Hypertensive Urgency
PGI Jorge John III P. Quilala
Objectives
• To present a case of hypertensive urgency
• To discuss what is hypertensive urgency,
its approach and management
R.I.M.
47 y/o
Filipino
Male
Roman Catholic
March 18, 1972
B-7 Samatad Comp. Tanique St.
Caloocan City
Metro Manila
Chief Complaint
Weakness of Hand, right
History of Present Illness
[2] Two Weeks PTA
Weakness of right
hand
Right shoulder pain
Naproxen, no relief,
no consult
History of Present Illness
In the interim,
• Persistence of above
symptoms, prompted consult
to a private clinic
• Was advised admission
Past Medical History
(-) Hypertension
(-) Diabetes Milletus
(-) Asthma
(-) Allergies
(-) Previous Myocardial Infarction, CVA,
Operations, Blood Transfusion, Hospital
Admissions
FAMILY HISTORY
Maternal Paternal
HPN +
DM
Asthma
Cancer
Allergy
Seizure
Renal
Personal/Social History
(+) occasional alcoholic beverage drinker
(brandy)
(-) non smoker
Cook – Ship Company
Sleep – only 2 – 3hr,
takes 15 – 30 min naps
Review of Systems
GENERAL [-] Weight loss/Gain
SKIN [-] Rash [-] Lesion [-] Hair loss [-] Pruritus
HEENT [-] Headache [-] Dizziness [-] Visual difficulty
[-]Lacrimation [-]Nasal/Aural Discharge [-]Hearing Loss [-]Epistaxis
CVS [-] Orthopnea [-] Fainting [-] Cyanosis [-] Syncope [-] Palpitation
RESPI [-] Cough [-] Chest Pain [-] DOB [-] Shortnes of Breath
GI [-] Vomiting [-] LBM [-] Constipation [-] Abdominal Pain [-] Jaundice [-] Food
Intolerance
GUT [-] Urine Color [-] Frequency [-] Dysuria [-] Edema [-] Enuresis [-]
Discharge
ENDOCRINE [-] Pain [-] Discharge [-]Cold/Heat Intolerance
NERVOUS/BEHAVIORAL [-] Tremors [-] Sleep and Eating problems
[-] Convulsion [-] Memory Loss [-] Mood Changes [-] Weakness [-] Paralysis [-] Behavioral
Changes
MUSCULSKELETAL [-] Bone, Joint, Muscle Pain [-] Swelling [-] Limitation of motion [-] Limping
HEMATOPOIETIC [-] Pallor [-] Bleeding [-] Bruising
Physical Exam
A. General Appearance
Well kempt, looks appropriately for age
B. Vital Signs
BP – 160/120 mmhg
CR - 60 bpm
RR – 24 cpm
T – 36.5 C
C. Integumentary
Skin is brown in color, good skin turgor, no lesions, no
discoloration.
Physical Exam
HEENT
Anecteric sclera, pink palpebral conjunctiva, no naso aural discharge, no cervical
lympadenopathy
CHEST AND LUNGS
Chest structure symmetrical, no visible subcutaneous blood vessels, No use of accessory
muscles during inspiration and expiration, breathing pattern is regular. No intercostal retraction.
Clear breath sounds.
HEART
Adynamic precordium, normal rate regular rhythm, no murmurs
ABDOMEN
Flat, Inverted Umbilicus, Normoactive bowel sounds, soft (-) Tenderness , [-] special tests
EXTREMITIES
Grossly normal extremities, no edema no cyanosis, full range of motion, full equal pulses
Physical Exam
Neuro
GCS 15 (E6M5V4) Oriented to (3) Three spheres,
Obeys command
CN I – NA
CN II – Pupils 2-3 mm ERLA
CN III, IV, VI – Intact EOMs
CN V – Intact
CN VII (-) Facial Assymetry
CN III Able to hear
CN IX – X + Gag Relfex / able to swallow
CN XI (+) shoulder shrug
CN XII – Tongue Midline
Physical Exam
Motor
4/5 5/5
5/5 5/5
Sensory
100 100
100 100
Approach to Diagnosis
Salient Features:
47 y/o, Male, Filipino
Roman Catholic
Weakness of Hand, right
Right shoulder pain
FHx : Hypertension (Maternal)
(+) occasional alcoholic
beverage drinker (brandy)
BP 160/120
Approach to Diagnosis
Risk Factors:
• Increase BP PE:
• Hypertension BP
(Maternal) 160/120
• (+) occasional
CARDIO
alcoholic
beverage
drinker
• Lack of Sleep
Weakness
Hand ENDO
Right
With
associated Labs/Diag
Shoulder nostics
Pain, Right 1. CT-Scan Other
Systems
Differential Diagnosis
RULE IN RULE OUT
Stroke
Weakness Hand, right (-) Neuro PE findings
Strong Risk Factor
Hypertensive RULE IN RULE OUT
Emergency Increased Bp No progression of BP reading
No end organ damage
Working Diagnosis
•Hypertensive Urgency
PLAN
• Admit patient
• Full low Salt Diet
• Lab/Diagnostic Requests
CBC, Creatinine, Uric Acid, Uric Acid, FBS, Lipid Profile,
ALT, Urinalysis, Chest X-Ray PA, 12 L ECG
• IV Fluids : PLR 1L x 16 hours
• Medications
Amlodipine 10 mg 1 tab now; then after breakfast daily
Lozartan 100 mg 1 tab now; then after breakfast daily
Metoprolol 50mg 1 tab BID
• Accurate I and O
• Monitor V/S
COURSE INCBC
THE WARD
Result
Hemoglobin 15.2
• Day 1 Hematocrit 42.0
RBC Count 5.06
BP 120/70 CR 59 RR 21MCV02 97% 83.0
Amlodipine 10 mg at PMMCH 30.0 H
MCHC 36.2 H
Started Vitamin B Complex
LeukocyteTab,
Count BID 6.05
Differential Count
Segmenters 53
Lymphocytes 32
Monocytes 7
Eosinophiles 7H
Basophils 1
Platelet Count 230
COURSE IN THE WARD
ALT 41.48 H
Uric Acid 369.64
Creatinine 93.58
Chest Xray Cardiomegaly
Atheromatous Aorta
Hypertension
Hypertension
American College of Cardiology and AHA
(ACC/AHA) 2017 blood pressure guidelines
threshold for the diagnosis of hypertension is
SBP/DBP of 130/80 mm Hg
Doubles the risk of cardiovascular diseases
Hypertension
Epidemiology
•Hypertension prevalence increases as patients age
•NaCl Intake – related hypertension prevalence
Obesity and Weight gain – strong independent risk
factors for hypertension
• Alcohol Consumption
• Psychosocial Stress
• Low Levels of Physical Activity
Hypertension
Hypertension
MECHANISMS OF HYPERTENSION
• Intravascular Volume
• Autonomic Nervous System
• Renin Angiotensin Aldosterone
• Vascular Mechanisms
• Immune Mechanisms, Inflammation and
Oxidative Stress
Hypertensive Urgency
HYPERTENSIVE URGENCY
defined as a diastolic blood pressure of 110 mm
Hg or greater without the acute signs of end-
organ damage.
HYPERTENSIVE EMERGENCY
defined as severe elevations in BP (>180/120
mm Hg) associated with evidence of new or
worsening target organ damage.
Hypertensive Urgency
• withdrawn from or are noncompliant with
antihypertensive therapy
• do not have clinical or laboratory evidence of
acute target organ damage.
Hypertensive Urgency
• Diagnosis and management of a hypertensive
crisis
Hypertensive Urgency
MANAGEMENT
1. These patients should not be considered as having a
hypertensive emergency
2. Treated by reinstitution or intensification of
antihypertensive drug therapy
3. Treatment of anxiety as applicable.
4. There is no indication for referral to the emergency
department, immediate reduction in BP in the
emergency department, or hospitalization for such
patients.
- acc/aha 2017 guidelines
• No RCT evidence that antihypertensive drugs
reduce morbidity or mortality in patients with
hypertensive emergencies.
• However, from clinical experience, it is highly
likely that antihypertensive therapy is an overall
benefit in a hypertensive emergency.
• 2 trials have demonstrated that nicardipine may
be better than labetalol in achieving the short-
term BP target
Thank You.
