Accerlerated hypertension

1. ACCERLERATED
HYPERTENSION
Dr. Sachin Verma MD, FICM, FCCS, ICFC
Fellowship in Intensive Care Medicine
Infection Control Fellows Course
Consultant Internal Medicine and Critical Care
Ivy Hospital Sector 71 Mohali
Web:- http://www.medicinedoctorinchandigarh.com
Mob:- [phone]
1

2. Hypertension is defined as a usual BP of
140/90 mm Hg or more.
In children and adolescents
Hypertension ▬ average SBP and/or DBP is
≥95th percentile for sex, age, and height on 3 or
more occasions.
Prehypertension ▬
Children with average SBP or DBP levels are
≥90th percentile, but <95th percentile.
Adolescents with BP levels ≥120/80 mmHg.
2

3. Blood Pressure Classification
Blood
Pressure
Classification
SBP mmHgDBP mmHg Lifestyle
Modification
Initial drug therapy
Without Compelling
Indication
With Compelling
Indications
Normal <120 and <80 Encourage
No antihypertensive
drug indicated.
Drug(s) for compelling
indications.‡
Prehypertension120–139 or 80–89 Yes
Stage 1
hypertension
140–159 or 90–99 Yes Thiazide-type diuretics
for most. May consider
ACEI, ARB, BB, CCB,
or combination.
Drug(s) for the compelling
indications.‡
Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB)
as needed.
Stage 2
hypertension
≥160 or ≥100 Yes Two-drug combination
for most† (usually
thiazide-type diuretic
and ACEI or ARB or BB
or CCB).
Isolated systolic
hypertension
≥140 and <90
* Treatment determined by highest BP category.
† Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡ Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
3

4. Classification of blood pressure
This classification of BP is for adults ages 18
and older.
The classification is based on the average of two
or more properly measured, seated BP readings
on each of two or more office visits.
Patients with prehypertension are at increased
risk for progression to hypertension; those in the
130–139/80–89 mmHg BP range are at twice
the risk to develop hypertension as those with
lower values.
4

5. Hypertensive crises encompass a spectrum of
clinical presentations where uncontrolled BPs
lead to progressive or impending target organ
dysfunction (TOD).
Hypertensive emergency represent severe
HTN with acute impairment of an organ system
(eg, central nervous system, cardiovascular,
renal). In these conditions, the BP should be
lowered aggressively within 1 hours.
Hypertensive urgency is defined as a severe
elevation of BP, without evidence of
progressive TOD. These patients require BP
control over several days to weeks.
5

6. 6
Accelerated-Malignant Hypertension
A syndrome associated with an abrupt increase of
blood pressure in a patient with underlying
hypertension or related to the sudden onset of
hypertension in a previously normotensive
individual.
When the rise in pressure causes retinal
hemorrhages, exudates, or papilledema, the term
accelerated-malignant hypertension is used
The absolute level of blood pressure is not as
important as its rate of rise.

7. Pathologically, the syndrome is associated with
diffuse necrotizing vasculitis, arteriolar thrombi, and
fibrin deposition in arteriolar walls (arterioles of
kidney, brain, retina, and other organs).
Clinically, the syndrome is recognized by progressive
retinopathy (arteriolar spasm, hemorrhages,
exudates, and papilledema), deteriorating renal
function with proteinuria, microangiopathic hemolytic
anemia, and encephalopathy.
In these patients, historic inquiry should include
questions about the use of monamine oxidase
inhibitors and recreational drugs (e.g., cocaine,
amphetamines).
7

8. Why is it Important to control Blood
Pressure ?
Reduce stroke incidence by 35-40%
Reduce MI by 20-25 %
Reduce Heart Failure by 50 %
8

9. What is the proper way of taking
Blood Pressure ?
1.Instruments should be properly calibrated.
2.Patients should be seated quietly for at
least 5 minutes.
3.Seated on a chair with arms supported at
heart level and feet planted on the floor.
4.Appropriate cuff size. (encircling at least
80% of area)
5.At least two measurements should be
made.
9

10. Ambulatory blood pressure
monitoring(ABPM)
It provides information about BP during daily activities and sleep
and ambulatory BP values are usually lower than clinic readings.
Warranted for evaluation of “white-coat” hypertension in the
absence of target organ injury.
To assess patients with apparent drug resistance, hypotensive
symptoms with antihypertensive medications, episodic
hypertension, and autonomic dysfunction.
Correlates better than office measurements with target organ
injury.
Awake, individuals with hypertension have an average BP of more
than 135/85 mmHg and during sleep, more than 120/75 mmHg.
In most individuals, BP decreases by 10 to 20 percent during the
night; those in whom such reductions are not present are at
increased risk for cardiovascular events.
10

11. Three Objectives in Evaluating Patients
with Documented Hypertension
1.To assess the lifestyle & identify other
cardiovascular risk factors or
concomitant disorders that may affect
prognosis & guide treatment.
2.To reveal identifiable causes of high BP.
3.To asses the presence or absence of
target organ damage & CVD.
11

12. Cardiovascular Risk Factors
12
Major Risk Factors
•Hypertension*
•Cigarette smoking
•Obesity* (body mass index ≥30 kg/m2)
•Physical inactivity
•Dyslipidemia*
•Diabetes mellitus*
•Microalbuminuria or estimated GFR <60 mL/min
•Age (older than 55 for men, 65 for women)
•Family history of premature cardiovascular disease
(men under age 55 or women under age 65)

13. Target Organ Damage
13
Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularization
• Heart failure
Brain
• Stroke or transient ischemic attack
Peripheral arterial disease
Chronic kidney disease
Retinopathy

14. Blood Pressure Variability and Its
Determinants
Nicotine in cigarette smoke (10 to 20 mm
Hg rise in BP with every single cigarette)
Alcohol consumption
Caffeine consumption (only a small
transient rise in BP).

Habitual physical inactivity (in part because
of weight gain).
Excessive consumption of calories and
salt.
14

15. Types of Hypertension
In ~80–95% of hypertensive patients are diagnosed as
having "essential" hypertension (also referred to as
primary or idiopathic hypertension).
In the remaining 5–20% of hypertensive patients, a
specific underlying disorder causing the elevation of
blood pressure can be identified.
In individuals with "secondary" hypertension, a
specific mechanism for the blood pressure elevation is
often more apparent. Renal disease is the most common
cause of secondary hypertension.
15

16. Identifiable causes of hypertension
•Sleep apnea
•Drug-induced or related causes (see table 9)
•Chronic kidney disease
•Primary aldosteronism
•Renovascular disease
•Chronic steroid therapy and Cushing’s syndrome
•Pheochromocytoma
•Coarctation of the aorta
•Thyroid or parathyroid disease
16

17. Systolic Hypertension with Wide
Pulse Pressure
1. Decreased vascular compliance (arteriosclerosis)
2. Increased cardiac output
a. Aortic regurgitation
b. Thyrotoxicosis
c. Hyperkinetic heart syndrome
d. Fever
e. Arteriovenous fistula
f. Patent ductus arteriosus
17

18. Secondary Causes of Systolic and
Diastolic Hypertension
Renal Parenchymal diseases, renal cysts (including polycystic kidney
disease), renal tumors (including renin-secreting tumors), obstructive
uropathy
Renovascular Arteriosclerotic, fibromuscular dysplasia
Adrenal Primary aldosteronism, Cushing's syndrome, 17-hydroxylase
deficiency, 11-hydroxylase deficiency, 11-hydroxysteroid
dehydrogenase deficiency (licorice), pheochromocytoma
Aortic coarctation
Obstructive sleep apnea
Preeclampsia/eclampsia
Neurogenic Psychogenic, diencephalic syndrome, familial dysautonomia,
polyneuritis (acute porphyria, lead poisoning), acute increased
intracranial pressure, acute spinal cord section
Miscellaneous endocrine Hypothyroidism, hyperthyroidism, hypercalcemia, acromegaly
Medications High-dose estrogens, adrenal steroids, decongestants, appetite
suppressants, cyclosporine, tricyclic antidepressants, monamine
oxidase inhibitors, erythropoietin, nonsteroidal anti-inflammatory
agents, cocaine
Mendelian forms of hypertension
18

19. Diagnosis
Diagnostic Procedure
Initial Additional
Chronic renal diseaseUrinalysis, serum creatinine, renal
sonography
Isotopic renography, renal biopsy
Renovascular diseaseRenal sonography Magnetic resonance or computed
tomography (CT) angiography,
aortographyDuplex Doppler sonography
Endocrine Serum sodium, potassium, calcium,
TSH
Metabolic Fasting blood glucose, total
cholesterol, HDL and LDL (often
computed) cholesterol, triglycerides
Coarctation Blood pressure in legs Echocardiography, magnetic resonance
imaging or contrast aortography
Primary aldosteronismPlasma and urinary potassium, plasma renin
and aldosterone
Urinary aldosterone after oral salt load,
adrenal CT, adrenal venous sampling
Cushing syndrome Morning plasma cortisol after 1 mg
dexamethasone at bedtime
Urinary cortisol after variable doses of
dexamethasone, adrenal CT, and
scintiscans
Pheochromocytoma Plasma-free metanephrine
Urine metanephrines and catechols
Plasma normetanephrine (basal and after
0.3 mg clonidine)
Other Hematocrit, electrocardiogram
19

20. Other laboratory tests may include
cardiac enzymes
For cushing's syndrome- 24-h excretion rates of
urine free cortisol or an overnight dexamethasone-
suppression test and late night salivary cortisol
(sensitive and convenient screening test)
For pheochromocytoma- 24-hour urine collection
for vanillylmandelic acid and catecholamines.
Chest radiograph - cardiac enlargement,
pulmonary edema, or involvement of other
thoracic structures, such as rib notching with aortic
coarctation or a widened mediastinum with aortic
dissection.
20

21. As a screening test, Renal blood flow may be
evaluated with a radionuclide [
131
I]-ortho iodo
hippurate (OIH) scan. or Glomerular filtration rate
may be evaluated with [
99m
Tc]-diethylene triamine
pentaacetic acid (DTPA) scan, before and after a
single dose of captopril .
Doppler ultrasound of the renal arteries produces
reliable estimates of renal blood flow velocity and .
 To track a renal artery lesion Gadolinium-contrast
magnetic resonance angiography, Contrast
arteriography remains the "gold standard" for
evaluation and identification of renal artery lesions.
21

22. Physical Examination Recommended
1.BP measurement / includes contralateral arm
2.Examination of optic disc
3.Calculation of BMI (Wt (Kg)/sq (Ht(m))
4.Auscultation ( carotid, renal & femoral bruits)
5.Palpation of thyroid gland
6.Examination of Heart & Lungs
7.Examination of Abdomen
8.Lower extremities
9.Neurological assessment
22

23. ABSTRACT
The “Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure” a new guideline for hypertension
prevention and management. The following are the
report’s key messages:
In persons older than 50 years, systolic blood pressure
greater than 140 mmHg is a much more important
cardiovascular disease (CVD) riskfactor than diastolic
blood pressure.
The risk of CVD beginning at 115/75 mmHg doubles with
each increment of 20/10 mmHg; individuals who are
normotensive at age 55 have a 90 percent lifetime risk for
developing hypertension.
23

24. Individuals with a systolic blood pressure of 120–
139 mmHg or a diastolic blood pressure of 80–89
mmHg should be considered as prehypertensive
and require health-promoting lifestyle modifications
to prevent CVD.
Thiazide-type diuretics should be used in drug
treatment for most patients with uncomplicated
hypertension, either alone or combined with drugs
from other classes.
Certain high-risk conditions are compelling
indications for the initial use of other
antihypertensive drug classes (angiotensin
converting enzyme inhibitors, angiotensin receptor
blockers,beta-blockers, calcium channel blockers).
24

25. Most patients with hypertension will require
two or more antihypertensive medications to
achieve goal blood pressure (<140/90 mmHg,
or <130/80 mmHg for patients with diabetes
or chronic kidney disease).
If blood pressure is >20/10 mmHg above goal
blood pressure, consideration should be
given to initiating therapy with two agents,
one of which usually should be a thiazide-type
diuretic.
The most effective therapy will control
hypertension only if patients are motivated. 25

26. Goals in Therapy
1. Reduction of Cardiovascular &
Renal Morbidity & Mortality.
2. For >50 year old, the focus is SBP
control.
3. <140/90 mmHg
4. <130/80 mmHg for patients with
hypertension, DM & renal disease.
26

27. Algorithm for Treatment of Hypertension
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
With Compelling
Indications
Lifestyle Modifications
Stage 2 Hypertension
(SBP >160 or DBP >100 mmHg)
2-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension
(SBP 140–159 or DBP 90–99
mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling
Indications
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension
specialist.
27

28. Hypertension: Treatment
Lifestyle Interventions
Lifestyle modifications are the first line of treatment in
hypertension.
Implications for both the prevention and treatment of
hypertension.
Recommended for individuals with pre-hypertension and
as an adjunct to drug therapy in hypertensive individuals.
According to the JNC, lifestyle modifications can reduce
systolic blood pressure from a low of 2-8 mm Hg for
dietary sodium restriction, to a high of 5-20 mm Hg for
weight reduction.
28

29. Life Style Modifications

30. Dietary Approaches to Stop
Hypertension (DASH Diet)
Promotes fruits, vegetables, whole grains and low fat dairy
products. Low in saturated fat, cholesterol, and total fat.
Rich in Calcium, Potassium, Magnesium, protein, and
fiber.
Low in red meat, sweets and sugar beverages.
Lowering homocysteine with DASH may reduce CVD risk
an additional 7%-9%.
Fully compatible with dietary recommendations for
reducing risk of CVD, osteoporosis and cancer.
Lowers systolic BP in normotensive patients by an
average of 3.5 mm Hg and in hypertensive patients by
11.4 mm Hg.
30

31. Pharmacologic Therapy
Drug therapy is recommended for individuals with blood
pressures ≥140/90 mmHg. The degree of benefit derived
from antihypertensive agents is related to the magnitude
of the blood pressure reduction.
Lowering systolic blood pressure by 10–12 mmHg and
diastolic blood pressure by 5–6 mmHg confers relative
risk reductions of 35–40% for stroke and 12–16% for
CHD within 5 years of initiating treatment. Risk of heart
failure is reduced by >50%.
Low-dose aspirin therapy should be considered only
when BP is controlled, because the risk of hemorrhagic
stroke is increased in patients with uncontrolled
hypertension.
31

32. Thiazide-type diuretics have been the basis of antihypertensive
therapy in most outcome trials. In these trials, including the recently
published Antihypertensive and Lipid Lowering Treatment to
Prevent Heart Attack Trial (ALLHAT), diuretics have been virtually
unsurpassed in preventing the cardiovascular complications of
hypertension.
Diuretics enhance the antihypertensive efficacy of multidrug
regimens, can be useful in achieving BP control, and are more
affordable than other antihypertensive agents.
Thiazide-type diuretics should be used as initial therapy for most
patients with hypertension, either alone or in combination with one
of the other classes (ACEIs, ARBs, BBs, CCBs) demonstrated to be
beneficial in randomized controlled outcome trials.
32

33. Blood Pressure Goals of
Antihypertensive Therapy
The maximum protection against combined cardiovascular
endpoints is achieved with pressures <135–140 mmHg for
systolic blood pressure and <80–85 mmHg for diastolic blood
pressure.
More aggressive blood pressure targets for blood pressure
control (< 130/80 mmHg) may be appropriate for patients with
diabetes, CHD, chronic kidney disease, or with additional
cardiovascular disease risk factors.
In diabetic patients, effective blood pressure control reduces
the risk of cardiovascular events and death as well as the risk
for microvascular disease (nephropathy, retinopathy). Risk
reduction is greater in diabetic than in nondiabetic individuals.
33

34. Clinical Trial & Guideline basis for compelling
Indications for individual Drug Classes
34

35. Heart failure
Heart failure(HF), in the form of systolic or diastolic
ventricular dysfunction, results primarily from
systolic hypertension and IHD. Fastidious BP and
cholesterol control are the primary preventive
measures for those at high risk for HF.
In asymptomatic individuals with demonstrable
ventricular dysfunction, ACEIs and BBs are
recommended.
For those with symptomatic ventricular dysfunction
or end-stage heart disease, ACEIs, BBs, ARBs and
aldosterone blockers are recommended along with
loop diuretics.
35

36. Diabetic Hypertension
Combinations of two or more drugs are usually
needed to achieve the target goal of <130/80
mmHg.
Thiazide diuretics, BBs, ACEIs, ARBs, and
CCBs are beneficial in reducing CVD and stroke
incidence in patients with diabetes.
ACEI- or ARB-based treatments favourably
affect the progression of diabetic nephropathy
and reduce albuminuria, and ARBs have been
shown to reduce progression to
macroalbuminuria. 36

37. Chronic Kidney Disease
In people with chronic kidney disease (CKD), as
defined by either
(1) reduced excretory function with an estimated
GFR below 60 ml/min per 1.73 m2 (corresponding
approximately to a creatinine of >1.5 mg/dL in men
or >1.3 mg/dL in women), or
(2) the presence of albuminuria (>300 mg/day or
200 mg albumin/g creatinine).
Therapeutic goals are to slow deterioration of renal
function and prevent CVD. Hypertension appears in
the majority of these patients, and they should
receive aggressive BP management, often with ≥3
drugs to reach target BP values <130/80 mmHg.
37

38. ACEIs and ARBs have demonstrated favorable
effects on the progression of diabetic and
nondiabetic renal disease. A limited rise in
serum creatinine of as much as 35 percent
above baseline with ACEIs or ARBs is
acceptable and is not a reason to withhold
treatment unless hyperkalemia develops.
With advanced renal disease (estimated GFR
<30 ml/min 1.73 m2, corresponding to a serum
creatinine of 2.5–3 mg/dL), increasing doses of
loop diuretics are usually needed in combination
with other drug classes. 38

39. Cerebrovascular Disease
Control of BP at intermediate levels
(approximately 160/100 mmHg) is
appropriate until the condition has
stabilized or improved.
Recurrent stroke rates are lowered by the
combination of an ACEI and thiazide-type
diuretic.
39

40. Obesity and the metabolic syndrome
Obesity (BMI >30 kg/m2) is an increasingly prevalent
risk factor for the development of hypertension and
CVD.
Metabolic syndrome as the presence of three or more
of the following conditions: abdominal obesity (waist
circumference >40 inches in men or >35 inches in
women), glucose intolerance (fasting glucose >110
mg/dL), BP >130/85 mmHg, high triglycerides (>150
mg/dL), or low HDL (<40 mg/dL in men or <50 mg/dL
in women).
Intensive lifestyle modification should be pursued in all
individuals with the metabolic syndrome, and
appropriate drug therapy should be instituted for each
of its components as indicated.
40

41. Left ventricular hypertrophy
Left ventricular hypertrophy (LVH) is an
independent risk factor that increases the
risk of subsequent CVD.
Regression of LVH occurs with
aggressive BP management, including
weight loss, sodium restriction, and
treatment with all classes of
antihypertensive agents except the direct
vasodilators hydralazine, and minoxidil.
41

42. Peripheral arterial disease
Peripheral arterial disease (PAD)
is equivalent in risk to IHD. Any
class of antihypertensive drugs
can be used in most PAD patients.
Other risk factors should be
managed aggressively, and aspirin
should be used.
42

43. Hypertension in older persons
Hypertension occurs in more than two-thirds of
individuals after age 65. This is also the population
with the lowest rates of BP control.
Treatment recommendations for older people with
hypertension, including those who have isolated
systolic hypertension, should follow the same
principles outlined for the general care of
hypertension.
In many individuals, lower initial drug doses may be
indicated to avoid symptoms; however, standard
doses and multiple drugs are needed in the majority
of older people to reach appropriate BP targets.
43

44. Postural hypotension
A decrease in standing SBP >10 mmHg, when
associated with dizziness or fainting, is more
frequent in older patients with systolic
hypertension, diabetes, and those taking
diuretics, venodilators (e.g., nitrates, alpha-
blockers, and sildenafil like drugs), and some
psychotropic drugs.
BP in these individuals should also be monitored
in the upright position. Caution should be used to
avoid volume depletion and excessively rapid
dose titration of antihypertensive drugs.
44

45. Dementia
Dementia and cognitive
impairment occur more commonly
in people with hypertension.
Reduced progression of cognitive
impairment may occur with
effective antihypertensive therapy.
45

46. Hypertension in women
Oral contraceptives may increase BP, and the
risk of hypertension increases with duration of
use. Women taking oral contraceptives should
have their BP checked regularly.
Development of hypertension is a reason to
consider other forms of contraception. In
contrast, menopausal hormone therapy does
not raise BP.
Women with hypertension who become
pregnant should be followed carefully because
of increased risks to mother and fetus.
46

47. Methyldopa, BBs, and vasodilators are preferred
medications for the safety of the fetus ACEI and ARBs
should not be used during pregnancy because of the
potential for fetal defects and should be avoided in
women who are likely to become pregnant.
Preeclampsia, which occurs after the 20th week of
pregnancy, is characterized by new-onset or
worsening hypertension, albuminuria, and
hyperuricemia, sometimes with coagulation
abnormalities.
In some patients, preeclampsia may develop into a
hypertensive urgency or emergency and may require
hospitalization, intensive monitoring, early fetal
delivery, and parenteral antihypertensive and
anticonvulsant therapy
47

48. Hypertension in children and
adolescents
Lifestyle interventions are strongly
recommended, with pharmacologic
therapy instituted for higher levels of BP or
if there is insufficient response to lifestyle
modifications.
Choices of antihypertensive drugs are
similar in children and adults, but effective
doses for children are often smaller and
should be adjusted carefully.
48

49. Hypertensive emergency
Although blood pressure should be lowered rapidly
in patients with hypertensive encephalopathy,
there are inherent risks of overly aggressive
therapy.
In hypertensive individuals, the upper and lower
limits of autoregulation of cerebral blood flow are
shifted to higher levels of arterial pressure, and
rapid lowering of blood pressure to below the lower
limit of autoregulation may precipitate cerebral
ischemia or infarction. Renal and coronary blood
flows may also decrease with overly aggressive
acute therapy. 49

50. The initial goal of therapy is to reduce
mean arterial blood pressure by no more
than 25% within minutes to 2 h or to a
blood pressure in the range of 160/100–
110 mmHg.
In patients with malignant hypertension
without encephalopathy or some other
catastrophic event, it is preferable to
reduce blood pressure over hours or
longer rather than minutes.
50

51. Acute, transient blood pressure elevations, lasting
days to weeks, frequently occur following thrombotic
and hemorrhagic strokes. Autoregulation of cerebral
blood flow is impaired in ischemic cerebral tissue,
and higher arterial pressures may be required to
maintain cerebral blood flow. Aggressive reductions
of blood pressure are to be avoided.
In the absence of other indications for acute therapy,
for patients with cerebral infarction who are not
candidates for thrombolytic therapy, one
recommended guideline is to institute
antihypertensive therapy only when a systolic blood
pressure > 220 mmHg or a diastolic blood pressure
> 130 mmHg.
51

52. If thrombolytic therapy is to be used, the
recommended goal blood pressure is
<185 mmHg systolic pressure and <110
mmHg diastolic pressure.
In patients with hemorrhagic stroke,
suggested guidelines for initiating
antihypertensive therapy are systolic >
180 mmHg or diastolic pressure > 130
mmHg.
52

53. The management of hypertension after
subarachnoid hemorrhage is controversial.
Cautious reduction of blood pressure is
indicated if mean arterial pressure is >130
mmHg.
In addition to pheochromocytoma, an
adrenergic crisis due to catecholamine excess
may be related to cocaine or amphetamine
overdose, clonidine withdrawal, acute spinal
cord injuries, and an interaction of tyramine-
containing compounds with monamine oxidase
inhibitors. These patients may be treated with
phentolamine or nitroprusside.
53

54. Preferred Parenteral Drugs for Selected
Hypertensive Emergencies
Hypertensive encephalopathy Nitroprusside, nicardipine, labetalol
Malignant hypertension (when IV therapy is
indicated)
Labetalol, nicardipine, nitroprusside,
enalaprilat
Stroke Nicardipine, labetalol, nitroprusside
Myocardial infarction/unstable anginaNitroglycerin, nicardipine, labetalol, esmolol
Acute left ventricular failure Nitroglycerin, enalaprilat, loop diuretics
Aortic dissection Nitroprusside, esmolol, labetalol
Adrenergic crisis Phentolamine, nitroprusside
Postoperative hypertension Nitroglycerin, nitroprusside, labetalol,
nicardipine
Preeclampsia/eclampsia of pregnancy Hydralazine, labetalol, nicardipine
54

55. Intravenous Doses of Antihypertensive
Agents Used in Hypertensive
Emergencies
Antihypertensive AgentIntravenous Dose
Nitroprusside Initial 0.3 (g/kg)/min; usual 2–4 (g/kg)/min; maximum 10
(g/kg)/min for 10 min
Nicardipine Initial 5 mg/h; titrate by 2.5 mg/h at 5–15 min intervals; max 15
mg/h
Labetalol 2 mg/min up to 300 mg or 20 mg over 2 min, then 40–80 mg at
10-min intervals up to 300 mg total
Enalaprilat Usual 0.625–1.25 mg over 5 min every 6–8 h; maximum 5
mg/dose
Esmolol Initial 80–500 g/kg over 1 min, then 50–300 (g/kg)/min
Phentolamine 5–15 mg bolus
Nitroglycerin Initial 5 g/min, then titrate by 5 g/min at 3–5 min intervals; if no
response is seen at 20 g/min, incremental increases of 10–20
g/min may be used
Hydralazine 10–50 mg at 30-min intervals
55

56. Drug
class
Examples Usual Total Daily
Dose (Dosing
Frequency/Day)
Other
Indications
Contraindicati
ons/Cautions
Diuretics
ThiazidesHydrochlorothiazide6.25–50 mg (1–2) Diabetes,
dyslipidemia,
hyperuricemia,
gout,
hypokalemia
Chlorthalidone 25–50 mg (1)
Loop
diuretics
Furosemide 40–80 mg (2–3) CHF, renal
failure
Diabetes,
dyslipidemia,
hyperuricemia,
gout,
hypokalemia
Ethacrynic acid 50–100 mg (2–3)
Aldosterone
antagonists
Spironolactone 25–100 mg (1–2) CHF, primary
aldosteronism
Renal failure,
hyperkalemia
Eplerenone 50–100 mg (1–2)
K
+
retaining

Amiloride 5–10 mg (1–2) Renal failure,
hyperkalemia
Triamterene 50–100 mg (1–2)
56

57. Drug Class Examples Usual Total
Daily Dose
(Dosing
Frequency/Day)
Other
Indications
Contraindications
/Cautions
Beta
blockers
Asthma, COPD, 2nd
or 3rd degree heart
block, sick-sinus
syndrome
Cardioselectiv
e
Atenolol 25–100 mg (1)Angina, CHF,
post-MI, sinus
tachycardia,
ventricular
tachyarrhythmias
Metoprolol 25–100 mg (1–2)
NonselectivePropranolol40–160 mg (2)
Propranolol LA60–180 (1)
Combined
alpha/beta
Labetalol 200–800 mg (2)? Post-MI, CHF
Carvedilol 12.5–50 mg (2)
Alpha
antagonists

Selective Prazosin 2–20 mg (2–3)Prostatism
Doxazosin 1–16 mg (1)
Terazosin 1–10 mg (1–2)
NonselectivePhenoxybenza
mine
20–120 mg (2–3)Pheochromocyto
ma

57

58. Drug Class Examples Usual Total
Daily Dose

(Dosing
Frequency/Day)
Other
Indications
Contraindication
s/Cautions
Sympatholytics


Central Clonidine 0.1–0.6 mg (2)
Clonidine patch0.1–0.3 mg
(1/week)

Methyldopa 250–1000 mg (2)
Reserpine 0.05–0.25 mg (1)
Guanfacine 0.5–2 mg (1)
ACE inhibitors Captopril 25–200 mg (2) Post-MI, CHF,
nephropathy
Renal failure,
bilateral renal artery
stenosis,
pregnancy,
hyperkalemia
Lisinopril 10–40 mg (1)
Ramipril 2.5–20 mg (1–2)
Angiotensin II
antagonists
Losartan 25–100 mg (1–2)CHF, diabetic
nephropathy,
ACE inhibitor
cough
Renal failure,
bilateral renal artery
stenosis,
pregnancy,
hyperkalemia
Valsartan 80–320 mg (1)
Candesartan 2–32 mg (1–2)
58

59. Drug Class Examples Usual Total
Daily Dose

(Dosing
Frequency/Day)
Other
Indications
Contraindicati
ons/Cautions
Calcium antagonists Heart failure, 2d
or 3d degree
heart block
Dihydropyridines Nifedipine
(long acting)
30–60 mg (1) Angina
NondihydropyridinesVerapamil
(long acting)
120–360 mg (1–
2)
Post-MI,
supraventricul
ar
tachycardias,
angina
Diltiazem(long
-acting)
180-420 mg (1)
Direct vasodilators Hydralazine25–100 mg (2) Severe coronary
artery disease
Minoxidil 2.5–80 mg (1–2) 59

60. Resistant Hypertension
Blood pressure persistently >140/90
mmHg despite taking three or more
antihypertensive agents, including a
diuretic, in reasonable combination and at
full doses.
Exclusion of identifiable cause of HTN
More common in patients >60 years
60

61. Causes of Resistant Hypertension
61

62. Followup and Monitoring
Once antihypertensive drug therapy is initiated, most patients
should return for followup and adjustment of medications at
approximately monthly intervals until the BP goal is reached.
More frequent visits will be necessary for patients with stage
2 hypertension or with complicating comorbid conditions.
Serum potassium and creatinine should be monitored at least
1–2 times/year.
After BP is at goal and stable, followup visits can usually be
at 3- to 6-month intervals.
Comorbidities, such as heart failure, associated diseases
such as diabetes, and the need for laboratory tests influence
the frequency of visits. Other cardiovascular risk factors
should be treated to their respective goals, and tobacco
avoidance should be promoted vigorously. 62

63. THANKS
63