HYPERTENSIVE CRISIS

By Group 6 2015/2016

Epidemiology of
Hypertension
NHMS 2011 reported,
Prevalence HPT Malaysian adults
18 years has increased from 32.2 %
in 2006 to 32.7 in 2011
>30 years old, prevalence 42.6% 43.5%
60.6% of total hypertensive were
undiagnosed
No gender predilection
Malay 34%, Chinese 32.3%, Indians

Classification & Prevalence

Definition
Hypertension
Persistent elevation of systolic BP of
140mmHg or greater and/or diastolic
BP of 90mmHg or greater
Severe Hypertension
Persistent elevation SBP >180 mmHg
and/or DBP >110 mmHg

Criteria for staging HPT

Clinical Presentation
Incidental finding in asymptomatic
patient
Non-specific symptoms: Headache,
dizziness, lethargy
Symptoms and signs of acute target
organ damage; Acute heart failure,
ACS, Acute renal failure, dissecting
aneurysm, SAH & Hypertensive
encephalopathy

Severe Hypertension
Categories
Asymptomatic severe hypertension
Hypertensive crisis:
Acute increase in BP usually diastolic
BP >120 mmHg, with or without endorgan damage. Adapted from Sarawak Handbook of
medical emergencies

-Hypertensive urgencies
-Hypertensive emergencies

Definition
Hypertensive emergencies
Increase BP with evidence of end-organ
damage or dysfunction
Hypertensive urgencies
Elevation of BP to a level, which may be
potentially harmful, but without signs,
symptoms or other evidence of end-organ
dysfunction

End-Organ manifestation
1. Retinal: Papilloedema
2. Cardiac: Pulmonary oedema,
Myocardial ischemia
3. Neurological: Severe headache,
mental status changes, seizure,
coma, hypertensive encephalopathy
4. Renal: Acute Renal Failure

Common Causes:

Investigations

BUSE
Creatinine
Urinalysis
Chest X-ray
ECG
Toxicology profile

Management
Asymptomatic Severe Hypertension:
May required admission in newly diagnosed
Reviewed drug regime in patient with
previous anti-hypertensive treatment
Oral combination therapy should be preferred
Subsequent follow up

Hypertensive Urgencies
Admit patient
Repeat BP measurement after 30 mins of
bed rest
Aim 25% reduction in BP over 24 hours to a
diastolic level of 100-110 mmHg BUT not
lower than 160/90mmHg
BP control using oral anti-hypertensive drug
Combination therapy is necessary
Sublingual Nifedipine SHOULD BE AVOIDED!

Hypertensive Urgencies

Combination Therapy is necessary for

most cases
when diastolic BP >110mmHg
Beta-blocker with or without diuretics OR
ACE Inhibitor/ ARB with or without
diuretics

Hypertensive Emergencies
All patient should be admitted
ABC : IV access, O2 support, cardiac
monitor
BP need to be reduce rapidly (to
reduce the risk of permanent
damage/death)
Aim reduce BP 25% over 3-12 hours
but not lower than 160/90mmHg
Best achieve with parenteral drugs

Condition

Drug choice for

management:
Drug of Choice

Coronary Artery
Disease
and Heart Failure

IV Nitroglycerin
Diuretics and morphine can be added

Pheochromocytoma

IV phentolamine or alpha-blocker eg.

Prazosin

Aortic dissection

IV beta blocker or labetalol +/nitroprusside

Pulmonary oedema

IV Nitroglycerin, IV frusemide, IV
nitroprusside, ACE inhibitor/ARB

HPT in pregnancy

Hydralazine, Labetalol and magnesium

sulphate

Stroke

Beta blocker, CCB, diuretic or ACE inhibitor/

ARB

Subsequent Therapy
Investigate for underlying cause
If parenteral agents are used initially,
oral medication should be
administered in combination shortly
thereafter to facilitate weaning from
parenteral therapy (over 1-2 days)

Reference
CPG Management of Hypertension
(4th edition)
Sarawak Handbook of Medical
Emergencies
Emergency Medicine, companion
Handbook. By Cline, Ma, Tintinalli,
Kellen, Stapczynski