2007 EMA Advanced Emergency & Acute Care Medicine Conference Atlantic City, NJ September 24, 2007

1. Emergency Department Patient Hypertensive Emergencies: Published Guidelines, Articles, & Their Findings

2. 2007 EMA Advanced Emergency & Acute Care Medicine ConferenceAtlantic City, NJSeptember 24, 2007

3. Edward P. Sloan, MD, MPH FACEPProfessorDepartment of Emergency MedicineUniversity of Illinois College of MedicineChicago, IL

4. Attending PhysicianEmergency MedicineUniversity of Illinois HospitalOur Lady of the Resurrection HospitalChicago, IL

5. Disclosures • FERNE Chairman and President • FERNE advisory board for The Medicine Company in May 2007 • FERNE grant by The Medicines Company to support this program • No individual financial disclosures

6. Hypertensive Crisis • Hypertensive urgency: • elevation of blood pressure without acute end organ damage • Hypertensive emergency • elevation of blood pressure with acute end organ damage • Diastolic BP usually >120 in both instances

7. Guideline Sources • www.Guidelines.gov • Published guidelines • Pivotal clinical trials • Clinical practice

9. ACEP Clinical Policy Are ED BP readings accurate and reliable for screening asymptomatic patients for hypertension? Level B: If ED BP persistently > 140/90, refer for possible HTN. Level C: A single elevate reading suggests possible need for outpt screening.

10. ACEP Clinical Policy Do asymptomatic patients with elevated BP benefit from rapid lowering of their BP? Level B: Initiating Rx not needed if there is scheduled follow-up. Level B: Rapidly lowering BP not necessary and may be harmful. Level B: If Rx started, expect gradual improvement, not in ED.

12. JNC7 Report Age > 50, SBP > 140 mm Hg is risk After 115/75, CVD risk doubles as BP increases 20/10 mm Hg 102-139 / 80-89 pre-hypertensive Start with thiazide-type diuretics

13. JNC7 Report Most pts will require two drugs If BP 20/10 mm Hg high, consider two drug therapy Patients must be motivated for successful intervention on BP

15. ASA Ischemic Stroke Policy Treat BP > 185 / 110 mm Hg Labetalol 10 – 20 mg IV, repeat x 1 Nitropaste 1 - 2 inches Nicardipine infusion 5 mg/hr, titrate up by 2.5 mg/hr at 5 – 15 intervals Reduce infusion to 3 mg/hr when desired BP attained Consider sodium nitroprusside

17. ASA ICH Guideline Therapy must be individualized In general, be more aggressive than with ischemic stroke Goals for BP control critical Reduce BP in order to minimize ongoing bleeding Caution with CPP decreases in setting of increased ICP

18. ASA ICH Guideline Hx HTN: maintain MAP < 130 mm Hg Labetalol, esmolol, nitroprusside, hydralazine, enalapril BP > 230/140 x 5 min, nitroprusside BP 180-230/105-140 x 20 min, start labetalol, esmolol, or enalapril

19. ASA ICH Guideline If more Rx needed, consider diltiazem, lisinopril, verapamil Use easy to titrate drugs If BP < 180 / 105, defer and BP Rx Keep CPP > 70 mm Hg

21. NINDS tPA Clinical Trial Hypertension common in study Modest BP effects observed by design, with little overshoot tPA patients who were hypertensive after randomization and received Rx were less likely to have a favorable outcome Significance of observation unclear

23. ED Clinical Study “Screening tests of urban ED patients with asymptomatic severely elevated blood pressure infrequently detect unanticipated hypertension-related abnormalities that alter ED management.”

25. Marik, Varon Review Good epidemiology and pathophysiology information Drug information and table Special considerations, populations Titratable medications might best be utilized in the ICU setting

26. Conclusions Guidelines, clinical studies, and review articles do provide guidance Treatment options must be individualized for each patient Specific strategies are defined It is possible to practice within a reasonable standard of care Pt outcomes can be optimized

27. Questions? edsloan@uic.edu 312 317 4996 www.ferne.org ferne_ema_2007_htn_emergencies_sloan_guidelines_findings_092407_finalcd 9/26/2014 7:36 PM