1. Evidence Based management ofHypertensionCase 6

2. A 52-year-old man presented to the emergency department with worsening occipital headache Confusion12 hours numbness and weakness involving the rightside of his body blurry vision. Past medical history Hypertension hyperlipidemia.. 3. On physical examination Blood pressure was 213/134 mm Hg. Confused. Papilledema was seen on fundoscopic examination. motor weakness (4/5) in the right upper extremity. 4. Laboratory studies revealedfollowing: serum potassium, 3.1 mEq/L; blood urea nitrogen, 36 mg/dL; and serum creatinine, 2.5 mg/dL (baseline creatinine, 1.5mg/dL). Electrocardiogram revealed left ventricular hypertrophy byvoltage criteria and nonspecific ST-T wave abnormalities inthe lateral leads. Computed tomography scan of the head without contrastrevealed diffuse bilateral white matter changes consistentwith hypertensive encephalopathy 5. Although not specifically addressed in the JNC 7 report, patients with a systolic BP > 179 mm Hg or a diastolic BP > 109 mm Hg are usually considered to be having a hypertensive crisis. Crises EmergencyUrgency 6. The term malignant hypertension has been used to describe a syndrome characterized by elevated BP accompanied by encephalopathy or acute nephropathy. This term, however, has been removed from National and International Blood Pressure Control guidelines and is best referred to as a hypertensive emergency. CHEST / 13 1/6/ JUNE, 2007 7. Left with 2 terms Hypertensive Emergency Hypertensive Urgency 8. Hypertensive emergency (crisis) severe elevation in blood pressure (> 180/120 mm Hg) complicated by evidence of impending or progressive target organ dysfunction. Target organ dysfunction (Acute) includeEmergency not definedby a coronary ischemia, specific number, but disordered cerebral function, rather by evidence of cerebrovascular events, acute dysfunction in intracerebral or subarachnoid hemorrhage or hypertensive encephalopathy. (cerebral edema)cardiovascular, pulmonary edema, andneurologic, or renalsystems renal failure. The rate of change in blood pressure Dept. of Health and Human Services, National Institutes of Health, Can Fam Physician 2011;57:1137-41National Heart, Lung, and Blood Institute; 2004. NIH Publication No.045230. 9. Examples of Hypertensiveemergency hypertensive encephalopathy, Intracerebral hemorrhage, acute MI, acute left ventricular failure with pulmonary edema, unstable angina pectoris, dissecting aortic aneurysm, Eclampsia, HELLP Syndrome Acute renal failure Microangiopathic hemolytic anemia Acute Postoperative Hypertension 10. Hypertensive urgency, severe elevation in blood pressure without progressivetarget organ dysfunction (>160/110) Examples upper levels of stage II hypertension associated with severe headache, shortness of breath, epistaxis, or severe anxiety. The Seventh Report of the Joint National Committee on Prevention,Detection,Evaluation, and Treatment of High Blood 11. Pathophysiology Check Activation of Coagulation cascade and standing pro-inflammatory mediatorsBP UnderlyingPrecipitatingHypertensionFactor 12. Index case The patient was admitted to the intensive care unit and started on intravenous nitroprusside. Blood pressure decreased to 190/100 mm Hg over the first 3 hours and neurologic symptoms resolved within 5 hours. He was switched to his usual oral regimen on the third day of hospital admission and was discharged home on the fifth day with controlled blood pressure 13. Management of Urgency Oral antihypertensive agents in an outpatient orobservational setting low doses incremental doses Avoid excessive reduction in elderly, patients with PAD/CVD/intracranial disease The initial goal is to reduce blood pressure to 160/110 mm Hgover several hours to days using conventional oral therapy(24-48 hrs) Mean arterial pressure should be reduced by no morethan 25% within the first 24 hours using conventional oraltherapy. 14. Captopril ACE inhibitor onset of action 15 to 30 minutes maximum drop in blood pressure 30 and 90 minutes 25-mg oral dose initially, followed by incremental doses of 50 to 100 mg 90 to 120 minutes later Significant adverse effects include cough, hypotension, hyperkalemia, angioedema, and renal failure (especially in patients with bilateral renal artery stenosis, in whom it should be avoided). 15. Nicardipine Calcium channel blocker oral dose is 30 mg, Repeated every 8 hours until the target blood pressure is achieved. Onset of action is to 2 hours. Common adverse reactions include palpitations, flushing, headache, and dizzinessAm Heart J 1995;129:91723 16. Labetalol has mixed 1- and -adrenergic blocking properties(1:7) onset of action within 1 to 2 hours Starting dose is 200 mg orally, which can berepeated every 3 to 4 hours Common side effects include nausea and dizziness. 17. Clonidine central sympatholytic (2-adrenergic receptor agonist) agent onset of action within 15 to 30 minutes peak effect within 2 to 4 hours oral regimen is a 0.1 to 0.2 mg loading dose followed by 0.05 to 0.1 mg every hour until target blood pressure is achieved, up to a maximum dose of 0.7 mg. Common side effects include sedation, dry mouth, and orthostatic hypotension. Beware of withdrawl 18. calcium channel blocker Peak effect within 10 to 20 minutes. Short-acting nifedipine is not approved by the US FDA(unpredictable drops in blood pressure and associated riskof stroke) In 1995, an ad hoc panel convened by the NationalHeart,Lung, and Blood Institute concluded that short-acting nifedipine should be used with great caution (if at all),especially at higher doses, in the treatment of hypertension. 19. Treatment of hypertensiveemergency Use parenteral drugs Continuous monitoring of blood pressure. Reduce the mean arterial pressure by 10% during the first hour and an additional 15% within thenext 2 to 3 hours JNC VII Reduce mean arterial BP by no more than 25 per-cent (within minutes to 1 hour), then if stable, to 160/100110 mmHg within the next 26 hours. If tolerated further gradual reductions toward a normal BP can be implemented in the next 2448 hours More rapid reduction in blood pressure may result in cardiac or renal or cerebrovascular hypo-perfusion. altered autoregulation curve Pressure natriuresis may cause volume depletion in patients with hypertensive emergency, and administering vasodilator medications to these patients can lead to precipitous drops in blood pressure. Patients with volume depletion should receive intravenous (IV) saline to restore intravascular volume and shut off the renin-angiotensin-aldosterone system. Elliot WJ. Clinical features and management of selected hypertensive emergencies. J Clin Hypertens (Greenwich) 2004;6:58792 20. Exceptions to treatment ofEmergency Aortic dissection Pulmonary edema Stroke Patient requiring thrombolysis 21. Hypertension in the setting of an intracerebral bleed Treat only when blood pressure is more than 180/ 105 mm Hg.(or 200/110) MBP should be maintained 130 mm Hg or a SBP> 220 mm Hg or DBP >120, should be carefully treated. Mean arterial pressure should be lowered by 15% to 20% (10- 15% JNC VII) over 24 hrs Bring BP 220 mm Hg or the DBP is from 121 to 140 mm Hg, and nitroprusside for a DBP > 140 mm HgThe diagnosis and management of hypertensive crises.Chest 2000 29. Take Home Message 30. 5 patients arrive with identical vital signs: heart rate of 100 beats/min, blood pressure(BP) of 209/105 mm Hg, respiration rate of 20 breaths/min, and temperature of 36.9oC Patient A is a 65-year-old man with nausea, Intravenous labetalol, bolus or infusion.Target:vomiting, and confusion and papilledemaReduce MAP by 20% to 25% over 2 to 8 hours Nitroglycerin infusion; intravenous Patient B is a 73-year-old woman with sudden enalaprilat or sublingual captopril.shortness of breath, pink sputum, and heavyFurosemide will work only after adequatechest pain and LVH decrease in preload and afterload Urgent imaging with simultaneous decrease in Patient C is a 56-year-old man with sharp, BP. Nitroprusside and esmolol infusion;tearing chest and back pain and diastoliclabetalol boluses or infusion.Target: Rapidlymurmer reduce systolic BP to 110 mm Hg if there is no evidence of hypoperfusion No treatment.Reduce BP only if it is greater Patient D is a 64-year-old woman with a 6- than 220/120 mm Hg (embolic) or greaterhour history of right-sided weakness. NCCT than 180/105 mm Hg (hemorrhagic)no hemorrage. Thrombolysis notcontemplated Restart the medications she was on (Diuretic Patient E is a 51-year-old woman with a mildheadache, concerned about her history of and ARB). Ask her to follow up in OPDhypertension.Poorly compliant. LVH + 31. Thank You