HYPERTENSIVE CRISIS done by DR WILLIAM NAKASERO

HYPERTENSIVE CRISIS

1. HYPERTENSIVE CRISIS: URGENCY/EMERGENCY Dr. Richard Arao

2. Definition Chronically elevated arterial blood pressure

3. Definition Category Systolic BP (mmHg) Diastolic BP (mmHg) Optimal <120 <80 Normal <130 <85 High Normal 130 - 139 85 - 89 Hypertension Grade I (Mild) 140 - 159 90 - 99 Grade II (Moderate) 160 - 179 100 - 109 Grade III (Severe) ≥180 110 Category Systolic BP (mmHg) Diastolic BP (mmHg) Normal <120 & <80 Elevated 120 - 129 & <80 Hypertension Stage I 130 - 139 / 80 - 89 Stage II ≥140 / ≥90 AHA/ACC 2017 Guidelines

4. Threshold for Drug Treatment Previously: Grade II Hypertension (≥160/100 mmHg) Targets: <140/90mmHg With comorbidities (Renal, DM) - <130/80 mmHg Currently : Stage II Hypertension ( ≥140/90 mmHg) Targets: < 120/80mmHg ≥65 yrs <130/80 mmHg

5. Primary & Secondary Hypertension Primary/Essential – 95% Secondary/Non-essential – 5%

6. Secondary Hypertension Obesity Pregnancy (Pre- eclampsia ) Renal Disease Renal Artery Stenosis Parenchymal Disease Polcystic Kidney Disease Endocrine Disease Phaoechromocytoma Hyper- or Hypothyroidism Hyperaldosteronism Cushing’s Syndrome Drugs Cocaine, Monoamine Oxidase Inhibitors (MAOIs), Oral Contraceptives Withdrawal: Alcohol, Beta Blockers or α -stimulants, Hydralazine

7. Management of Hypertension A C or D A + C or A + D A + C + D Add Further diuretic therapy or α -blocker or β -blocker Consider seeking specialist advice Younger than 55 yrs 55 yrs or older or black patient of any age Step 1 Step 2 Step 3 Step 4

8. Target Organ Damage CNS Hypertensive Encephalopathy Cardiovascular Angina Myocardial Infarction CHF Pulmonary Edema Retinal Retinal hemorrhage Soft exudates Papilledema Renal AKI, Acute on Chronic Disease, CKD

9. Hypertensive Emergency Malignant Hypertension Papilledema vascular lesion: fibrinoid necrosis of arterioles and small arteries Microangiopathic hemolytic anaemia Accelerated Hypertension Papilledema absent

10. Management In-depth clinical history Current illness Past medical history Medications, compliance Family history

11. Investigations FHG UECs RBS Lipid Profile TFTs Urinalysis Urinary Catecholamines Urinary Cortisol and Dexamethasone Suppresion Test Plasma Renin activity, Aldosterone

12. Investigations Chest Xray BP Readings Echo Renal Ultrasound/Angiography CT Scan (Chest, Head)

13. Treatment Targets Reduce mean arterial BP by no more than 25% (within minutes to 1 hour). If the patient remains stable, further reduce the BP to 160 mmHg systolic and 100-110 mmHg diastolic within the next 2 to 6 hours. Normal BP may be targeted over the next 24 to 48 hours.

14. Approach ICU/HDU admission Continuous cardiac monitoring Frequent assessment of neurologic status Administration of IV antihypertensives Input/output charting

15. Medication Sodium Nitroprusside Vasodilator 0.3 – 1mcg/kg/min (Max. rate: 10 mcg/kg/min) Labetalol Combined β and α -antagonism IV/IM 2mg/min (Max. 200mg) Hydralazine Vasodilator 5-10 mg IV/IM; repeated at half-hourly intervals Phentolamine Non-selective α - adrenoreceptor antagonist Phaeochromocytoma , MAOIs. 5 – 15mg IV Others: Esmolol , Metoprolol , Diltiazem , Verapamil , Enalapril

16. Plan Stabilize BP Graduate patient to oral medication and ensure compliance Regular multidisciplinary follow-up for comorbidities

17. References Davidson’s Principles & Practice of Medicine Medscape BMJ