Hypertensive Emergency Vs Urgency

Dr. T. Joshi

Hypertensive Urgency No end organ damage despite systolic blood pressure ≥180

mmHg and/or diastolic blood pressure ≥120 mmHg

When it is associated with end organ damage, it is called hypertensive emergency. There may be evidence of cardiac, retinal, renal and cerebrovascular damage

Treatment Do not decrease the blood pressure too fast SL Nifedipine is contraindicated Rest in a quiet room Initial goal of reducing the blood pressure to ≤160/100 mmHg

over several hours to days with conventional oral therapy B blocker, Calcium channel blocker, ACE inhibitor eg

Captopril. Sustained release formulations are preferred

Treatment For previously treated patients, adjust their existing

medication regimen, or reinstitute their medications (if nonadherent).

For all patients, initial close follow-up is recommended (every one to two days).

Hypertensive Emergency Severe hypertension associated with acute end-organ

damage such as hypertensive encephalopathy, subarachnoid or intracerebral hemorrhage, acute pulmonary edema, aortic dissection

Initial Aim : Decrease up to 25% of BP over two to six hrs Or diastolic to 100 to 105. Use IV agents

Then switch to the oral agents, and aim to normalize BP over many months

MAP = DP+ 1/3PP= (SP + 2DP)/3

Pheochromocytoma Hypertensive Crisis : Nitroprusside, Phentolamine or Nicardipine

Combined alpha- and beta-adrenergic blockade is one approach to control blood pressure and prevent intraoperative hypertensive crises.

Just B blockade may result in unopposed alpha constriction and hypertension

Preoperative medical therapy is aimed at: Controlling hypertension (including preventing a hypertensive crisis during

surgery) Volume expansion

Scleroderma renal crisis can progress to ESRD over a period of one to two months

and death usually within one year

ACE inhibitors are drug of choice eg Captopril

Blood Pressure in Acute Stroke Acute Ischemic Stroke : Treat if BP more then or equal to

220/120 or the patient has an active ischemic coronary disease, heart failure, aortic dissection, hypertensive encephalopathy, acute renal failure, or pre-eclampsia/eclampsia. In that case lower 15% of BP in initial 24 hrs. Drug of Choice is labetelol

If thrombolysis is planned , then decrease below 185/110

ICH

For patients with SBP >200 mmHg or MAP >150 mmHg, consider aggressive reduction of blood pressure with continuous intravenous infusion of medication accompanied by frequent (every five minutes) blood pressure monitoring

For patients with SBP >180 mmHg or MAP >130 mmHg and evidence or suspicion of elevated ICP, consider monitoring ICP and reducing blood pressure using intermittent or continuous intravenous medication to keep cerebral perfusion pressure in the range of 61 to 80 mmHg

For patients with SBP >180 mmHg or MAP >130 mmHg and no evidence or suspicion of elevated ICP, consider a modest reduction of blood pressure (eg, target MAP of 110 mmHg or target blood pressure of 160/90 mmHg) using intermittent or continuous intravenous medication, and clinically reexamine the patient every 15 minutes

These guidelines also concluded that in patients presenting with a SBP of 150 to 200 mm Hg, acute lowering of SBP to 140 mm Hg is probably safe [Labetalol, nicardipine, esmolol, enalapril, hydralazine, nitroprusside, and nitroglycerin are useful intravenous agents for controlling blood pressure