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Hypertensive emergencies
The document discusses hypertensive emergencies, which are acute, severe elevations in blood pressure that can cause target organ damage. It notes key risk factors and various potential causes. It outlines goals for lowering blood pressure during hypertensive emergencies, which depend on the specific target organ(s) affected and time since presentation. Common medications used for treatment are discussed along with their indications and special considerations. Treatment goals differ for conditions like pregnancy, stroke, and aortic dissection. The importance of determining whether target organ damage is present and tailoring treatment accordingly is emphasized.
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Hypertensive emergencies
- 1. Dr. Prasenjit Gogoi M.E.Mpgt 3RD YR Fortis Hospital, Kolkata Hypertensive Emergencies
- 2. Introduction Hypertensive crisisare acute, severe elevations in blood pressure that may or may not be associated with target-organ dysfunction. Blood pressure > 180/110 mmHg Hypertensive emergencies significant morbidity and potentially fatal target-organ damage 1-3% of patients with HTN will have HTN emergency during their lifetime.
- 4. Risk factors Femalesex Higher grades of obesity Hypertensive or coronary heart disease Mental illness Non-adherence of anti-hypertensive medications.
- 7. Causes vary nationally, regionallyand institutionally Intoxications – cocaine, amphetamines, phencyclidine hydrochloride, stimulant diet supplements Non-adherence to antihypertensive regimens Withdrawl syndromes – clonidine or beta antagonist Drug-drug/drug-food interactions Spinal cord disorders Pheochromocytoma Pregnancy Collagen vascular disease
- 8. Acute Target-Organ Damageand Clinical Manifestations Neurologic Cerebral infarction Hypertensive encephalopathy ICH or SAH Cardiovascular Acute pulmonary edema (LVF) Acute congestive failure (left/right ventricular failure) Acute coronary ischaemia (MI or unstable angina) Renal Acute kidney injury/failure Liver Liver enzymes elevations (HELLP syndrome) Ocular Retinal hemorrhage/exudate Vascular Eclampsia Aortic dissection
- 10. BP Treatment goalsfor Hypertensive Emergency Goal Time BP Target First hour Reduce MAP by 25% (maintain goal DBP>100mmHg) Hours 2-6 SBP 160 mmHg and/or DBP 100-110 mmHg Hours 6-24 Maintain goals for hours 2-6 during first 24 hrs 24-48 hrs Outpatient BP goals according to the 2017 Guidelines for Management of High BP in adults.
- 11. Treatment Goals AcuteAortic Dissection Medical management should be considered first line for most non-life threatening type B aortic dissection. Goal heart rate – 60 beats/min within minutes of presentation. Goal Blood Pressure – SBP < 120 mmHg and/or as low as clnically tolerated.
- 12. Treatment Goals AcuteIschemic Stroke Adaptive response to maintain CPP to the brain. Current Guidelines for BP reduction Use of thrombolytic therapy Other target organ damage ( aortic dissection, MI ) Severe elevated blood pressure SBP>220 mmHg & DBP>110 mmHg For thrombolytic therapy initiation BP goal is less than 185/110 mmHg During therapy and subsequent 24 hrs BP goal is <180/105 mmHg Other circumstances – BP goal is 15% (10-20%) reduction in MAP to allow maintainence of CPP
- 14. Treatment Goals AcuteHemorrhagic Stroke Recent evidences suggest elevated BP during acute ICH are associated with hematoma expansion, neurologic deterioration and death. BP goal – SBP < 160 mmHg over the first few hours is relatively safe. ATACH-2 trial, patients were randomised with SBP target of < 140 mmHg or 140-180 mmHg acutely after ICH hypertensive emergency. Functional outcome did not differ.
- 16. Acute Hypertensive Definationsin the Pregnant Patient Name BP Criteria Additional Criteria “Severe” acute hypertension SBP > 160 mmHg or DBP > 110 mmHg Preeclampsia SBP > 140 mmHg or DBP > 90 mmHg BP readings must occur on >2 occasions, > 4 hrs apart > 20 weeks gestation Either : Proteinuria Severe features Eclampsia Same as above New-onset grand mal seizures in a woman with no known seizure disorder HELLP syndrome With or without preeclampsia degree of BP elevation Evidence of the following Hemolysis Elevated lover enzymes Low platelet Hypertensive emergency BP > 240/140 mmHg
- 17. Treatment Goals Treatmentgoals differ in pregnant patients compared with general hypertensive crisis. BP goal for Preeclampsia <160/110 mmHg – avoid abrupt decrease in blood pressure. MAP should be decreased by 20-25% over the first few minutes to hours and blood pressure further decreased to the target of 160/110 mmHg or less over the subsequent hours.
- 18. Treatment of Hypertensive Emergency No drug of choice. Choice of medication depends on a risk-benefit analysis of each agent considering the. Affected target organ on presentation Pharmacokinetics & pharmacodynamics Hemodynamic, adverse effect and BPV profile of the medication profile. Extreme caution should be used with acute and profound lowering of BP Ischaemic complications.
- 19. Medications Agent Dosing rangeOnset Duration Vasodilators Hydralazine IV Bolus: 10-20 mg IM : 10-40 mg q30 min PRN IV: 10 mins IM: 20 mins IV: 1-4 hours IM: 2-6 hours Nitroglycerine IV 5-200 mcg/min Titrate by 5-25 mcg/min q5-10 mins 2-5 mins 5-10 mins Sodium nitroprusside IV 0.25-10 mcg/kg/min Titrate by 0.1-0.2 mcg/min q5min seconds 1-2 mins CCB Clevidipine IV 1-6 mg/hr Titrate by 1-2 mg/hr q90s; max 32 mg/hr 1-4 min 5-15 min Nicardipine IV 5-15 mg/hr Titrate by 2.5 mg/hr q5-10 min 5-10 min 2-6 hours
- 20. Agent Dosing rangeOnset Duration Beta Blockers Esmolol IV 25-300 mcg/kg/min Titrate by 25 mcg/kg/min q3-5 mins 1-2 mins 10-20 mins Labetalol IV bolus: 20 mg; may repeat doses of 20-80 mg q5-10 mins PRN IV 0.5-10 mg/min Titrate by 1-2 mg/min q2hr. 2-5 min; peak 5-15 mins 2-6 hr Upto 18 hr Metoprolol IV bolus: 5-15 mg q5-15 min PRN 5-20 min 2-6 hr ACEI Enalaprilat IV bolus: 1.25 mg q6hr Titrate no more than q12-24 hr: Max dose : 5 mg q6hr 15-30 min 12-24 hr a-Antagonist Phentolamine IV bolus: 1-5 mg PRN; Max 15 mg Seconds 15 min D1 Receptor Agonist
- 21. Indications and SpecialConsiderations for Medications Used for Hypertensive Emergency Medication Indications Special Considerations Hydralazine Pregnancy Prolonged hypotension Risk of reflex tachycardia Headaches, lupus like syndrome Nitroglycerin Coronary ischaemia or infarction Acute LVF Pulmonary edema Tachyphylaxis Flushing, headache, erythema Venous greater than arterial dilator Sodium nitroprusside Most indications (excluding ICP elevations and coronary infarction/ischaemia) Liver failure – cyanide accumulation Renal failure – thiocyanate accumulation Toxicity with prolonged infusion Increases ICP Clevidipine Acute ischaemia or hemorrhagic Soy or egg allergy
- 22. Medication Indications SpecialConsiderations Esmolol Aortic dissection Coronary ischaemia/infarction Contraindicated in acute decompensated heart failure Useful in tachyarrhythmias Labetalol Acute ischaemic or hg stroke Aortic dissection Coronary ischaemia/infarction Pregnancy Monotherapy in acute aortic dissection Contraindicated in acute decompensated heart failure Prolonged hypotension Metoprolol Aortic dissection Coronary ischaemia/infarction Contraindicated in acute decompensated heart failure Use in conjunction with arterial vasodilator Useful in tachyarrhythmias Enalaprilat Acute LVF Contraindicated in pregnancy Prolonged duration of action Phentolamine Cetecholamine excess e.g. pheochromocytoma Use in catecholamine-inducd HTN er Used for cocaine induced HTN crisis with BZDs Fenoldopam Most indications Caution with increased ICP or IOP
- 24. Practice points • Determinethe presence or absence of target- organ damage. • Assessment • Screen for exceptions – stroke, pregnancy induced acute htn, aortic dissection- target goal development. • In general hypertensive emergencies the goal in the first 60 mins of treatment is reduce the MAP by25%. • Patient with exceptions have unique treatment goals leading to unique medication selection. • Goal of medication selection is to provide
- 25. References American collegeof cardiology – 2017 guideline for detection, evaluation and management of high blood pressure in adults. American college of clinical pharmacology – ccsap2018 – hypertensive emergencies. American college of obs&gynae (ACOG) – task force for htn in pregnancy.
- 26.