipine 10 mg tab 1 tab
OD were also given to manage the patient’s BP.
● Patient’s condition improved, subsequently discharged, prescribed with home
medications Losartan 100 mg/tab OD every morning and Amlodipine 10 mg/tab
OD every evening and advised for follow up on opd.
Take Home Message
➢ Patients need to be educated about the importance of antihypertensive
medications.
➢ They need to be advised about the need to regularly monitor their BP and
follow-up with their health care provider.
➢ They need to advised to change their lifestyle, to eat healthy, to exercise, to stop
smoking and to be compliant with their maintenance medications.
➢ The best way to prevent hypertensive emergencies is to remain compliant to
antihypertensive medications to prevent kidney impairment, stroke and death.
Thank you!