HTN EMERGENCIES AND URGENCIES

1. HYPERTENSION EMERGENCIES and HYPERTENSION URGENCIES Case based approach and management

2. Introduction Hypertension is the most common modifiable risk factor for cardiovascular diseases. Most common indication for adults to visit a physician. Its prevalence will continue to increase ,both among the young because of increasing obesity and in older adults because of longer life expectancy . Despite being common, it is inadequately treated.

3. Epidemiology Approximately 1% hypertension pts may develop hypertensive crises during their lifetime. Annual incidence of hypertensive emergencies being 1-2 cases/1,00,000 pts. Higher rates have been reported in African Americans, low socioeconomic people, in developing countries. Incidence in men 2 times higher than in women Curr Opin Cardiol 2006; Curr Hypertens Rep 2003;

4. Joseph varon et al.Critical care 2008

5. Hypertensive Crises More generalised term . Not defined by a specific blood pressure reading, rather it is a clinical syndrome that is associated with acute elevation of blood pressure. It includes Hypertensive Emergency Hypertensive Urgency

6. Characterised by severe increase in systolic and/or diastolic blood pressure assosciated with signs or symptoms of acute end-organ damage. No blood pressure threshold for diagnosis. Usually, SBP > 180-220 mm Hg DBP > 120-130mm Hg MAP > 180 mm Hg Requires an immediate BP reduction in few minutes –hours . Requires an ICU care. IV drugs Hypertensive Emergency

7. Hypertensive Emergencies Hypertensive encephalopathy Hypertension assosciated with acute cerebrovascular disease Hypertension assosciated with pulmonary edema Hypertension assosciated with acute coronary syndromes Hypertension assosciated with dissecting aortic aneurysm Pheochromocytoma Hypertension associated with acute renal failure Eclampsia Microangiopathic anemia

8. What is the primary reason for hypertensive emergencies ? Renovascular Disease Pheochromocytoma Non-adherence to anti-hypertensive medication Hyperaldosteronism Erythropoeitin

9. Hypertensive Urgency Severe elevation in BP >180/120 mm Hg without symptoms or signs of acute target organ involvement. Adequate treatment of these conditions, a BP lowering within 24 hrs by administration of oral drugs. ICU admission is usually not required.

10. Hypertensive Urgency Severe uncomplicated essential hypertension Severe uncomplicated secondary hypertension Postoperative hypertension Hypertension assosciated with severe epistaxis Drug induced hypertension Rebound hypertension ( i.e sudden withdrawal of clonidine ) Cessation of prior antihypertensive therapy Anxiety ,panic attacks or pain

11. Why rapid reduction of BP not recommended in absence of end organ damage?? An aggressive approach. A precipitous and unpredictable BP fall Harmful ( esp . In pts with multiple risk factors) Cardiol clinics 2006;24:135-46.

12. Accelerated - Malignant Hypertension Severe hypertension and presence of retinopathy . Exudates,hemorrhages – Accelerated hypertension. Papilledema – Malignant hypertension.

13. Acute target organ damage in hypertension Target organ Complications Brain Hypertensive encephalopathy Cerebral infarction Cerebral hemorrhage Advanced retinopathy Heart Acute coronary syndrome Acute heart failure Aorta Aortic dissection Kidney Acute renal failure Placenta Eclampsia

14. Single organ inv. in approximately 83%. Two organ inv. found in 14% ,multiorgan inv. in 3 % pts. Most common clinical presentations - cerebral infarction (24%) - pulmonary oedema (22%) - HTN encephalopathy (16%) - Cong. HF (12%) Less common presentations – IC hemorrhage , Aortic dissection and Eclampsia ESC/ESH 2013

15. Joseph varon et al.Critical care 2008

16. Etiology Essential hypertension : Inadequate blood pressure control and noncompliance are common precipitants (MOST COMMON) Renovascular Eclampsia /pre- eclampsia Acute glomerulonephritis Pheochromocytoma Anti-hypertensive withdrawal syndromes Head injuries and CNS trauma Renin -secreting tumors Drug-induced hypertension Burns Vasculitis Post-op hypertension Coarctation of aorta (very rare) 2 nd common

17. Unclear , but some candidates ACE DD genotype Absence of the β and γ subunit of ENaC Elevated adrenomedullin levels Elevated natriuretic peptide level Abnormalities in oxidative stress markers and endothelial dysfunction Vaughan and Delanty Lancet 2000; 356:411 Why only some are affected?

18. Pathophysiology Activation of coagulation cascade,platelets Deposition of fibrin IL-6 PRESSURE NATRIURESIS End organ hypoperfusion , ischemia, dysfunction Increase in SVR Humoral factors Vaughan and Delanty Lancet 2000; 356:411 Fibrinoid necrosis

19. Vaughan and Delanty Lancet 2000; 356:411

20. CASE 1 A 65 yr old male, hypertensive , chronic smoker, driver by occupation admitted in ED with c/o headache since 3 days ,increased in severity over the past one day , associated with vomitings and altered sensorium . He has been noncompliant to drugs since 15 days. At presentation his pulse rate was 70/ min,regular , BP recording was 240/140 mm Hg, CVS- being normal on auscultation, lungs b/l basal crepts . What is the diagnosis ?What would you do ? Admit ? What would be BP goal in this patient?

21. CASE 2 A 38 yr old male,daily labourer , hypertensive since past 6yrs,came for follow up at OPD. His BP was 180/100 mm Hg . ECG showed LV strain. No symptoms of SOB on exertion,angina . Admit ?/ OPD Rx ? IV drugs / oral?

22. CASE 3 A 28 yr old female, primi (6 months amenorrhea) was referred to physician with c/o headache,vomitings,decreased urine output. her BP was recorded to be 170/100 mm Hg CBP – leucocytosis,low platelets. CUE –pus cells,RBC LFT – mildly raised aminases,bilirubin being 2.8mg/dl ECG –sinus tachycardia ,LVH with strain. 2Decho – concentric LVH. What to do ? Admit ? Normalize BP ?

23. CASE 4 A 54 yr old male was admitted in ED with c/o weakness of right upper limb and lower limb since morning, Known hypertensive,diabetic . Alcoholic Was unconscious, BP was 190/100 mm Hg CT brain – large MCA territory ischemic infarct What to do ? Normalize BP?

24. CASE 5 A 45 yr old male ,K/C/O CAD, hypertensive,diabetic , smoker came with sudden onset of ripping pain, sharp sensation in the back, along with SOB class IV. At presentation BP was 240/140 mm Hg Pulses discreprenancy on palpation. What to do ? Normalize BP ?

25. CASE 6 A 23 yr old male,degree student, was brought to casualty with sudden onset of SOB since 2 hours,saturations at room air were normal. BP – 180/100 mm Hg CVS/RS –NAD What to do ? IV/oral/reassurance

26. Clinical assessment Complete history collection Detailed physical examination Duration and degree of pre existing hypertension Evidence of target organ damage Details of antihypertensive therapy Compliance with medications Use of the over counter drugs Illicit drugs usage

27. Symptom End organ damage Chest pain Acute myocardial infarction Myocardial ischemia Thoracic aortic dissection Back pain (ripping ) Thoracic aortic dissection Dyspnea Acute pulmonary edema Delirium,nausea,vomiting,seizures , altered consciousness Hypertensive encephalopathy Ischemic or hemorraghic stroke

28. Examination of pt BP sitting and standing position (if possible) with an appropriate size cuff in both arms(difference - aortic dissection). If peripheral pulses are markedly reduced (lower limb BP required). RR,HR O2 saturation Fundoscopic examination. CVS – murmurs (aortic insufficiency, ischemic MR) S3,gallop,crackles in lung fields, raised JVP (signs of HF) Renal bruit ( renovascular HTN) Abdominal mass (PCKD) Level of consciousness ,focal signs of ischemia

29. Joseph varon et al.Critical care 2008

30. ESC/ESH,2013

31. Keith-Wagener-Barker Classification Grade 1 Mild narrowing of the arterioles “Copper Wire” Grade 2 Moderate narrowing – Copper wire and AV nicking Changes associated with long standing essential hypertension Grade 3 Severe Narrowing - Silver wire changes, hemorrhage, cotton wool spots, hard exudates Grade 4 Grade 3 + Papilledema Grade 3 and 4 highly correlated with progression to end organ damage and decreased survival

32. Normal

33. Grade 1

34. Grade 2

35. Grade 3 KWB Retinopathy

36. Investigations Blood electrolytes Creatinine Urea nitrogen Cell count Smear ( microangiopathic hemolysis ) ECG CXR CT Brain CT chest/MRI

37. Management

38. Normalisation of BP is usually not recommended* How fast and how much BP to be lowered to be given importance. *Conditions apply

39. Why ?? Sudden fall in BP may cause acute hypoperfusion of vital organs and results in myocardial ischemia or infarction, hemiplegia,or acute renal failure. Older patients with long lasting hypertension and preclinical organ involvement (LVH, atherosclerosis and arteriolar remodelling ) are at risk of these complications as the lower limit of autoregulation shifted to right.

40. Appropriate treatment is dictated more by the features of the acute syndrome and by the patient’s characteristics than by a body of scientific evidence . Controlled trials not available (extremely heterogenous population) Tailored on individual patient Organ at risk. Varon J et al ; Crtical care 2003 ESC/ESH manual of Hypertension 2009

41. HYPERTENSIVE EMERGENCIES

42. Hypertensive Emergency Damage Heart - CHF, MI, angina Kidneys - acute kidney injury, microscopic hematuria CNS - encephalopathy, intracranial hemorrhage, Grade 3-4 retinopathy Vasculature - aortic dissection, eclampsia

43. GOAL reduce MAP by no more than 20-25%, DBP to 100-110mm Hg within few minutes to 2 hours. More aggressive and rapid BP reduction (Acute Pulmonary edema ,Aortic dissection) More slowly for acute cerebrovascular damages with monitoring of neurological status. Constant infusion of intravenous agents required (no intermittent IV boluses/oral/sublingual drugs- drastic BP fall).

44. Ideal drug Fast acting Easily titratable Rapidly reversible and safe No single agent has these characteristics

45. Sodium nitroprusside Potent short acting arterial and venous dilator (reduces pre- and after- load) Rapid onset of action.(seconds) Continuous intra-arterial BP monitoring required. Infusion chamber and tubing to be covered.  intracranial pressure (caution in intracerebral hemorrhage) Induces coronary steal (non selective coronary vasodilation ) Increases mortality in pts with acute MI. (NEJM,1982) Thiocyanate toxicity ( nausea,vomiting,lactic acidosis and altered mental status) Usually rare, seen in pts with renal ,hepatic dysfunction. Freiderich et al, Anesth Analo 1995:81:152-162

46. Fenoldopam A peripheral dopamine-1 receptor antagonist (DA1). {highly specific} 10 –fold more potent than dopamine as a renal vasodilator. Antihypertensive effect by combined natriuretic and vasodilatory effect (esp. intrarenal arteries) Not to be used as prophylactic agent for preventing CIN (CAFCIN Trial) Agent of choice in hypertensive emergencies assosciated with renal dysfunction. Adv effects – hypotension , hypokalemia Clin Invest 1993;72:60-64

47. Nicardipine Second generation DHP CCB. Strong cerebral and coronary vasodilation . Onset of action 5-15 min, Duration being 2-6 hrs. Increases both stroke volume and coronary blood flow with a favourable effect on myocardial oxygen balance. CAD with Systolic HF. C/I in Aortic stenosis . Dosage independent of weight. Infusion rate of 5mg/h – 2.5 mg/h increments every 5 min –max being 15 mg/h. IV Nicardipine maintained BP in Treatment range > IV Labetalol (CLUE trial) BMJ,2013 J Emerg Med 1987:5:463-473

48. Clevidipine Third generation, intravenous, dihydropyridine caclium channel antagonist. FDA approval (2008) Ultra short half life of about 1 min. Potent arterial vasodilation (no effect on venous capacitance, myocardial contractility)* No significant adverse effect on heart rate’. Injectable emulsion. 99.9% bound to protein. Safe in pts with renal,hepatic dysfunction. C/I –allergies to soy products,eggs and egg products,defective lipid metabolism. *Rivera et al .,2010,Polly et al 2011. 50mg/100ml

49. Dosage An IV infusion at 1–2 mg/hour is recommended for initiation and should be titrated by doubling the dose every 90 seconds . As the blood pressure approaches goal, the infusion rate should be increased in smaller increments and titrated less frequently. The maximum infusion rate for Cleviprex is 32 mg/hour . Most patients in clinical trials were treated with doses of 16 mg/hour or less. No more than 1000 mL (or an average of 21 mg/hour) of Cleviprex infusion is recommended per 24 hours.. Am J Cardiovascular Drugs 2009;9;117-134

50. Clevidipine ESCAPE1 (pre op), ESCAPE 2 (post op) plaebo controlled trials – 15% reduction in SBP within 6 min post infusion. Rivera et al.,2010. Levy et al .,2007 . ECLIPSE – Clevidipine maintained BP within target range with minimal excursions. Singla et al .,2008 VELOCITY study for hypertensive crises. Pollack et al .,2009 ACCELERATE trial –management of severe HTN with ICH Graffagnino et al ., 2009

51. Labetalol Combined selective 1 adrenergic and non selective β adrenergic receptor blocker (1:7). Hypotensive effect – in 2-5 min after IV admin. Maintains cardiac output (unlike other BB). Reduces SVR, but does not decrease PBF. Cerebral,renal,coronary blood flow maintained. Less placental transfer can be used in pregnancy induced HTN emergency. Metabolised by liver. Oral/IV. Drugs 1984,Suppl 2 :35-50.

52. Esmolol Ultrashort acting cardioselective β adrenergic blocking agent. Ideal β blocker in critical cases. Useful in severe postoperative HTN. Onset of action is within 60 sec Duration of action being 10-20min. Rapid hydrolysis of ester linkages by RBC esterases (metabolism), not dependent on renal or hepatic function. 0.5 to 1mg/kg loading dose over 1min,followed by an infusion -50ug/kg/min.(max 300ug/kg/min) Chest 1988;93:398-403

53. Not to use Sublingual Nifedipine Drug is poorly soluble, not absorbed through buccal mucosa Sudden uncontrolled and severe reductions in BP,may precipitate cerebral,renal and myocardial ischemic events. Lack of clinical documentation attesting to a benefit from its use. The Cardiorenal Advisory Committee of the FDA has concluded “that the practice of administering SL/oral nifedipine should be abandoned because this agent is not safe nor efficacious ”. Anaesth Clin North Am.1999.

54. SPECIAL SCENARIOS

55. Myocardial ischemia/infarction may be assosciated with HTN at presentation (usually in a previously HTN pt). High BP exacerbated by pain and agitation. IV Nitrates reducing systemic vascular resistances,LVpreload , improves coronary perfusion. B blockers may contribute to a fall in BP (reduces myocardial O2 consumption) BP control mandatory before thrombolysis (BP<180/100 mmHg). Vaughan et al Lancet 2000;356:411-7

56. Acute Cardiogenic Pulmonary Edema Ventilation Reduction of LV preload and afterload . IV nitrate, loop diuretics. Others – urapidil , nicardipine,sodium nitroprusside . {Urapidil  is a  sympatholytic antihypertensive drug. Peripheral α 1-adrenoceptor antagonist and a central 5-HT receptor agonist, does not elicit reflex tachycardia(weak  β 1adrenoceptor antagonist activity, effect on cardiac vagal drive).  Not approved by the  USFDA , but it is available in Europe }. Bolus 12.5-25 mg (50 mg),infusion 5-40mg/ h,onset 3-6 min,duration 4-6 hr . Salgado et al.Annals of intensive care 2013;3:17

57. Aortic Dissection Most dramatic and rapid fatal complication in HTN emergencies. Acute BP reduction reduces shear forces on damaged aorta. Aim of treatment to reduce SBP as rapidly as possible down to 100-110 mmHg , simultaneously control tachycardia resulting form the sympathetic activation. B blocker + vasodilator to be given Esmolol + nitroprusside would be a better combination . Hydralazine is C/I Circulation 2006;114:1384-89

58. Ischemic stroke BP elevations can occur in previously hypertensive and in normotensive pts. BP declines to pre stroke values within 3-4 days after an ischemic stroke. Severe HTN Rx controversial issue. Arch Intern Medicine 2003;163:211-216

59. Shift to right in case of chronic HTN

60. AHA recommendation Threshold for treatment BP > 220/120 mmHg Target BP should be a 10-15% lowering of BP . Raised ICP – MAP<130 (1 st 24hrs) No raised ICP – MAP<110 IV Labetalol or Nicardipine . IV tPA (if to be given) BP <185/110mm Hg. Stroke 2003;34:1056-83

61. IC bleed To prevent rebleeding and reduce edema formation. BP >180/105 mmHg ,may benefit from gradual 20-25% reduction in BP. Nimodipine , a dihydropyridine calcium blocker,is effective (antagonist effects on cerebro vasospasm). AHAguidelines;Critical care Med 2006;34:1975-1980

62. Hypertensive Encephalopathy Potential lethal complication of severe or abrupt BP elevation. Previously HTN/ normotensive pts. Acute glomerular nephropathy, Eclampsia , TTP, Pheochormocytoma , Erythropoietin administration, immunosupressive drugs Hinchey J et al,NEJM 1996;334:494-500

63. Cerebral ischemia resulting from arteriolar spasm*. Severe headache,vomitings,visual disturbances,confusion , focal or generalized seizures. Fundoscopic examination(key role) Mean BP should be reduced by 20% within first hour. IV sodium nitroprusside is DOC (rapid onset of action) ESC/ESH 2003 IV labetalol,nicardipine,hydralazine . Circulation,2004;110:2241-5

64. Eclampsia Hypertension complicates 12% pregnancies, 18% maternal deaths. Volume expansion,MgSo4 for seizure prophylaxis. MgSo4 4-6 g in 100ml 5%D over 15- 20 min - 1-2g/h infusion (hourly DTR,urine output). Antihypertensive therapy (to prevent complications in mother). SBP :155-160 mmHg,DBP >105mm Hg.(initiation of Rx) ICH is a devastating complication. Methyl dopa,Hydralazine DOC, Others being IV labetalol,nicardipine . Avoid sublingual or oral nifedipine . Nitroprusside,ACEI – C/I Am J Obst 2000:183:S1-S22

65. HTN emergencies due to catecholamine excess Abrupt increase in alpha adrenergic tone. IV labetalol Pheochromocytoma crisis (IV alpha blocker phentolamine ) followed by B blocker(for tachycardia or VPCs). Withdrawal of centrally acting anti HTN drugs ( clonidine ) Pheochromocytoma Cocaine intoxication Abuse of sympathomimetics Post operative Hypertension

66. ORAL DRUGS FOR HTN URGENCIES Drug Initial dose Onset duration Adverse effects Labetalol 200-400 mg 30-120 min 2-12 h Orthostatic hypotension, bronchoconstriction Clonidine 0.150-0.300 mg 30-60 min 8-16 h Hypotension,dry mouth. Prazosin 1-2 mg 60-120 min 8-12 h Syncope(1 dose), tachycardia Nicardipine 20-40 mg 30-60 min 8-12 h Headache,tachycardia Amlodipine 5-10 mg 60-120 min 12-18h Headache,flushing Captopril 25-50 mg 15-45 min 6-8h Renal failure in B.R.A.S

67. Acute and transient BP elevations Anxiety Panic attacks Pain Rx - Administration of anxiolytic or analgesic drugs. Refractory nose bleeding IV drugs to be used sometimes

68. TAKE HOME MESSAGE Most common cause for HTN crises is UNDIAGNOSED/UNTREATED/ INADEQUATELY TREATED HYPERTENSION Differentiation of emergency from urgency is absence of target organ damage in the later . Clevidipine is the new drug approved for hypertensive emergencies. IV Nicardipine , IV Labetalol are preferred for most of emergency situations. SL/oral nifedipine not to be used ..

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