HYPERTENSIVE CRISIS.pptx@12345567888865432457

This is for medical students

1. SEMINAR PRESENTATION ON DIAGNOSIS AND MANAGEMENT OF HYPERTENSIVE CRISIS MODERETOR : Dr. JARSO (MD, INTERNIST) PRESENTER : ADISSU BEZABIH 16/03/2023 1

2. OUT LINE Definition of hypertension Classification Clinical Manifestation Hypertensive crisis Patient approach Management of hypertension and hypertension crisis 16/03/2023 2

3. DEFINING HYPERTENSION From an epidemiologic perspective, there is no obvious level of blood pressure that defines hypertension. In adults, there is a continuous, incremental risk of cardiovascular disease stroke renal disease across levels of both systolic and diastolic blood pressure. 16/03/2023 3

4. Con...t Recommended criteria for a diagnosis of hypertension, based on 24-h blood pressure monitoring, are average awake blood pressure ≥ 135/85 mmHg and asleep blood pressure ≥120/75 mmHg. These levels approximate a clinic blood pressure of 140/90 mmHg. 16/03/2023 4

5. Epidemiology In USA approximately 30% of adults, or at least 65 million individuals, have hypertension The likelihood of hypertension increases with age. 1 billion world wide The prevalence is higher among blacks than whites. 16/03/2023 5

6. In the United States, ~78 million adults have hypertension. Hypertension prevalence is 33.5% in non-Hispanic blacks, 28.9% in non-Hispanic whites, and 20.7% in Mexican Americans. The likelihood of hypertension increases with age, and among individuals aged ≥ 60 years, the prevalence is 65.4%. 16/03/2023 6

7. CON….TD According to 2014 W.H.O data the crude adjusted estimate of raised blood pressure for those aged 18+ years in Ethiopia was 24% for both sexes Hospital based studies done in Tikur Anbessa Hospital and Jimma Hospital showed that hypertension with hypertensive heart disease is the second most common diagnosis in the cardiac clinics of these hospitals 16/03/2023 7

8. CON…TD Among all regions the highest prevalence is reported in Addis Ababa and the prevalence was 31.5% in male and 28.9% in female The lowest prevalence was reported in Oromia region with the prevalence of 3.1% in male and 4.4% in female 16/03/2023 8

9. Risk Factors Obesity( BMI> 30 ) and weight gain Excess sodium intake Excess Alcohol use Low dietary intakes of calcium and potassium low levels of physical activity Smoking DM Hyperlipidemia Family history Age( >55 M, >65 F) male sex 9 16/03/2023

10. Etiologic Classification of Hypertension Primary or essential – unknown cause, accounts for 80-95% of HTN Genetic predisposition Environment-sedentary life style Pregnancy-induced hypertension Secondary Renal – renal parenchymal disease, polycystic kidney disease, renal tumors Renovascular obstruction ex RAS Adrenal- Primary aldosteronism, Cushing's syndrome, pheochromocytoma…. 16/03/2023 10

11. Hypertensive crisis D efined as severe hypertension characterized by diastolic blood pressure greater than 130 mmHg. 1 –2% of the hypertensive population develop this complication C an cause vascular damage, encephalopathy, retinal hemorrhage, renal damage and death. 16/03/2023 11

12. categorized into two: Hypertensive Emergency • Hypertensive Urgency 16/03/2023 12

13. Hypertensive emergency defined as severe elevations in BP (>180/120 mm Hg) associated with evidence of new or worsening target organ damage demand immediate reduction of BP (not necessarily to normal) to prevent or limit further target organ damage 16/03/2023 13

14. R equire parenteral antihypertensive therapy to reduce the blood pressure promptly, but in a controlled manner and with careful monitoring O ver-rapid treatment may, leading, on occasions, to ischemic complications such as stroke, myocardial infarction, or blindness 16/03/2023 14

15. If not recognized or treated appropriately, the mortality and morbidity can be very high, with the 1-year mortality being 70–90%, and the 5-year mortality 100 %. With adequate blood pressure control, the 1-year and 5-year mortality rates decrease to 25 and 50%, respectively. 16/03/2023 15

16. Very severe and malignant hypertension are more likely to be associated with underlying causes such as renovascular disease primary renal diseases phaeochromocytoma… About 40% of patients with malignant hypertension have an underlying cause 16/03/2023 16

17. Pathologic consequence of hypertension Hypertensive left ventricular failure Hypertensive encephalopathy Hypertension with acute stroke and after a stroke hypertensive retinopathy Peripheral arteries 16/03/2023 17

18. Hypertensive left ventricular failure pressure overload on the heart due to the raised peripheral vascular resistance results in structural and functional adaption reduced left ventricular compliance an increased risk for coronary artery disease and the precipitation of cardiac arrhythmias 16/03/2023 18

19. Hypertensive encephalopathy following severe and sudden rises in blood pressure results in failure of autoregulation of cerebral blood flow at the upper pressure limit, resulting in vasodilation and hyperperfusion . 16/03/2023 19

20. CONT….D severe headache, nausea and vomiting (often of a projectile nature), focal neurologic signs, and alterations in mental status. Untreated , hypertensive encephalopathy may progress to stupor, coma, seizures, and death within hours. 16/03/2023 20

21. Hypertensive Retinopathy 16/03/2023 21

22. Hypertensive Urgency severe HTN (as defined by a DBP >120 mmHg) in asymptomatic patients or with out organ damage These patients require BP control over several days to weeks . 16/03/2023 22

23. Resistance hypertenation When a patient takes 3 antihypertensive medications ( a diuretic should be 1 component ) but does not achieve control common risk factors include older age obesity CKD black race, and DM . 16/03/2023 23

24. R efractory hypertension an extreme phenotype of antihypertensive treatment failure , defined as failure to control BP despite use of at least 5 antihypertensive agents of different classes patients with refractory hypertension experience high rates of complications , including LVH, HF, and stroke 16/03/2023 24

25. Approach to patients with hypertensive crisis History search for those fact the presence of precipitating or aggravating factors, the natural course of the blood pressure, the extent of target organ damage, and the duration as well as the severity of hypertension 25 16/03/2023

26. all current medications including prescription and nonprescription drugs taken compliance with current antihypertensive therapy. A history of medical problems, specifically cardiovascular and renal disease 16/03/2023 26

27. Associated cardiovascular risk factors: Cigarette smoking Lipid abnormality or hypercholesterolemia Diabetes mellitus Alcoholism 16/03/2023 27

28. CONT…D Finally , common symptoms of hypertensive crises include headache, blurry vision, and chest pain, Dizziness , palpitation , easy fatigability 16/03/2023 28

29. Physical examination An accurate measurement of blood pressure is the key to diagnosis. patient should seat > 5 min the arm level with the heart use calibrated & appropriate cuff( 80 % of circumference) two readings should be taken separated two minutes at more than two visits Funduscopic evaluation CVS examination Neurologic examination 16/03/2023 29

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31. Based on JNC-8 16/03/2023 31

32. Based on AHA 16/03/2023 32

33. Lab Studies The following routine laboratory studies should be performed: CBC count , serum electrolytes , serum creatinine , serum glucose , and urinalysis Lipid profile total cholesterol, LDL and HDL , and triglycerides) ECG TSH, renal duplex Doppler flow study, 24hr urine assay for creatinine Imaging ; CXR, Echo 16/03/2023 33

34. Treatment Hypertension Treatment- Goal options BP <140/90 mmHg Hypertension with DM, CVD, CKD,CAD, PVD BP <130/80 Control other risk factors BMI, quitting smoking, cholesterol, moderation on alcohol consumption, and exercise Achieve SBP goal especially in persons > 50 years of age <150/80 For adult without CVS risk factor <140/80 16/03/2023 34

35. Lifestyle Interventions 16/03/2023 35

36. A. Diuretics : are often the first line drugs , and reduce extra cellular fluid volume Thiazide diuretics : are more effective anti-hypertensive agents than loop diuretics Dose : Hydrochlorothiazide 25 mg PO daily and may be increased gradually Side effects : hypokalemia , hyperuricemia , hyperglycemia Contraindcation: Gout Potassium-sparing diuretics (e.g. Spironolactone ) Dose: 25-50 mg PO 2 to 4 times daily Pharmacologic Therapy of hypertension 16/03/2023 36

37. B. β-adrenergic blocking agents : reduce cardiac output and renin release β- blockers : Propranolol , Metoprolol , Labetalol , Carvidolol , Atenolol Doses: Propranolol 20 mg PO /day to Maximum of 120 mg PO 4X/day Metoprolol: 25 – 150 mg PO BID Atenolol : 25-100 mg PO/day Side effects: bronchospasm, bradycardia, worsening of heart failure, impotence , depression Contraindication: Asthma, peripheral vascular disease (severe) 16/03/2023 37

38. C. Centrally acting agents : These agents inhibit sympathetic out flow from the CNS . • Methyldopa : 250 mg -1000 mg PO BID , TID or QID Side effects: postural hypotension, depression, gyneacomastia. Cont …d 16/03/2023 38

39. D. Vasodilators: dilate arteriols and arteries, reducing peripheral vascular resistance which inturn reduces high blood pressure. • Hydrallazine : Oral 10-75 mg PO QID Paraneteral: 10-50 mg IV or PO every 6 hours. Side effects: – headache Minoxidil : 2.5 -40 mg PO BID Side effects: Orthostatic hypotension 16/03/2023 39

40. E. Calcium channel blockers Dihydropyridines: Nifedipine, Felodipine, Amlodipine Non dihydropyridines : Diltiazime , and Verapamil Doses: Nifedipine: 30 – 90 mg PO daily Amlodipine: 2.5 -10 mg PO daily Contraindication: Heart failure 16/03/2023 40

41. F. ACE inhibitors Doses: Captopri : 12.5 -75 mg PO BID Enalapril : 2.5-40 mg daily Side effects: Cough ,, angioedema, hyperkalemia. Contraindicated in: Bilateral renal artery stenosis , Renal failure . G. Angiotensin receptor blockers : Losartan : 25-50 mg once or twice daily 16/03/2023 41

42. Management of hypertensive emergency 16/03/2023 42 • Rapid assessment of the patient with brief history and targeted physical examination (of the CNS, CVS , retina ) • Laboratory investigations : o CBC o Urinalysis o Renal function test o ECG

43. Pharmacologic therapy 16/03/2023 43

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46. Several parenteral antihypertensive agents are most often used in the initial treatment of malignant hypertension Nitroprusside  — an arteriolar and venous dilator, given as an intravenous infusion. Initial dose: 0.25 to 0.5 µg/kg per min; maximum dose: 8 to 10 µg/kg per min. acts within seconds and has a duration of action of only two to five minutes. hypotension can be easily reversed by temporarily discontinuing the infusion, providing an advantage over the other drugs 16/03/2023 46

47. Nicardipine  — an arteriolar dilator, given as an intravenous infusion. Initial dose: 5 mg/h; maximum dose: 15 mg/h. Clevidipine  — a short-acting dihydropyridine calcium channel blocker. It reduces blood pressure without affecting cardiac filling pressures or causing reflex tachycardia. Initial dose: 1 mg/hour; maximum dose: 21 mg/hour. 16/03/2023 47

48. Labetalol   — an alpha- and beta-adrenergic blocker, given as an intravenous bolus or infusion . Bolus: 20 mg initially, followed by 20 to 80 mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg/min. Fenoldopam  — a peripheral dopamine-1 receptor agonist, given as an intravenous infusion . Initial dose: 0.1 µg/kg per min; the dose is titrated at 15 min intervals, depending upon the blood pressure response. 16/03/2023 48

49. Hypertensive Emergency useful when there is no rapid access to the parenteral medications described above sublingual nifedipine   10 mg sublingual captopril   25 mg can substantially lower the BP within 10 to 30 minutes in many patients 16/03/2023 49

50. Reference Harrisons principles of internal medicine 21 th edition national training on hypertension for health care workers in Ethiopia, Participant’s Manual 2017 ACC/AHA Guideline for the Prevention, Detection , Evaluation, and Management of High Blood Pressure in Adults , october 2016 16/03/2023 50

51. THANK YOU 16/03/2023 51