Hypertensive Emergency and urgency .pptx

HTN emergency

1. Hypertensive Crises Diagnosis and Treatment Dr . Habib Shafi Niazi Feb, 2025

2. Outline Definition of HTN Definition of Hypertensive Emergency and Urgency Management of Hypertensive urgency Management of Hypertensive Emergency Stroke ACS Dissection AKI

3. HTN Normal blood pressure < 120/80 mm Hg Elevated blood pressure 120–129/< 80 mm Hg Stage 1 hypertension 130–139/80–89 mm Hg Stage 2 hypertension ≥ 140/90 mm Hg

4. Hypertensive Urgency Severely elevated (BP>180/120 mmHg ) blood pressure without signs and symptoms of acute end organ damage Often a mild headache Can be managed as an outpatient Can be managed with short acting oral medications

5. Hypertesive Urgency rarely require emergency therapy Lower BP in a few hours Parenteral drug therapy is not usually required ; partial reduction of blood pressure with relief of symptoms is the goal . Effective oral agents are clonidine, captopril, and slow-release nifedipine

6. Hypertensive Emergency Severely elevated blood pressure ( BP >=180/120 mmHg ) with signs and symptoms of acute end organ damage Require hospitalization

7. Hypertensive Emergency Damage Heart - CHF, MI, angina Kidneys - acute kidney injury, microscopic hematuria CNS - encephalopathy, intracranial hemorrhage , Ischemic stroke, Grade 3-4 retinopathy Vasculature Vasculature - aortic dissection, eclampsia Lungs – Acute Pulomonary edema

8. Epidemiology Hypertensive emergencies are common Occur in 1-2% of the hypertensive population But, 50 million hypertensive Americans 500,000 hypertensive emergencies/year Higher in the elderly Incidence in men 2 times higher than in women

9. Initial Evaluation Assess for end-organ damage Vascular Disease Assess pulses in all extremities Auscultate over renal arteries for bruits Cardiopulmonary Listen for rales (CHF) Murmurs or gallops

10. Initial Evaluation Neurologic Exam Hypertensive Encephalopathy - mental status changes, nausea, vomiting, seizures Lateralizing signs uncommon and suggest cerebrovascular accident Retinal Exam

11. Retinopathy Grading Grade 1 Mild narrowing of the arterioles “Copper Wire” Grade 2 Moderate narrowing - Copper wire and AV nicking

12. Retinopathy Grading 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

13. Normal

14. Grade 1

15. Grade 3 Retinopathy

16. Lab Testing ECG LVH, look for signs of ischemia, injury, infarct Renal Function Tests (urine included) Elevated BUN, Creatinine, proteinuria, hematuria CBC CXR - pulmonary edema, aortic arch, cardiac enlargement

17. Lab Testing Aortic Dissection? Suspect with severe tearing chest pain, unequal pulses, widened mediastinum TEE Shouldn’t delay treatment Contrast Chest CT Scan or MRI Pulmonary Edema/CHF Transthoracic Echocardiogram

18. Management require substantial reduction of blood pressure within 1 hour to avoid the risk of serious morbidity or death It is the presence of critical multiple end-organ injury that determines the seriousness of the emergency and the approach to treatment

19. Goal - Reduce diastolic BP by 10-15% or to 110 mm Hg over a period of 30 - 60 minutes Parenteral therapy is indicated in most hypertensive emergencies , especially if encephalopathy is present.

20. The initial goal in hypertensive emergencies is to reduce the pressure by no more than 25% (within minutes to 1 or 2 hours) and then toward a level of 160/100 mm Hg within 2–6 hours . Excessive reductions in pressure may precipitate coronary , cerebral, or renal ischemia.

21. To avoid such declines, the use of agents that have a predictable, dose-dependent, transient, and progressive antihypertensive effect is preferable In that regard, the use of sublingual or oral fast-acting nifedipine preparations is best avoided .

22. Management Where? ICU with close monitoring Severe requires intra-arterial BP monitoring Which Parenteral meds? Depends on the situation

23. Management based on target organ damage

24. Acute hypertensive microangiopathy initial goal: dec no more than 25 % ( within minutes to 1 or 2 hours) and then toward a level of 160/100 mm Hg within 2–6 hours. using agents that have a predictable, dose-dependent, transient, and progressive antihypertensive effect In that regard, the use of sublingual or oral fast-acting nifedipine preparations is best avoided

25. Acute ischemic stroke often associated with marked elevation of blood pressure will usually fall spontaneously antihypertensive should only be used if the systolic blood pressure exceeds 180–200 mm Hg blood pressure should be reduced cautiously by 10–15 % over 24 hours

26. Acute ischemic stroke If thrombolytic are to be given: Keep BP less than 185/110 mmHg during treatment and for 24 hours following treatment

27. Intracerebral hemorrhage minimize bleeding by reducing the SBP in most patients to 140 mm Hg within the first 6 hours. In acute subarachnoid hemorrhage, as long as the bleeding source remains uncorrected, a compromise must be struck between preventing further bleeding and maintaining cerebral perfusion in the face of cerebral vasospasm. In this situation , blood pressure goals depend on the patient’s usual blood pressure.

28. ICH In previously normotensive patients, Target BP of 110–120 mm Hg; in hypertensive patients, blood pressure should be reduced to 20% below baseline pressure. In the treatment of hypertensive emergencies complicated by ( or precipitated by) CNS injury, labetalol and nicardipine are good choices since they are nonsedating and do not appear to cause significant increases in cerebral blood flow or intracranial pressure.

29. Stroke HTN crises with acute or hemorrhagic stroke With thrombolytic therapy BP <185/110 Without thrombolytic therapy 15% reduction in BP In hemorrhagic strokeSBP <180 Urapidil , nicardipine , labetalol Avoid of nitroprusside, hydralazine

30. Retinopathy HTN crises with advanced retinopathy without reduction of consciousness ( labetalol,nitroprusside,urapidil,nicardipine ) HTN crises with encephalopathy Brain edema(posterior region)+ reduce of consciousness(10% reduction of BP in first hour and 15% in next 12 hours to 160/110

31. ACS Acute coronary syndrome TNG +IV motoprolol or esmolol Labetalol Nitroprusside is cotraindicated Acute heart failure  Nitroprusside is choice(+Lasix)

32. Misc Adernergic crisis: (Pheochromocytoma  phentolamine+beta blocker or nitroprusside , urapidil Clonidine withdrawal clonidine Cocaine or methamphetamine- induced HTN benzodiazepine + phentolamine

33. acute aortic dissection SBP and HR --- within 30 minutes to < 120 mm Hg and < 60 beats/min, using a combination of vasodilation and beta-blockade Esmolol + Nicardipine Nitroprusside can be used as well

34. CHOICE OF DRUGS Sodium nitroprusside is no longer the treatment of choice for acute hypertensive problems; in most situations: nicardipine or clevidipine plus labetalol or esmolol

35. Sodium N itroprusside Disadvantages of sodium nitroprusside Decrease cerebral blood flow and increases intracranial pressure Can reduce regional blood flow in coronary artery disease Risk of cyanide toxicity Use when other agents not effective Monitor thiocyanate levels Avoid in renal or hepatic dysfunction Choice in Aortic Dissection,CHF 0.3-10 microgm/kg/min

36. Labetalol Alpha&Beta Blocker(Beta>Alpha) Choice in Hypertensive encephalopathy , Ischemic & Hemorrhagic Stroke , Severe preeclampsia/eclampsia , Aortic Dissection 2-4 mg/min

37. Oral agents less severe acute hypertensive syndromes Suitable drugs will reduce the blood pressure over a period of hours consequence of noncompliance, it is usually sufficient to restore the patient’s previously established oral regimen

38. Clonidine 0.2 mg then 0.1 mg every hour to 0.8mg rebound Captopril 12.5 to 25mg 15-30 min Nifidepine unpredictable

39. Subsequent Therapy When the blood pressure has been brought under control, combinations of oral antihypertensive agents can be added as parenteral drugs are tapered off over a period of 2–3 days

40. Thank you! Questions?