Professional Documents
Culture Documents
Faris Mahmud
DEFINITION
Hypertensive crisis is defined as a severe
elevation in blood pressure (BP>180/110 mmHg)
If these conditions are not treated promptly, a
high rate of morbidity and mortality will ensue
These conditions are divided into two general
categories:
Hypertensive
urgencies
Hypertensive emergencies
CLASSIFICATION OF
HYPERTENSIVE CRISES
Hypertensive urgency
Severely
Hypertensive emergency
Severely
Hypertensive Emergency
Severely elevated blood pressure
(BP >180/110 mmHg)
Overt symptoms of end organ
damage present:
CNS (encephalopathy,
Hypertensive Urgency
Severely elevated blood pressure
(BP>180/110 mmHg)
No evidence of end-organ damage
intracranial/subarachnoid
hemorrhage, stroke)
Heart (left ventricular failure,
pulmonary edema, MI, aortic
dissection)
Renal failure/insufficiency
Eyes (ocular hemorrhage,
funduscopic changes, blurred
vision, loss of sight)
Requires immediate pressure
reduction
Requires IV therapy
COMMON CAUSES OF
HYPERTENSIVE CRISES
Renal parenchymal
disease
Chronic
Primary
pyelonephritis
glomerulonephritis
Tubulointerstitial
nephritis
lupus
erythematosus
Systemic sclerosis
Vasculitides
Atherosclerotic
Renovascular
disease
Fibromuscular disease
Polyarteritis nodosa
Endocrine
Phaeochromocytoma
Conn
syndrome
Cushing syndrome
Recreational drugs
Coarctation of aorta
Pre-eclampsia/eclampsia
HYPERTENSIVE URGENCY
GOAL OF THERAPY
Initial goal is BP reduction of up to 25% over
several hours (generally, 24-48 hours)
If the patient is then stable, BP can be further
reduced toward 160/100 mmHg
Precipitous
APPROACH OF TREATMENT
a new antihypertensive
increasing the dose(s) of the present medication(s)
restart the medications (if the therapy was defaulted
or interrupted)
Dose
Onset of
action (hr)
Duration (hr)
Frequency
(prn)
Maximum
daily dose
Captopril
25 mg
0.5
1-2 hrs
450 mg
Nifedipine
10-20mg
0.5
3-5
1-2 hrs
120-180 mg
Labetalol
200-400 mg
2.0
4 hrs
2400 mg
Available at HKB:
T. Capropril 25 mg
T. Nifedipine 10 mg
T. Labetalol 100 mg
USE OF NIFEDIPINE IN
HYPERTENSIVE URGENCIES
Oral nifedipine was commonly used as a rapid-acting
therapy in the acute management of hypertension
However, its use has been associated with lifethreatening adverse events such as ischemia, MI, and
stroke (Psaty BM et al. 1995; Schwartz M et al. 1990; Fami MJ et al. 1998)
Prompt
USE OF CAPTOPRIL IN
HYPERTENSIVE URGENCIES
Most
USE OF LABETALOL IN
HYPERTENSIVE URGENCIES
HYPERTENSIVE
EMERGENCY
GOAL OF THERAPY
Precipitous
maintaining
time
APPROACH TO TREATMENT
Drugs
Dose
Onset of
Duration
Remarks
action
Sodium
nitroprusside
0.25-10 mcg/kg/min
seconds
1-5 min
Caution in
renal failure
Labetalol
IV bolus 50 mg (over at
least 1 min) may
repeat at 5 min
interval
IVI 2 mg/min
(max 200 mg)
<5 min
3-6 hr
Caution in
renal failure
Nitrates
5-100 mcg/min
2-5 min
3-5 min
Prefered in ACS
& APO
Hydralazine
3-8 hr
Caution in ACS,
CVA and
dissecting
aneurysm
Nicardipine
5-10 min
1-4 hr
Caution in AHF
and ACS
Esmolol
NEUROLOGIC EMERGENCIES
Hypertensive encephalopathy
Hypertensive encephalopathy was used to describe the
encephalopathic findings associated with the malignant
hypertensive phase
Results from hydrostatic exudation of fluid into the brain
due loss of blood-brain barrier integrity
The clinical symptoms are usually reversible with prompt
initiation of therapy
The treatment target is to reduce the MAP 25% over 8
hours (Pancioli AM. 2007)
Labetalol, nicardipine, esmolol are the preferred
medications (Pancioli AM. 2007)
Nitroprusside and hydralazine should be avoided (Pancioli AM.
2007)
NEUROLOGIC EMERGENCIES
Acute ischemic stroke
Brain vascular occlusion results in depletion of
oxygen and ATP to the neurons
UNLESS the patient is receiving IV fibrinolysis,
ntihypertensive medications should be withheld
unless the BP is >220/120 mmHg (Castillo J et al. 2004)
An
If
NEUROLOGIC EMERGENCIES
Intracerebral hemorrhage / hemorrhagic
stroke
Bleeding that occurs directly into the brain
parenchyma
The usual mechanism is thought to be leakage
from small intracerebral arteries damaged by
chronic hypertension
The treatment is based on evidence of increased
intracranial pressure (ICP) (Anderson CS et al. 2008)
For the 1st 24 hours after onset:
NEUROLOGIC EMERGENCIES
Intracerebral hemorrhage / hemorrhagic
stroke
Preferred medications are labetalol, nicardipine,
and esmolol (Anderson CS et al. 2008)
Avoid nitroprusside and hydralazine (Anderson CS et al.
2008)
NEUROLOGIC EMERGENCIES
Subarachnoid hemorrhage (SAH)
Extravasation of blood into the subarachnoid
space
~80% of non-traumatic SAH are due to a
ruptured berry aneurysm related to
hemodynamic stress on the arterial walls
Preferred medications are labetalol, nicardipine,
and esmolol (Anderson CS et al. 2008)
Avoid nitroprusside and hydralazine (Anderson CS et al.
2008)
CARDIOVASCULAR EMERGENCIES
Aortic Dissection
Separation of the layers within the aortic wall
Occurs when blood pushes into the intima-media
space through a tear in the intimal layer
Can be rapidly fatal, even with immediate
medical attention
Treatment goal is to maintain maintain the SBP
at < 110 mm Hg, unless signs of end-organ
hypoperfusion are present (Cheung AT, Hobson RW. 2008)
CARDIOVASCULAR EMERGENCIES
Aortic Dissection
Preferred treatment includes a combination of
narcotic analgesic (morphine), B-blockers
(labetalol, esmolol), and vasodilators
(nicardipine, nitroprusside) (Cheung AT, Hobson RW. 2008)
Non-DHP
CARDIOVASCULAR EMERGENCIES
Acute Coronary Syndrome & Heart Failure
Treatment is indicated if the BP rises >160/100
mm Hg (Diercks EB, Ohman EM. 2008)
Reduce
PREECLAMPSIA/ECLAMPSIA
If
JR. 2008)
CONCLUSION
Hypertensive urgencies and emergencies both are characterized
by the presence of very elevated BP, typically greater than
180/120 mm Hg
Hypertensive urgencies are ideally managed by adjusting
maintenance therapy, by adding a new antihypertensive, and/or
by increasing the dose of a present medication
Hypertensive urgency requires BP reductions with oral
antihypertensive agents to stage 1 values over a period of hours
to days
Hypertensive emergencies are situations that require immediate
BP reduction to limit new or progressing target-organ damage
Hypertensive emergencies require parenteral therapy, at least
initially, with one of the specific agents listed
In most of the hypertensive emergencies, IV labetalol are
preferred unless contraindicated
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