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Hypotension and Hypertension

Hypotension and Hypertension. Nisarg Shah, M.D. May, 2005. Hypotension. Inadequacy of tissue oxygen supply versus demand resulting in global tissue hypoperfusion. Hypotension 4 types of shock. Hypovolemic - inadequate circulating volume hemorrhage fluid depletion.

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Hypotension and Hypertension

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  1. Hypotension and Hypertension • Nisarg Shah, M.D. • May, 2005

  2. Hypotension • Inadequacy of tissue oxygen supply versus demand resulting in global tissue hypoperfusion

  3. Hypotension4 types of shock • Hypovolemic - inadequate circulating volume • hemorrhage • fluid depletion

  4. Hypotension4 types of shock • Cardiogenic – inadequate cardiac pump function • arrhythmia • MI, dilated CM, decreased output from sepsis • mechanical – VSD, aortic stenosis

  5. Hypotension4 types of shock • Obstructive – extra cardiac obstruction to blood flow • pericardial tamponade • pulmonary embolism • severe pulmonary hypertension

  6. Hypotension4 types of shock • Distributive – peripheral vasodilation and maldistribution of blood flow • sepsis • drug overdose • anaphylaxis • neurogenic • endocrinologic

  7. Hypotension • Find the type and treat cause • history – vomiting, bleeding, CP, fever, medication use • physical – temp, heart rate, skin color, jugular veins, respiratory rate

  8. Hypertension

  9. Overview • History • Pathophysiology • Definitions • Hypertension • Hypertensive Urgency • Hypertensive Emergency • • Approach to patients • – Urgency vs Emergency • • ED Management • – Goals of ED treatment • – Pharmacotherapy • – Specific Treatments • – The Discharged Patient

  10. History • 1628 • William Harvey describes blood circulation • 1733 – Stephen Hales first measures blood pressure • 1816 – Rene Laennec invents the stethoscope

  11. History • Measuring blood pressure… • Sphygmograph, 1863 – Sphygmomanometer, 1898 – Karotkoff, 1905

  12. History • Hypertension… • Osler, 1912 • Simple HTN without disease • Atherosclerosis with associated hypertension • Chronic nephritis with secondary hypertension • Framingham and VA studies, 1970’s • Joint National Committee on Detection, Evaluation, and Management of High Blood Pressure

  13. Pathophysiology

  14. Pathophysiology • Essential Hypertension [~94%] • Prevalence >50% • Unknown cause • Secondary Hypertension [~6%] • Prevalence ~6% • Renal • Endocrine • Miscellaneous

  15. Pathophysiology • Prevalence increases with • Age • Male gender • Obesity • African American race

  16. Pathophysiology • Interestingly…

  17. Pathophysiology • The old renin-angiotensin-aldosterone system...

  18. Aside • Leading cause of office visits and the leading use of prescription drugs (aside from vicoden) in the U.S. • Over 100,000,000 office visits in 1997 • HOWEVER • - only 2/3 of Americans with HTN are aware of dx • - almost 75% of known HTNsives are not controlling BP under 140/90 • - only 50% of known HTNsives are taking their meds as prescribed

  19. Definitions

  20. Definitions • JNC-VI, 1997 • Optimal: <120 / and <80 • Normal: <130 / and <85 • High-Normal: 130-139 / or 85-89 • Stage I: 140-159 / or 90-99 • Stage II: 160-179 / or 100-109 • Stage III: ≥180 / or ≥110

  21. Definitions thankfully simplified JNC-VII, 2003 NORMAL: <120/ and <80 Pre-Hypertension: 120-139/ or 80-89 Stage I: 140-159 / or 90-99 Stage II: >160 / or ≥100-109

  22. Definitions • Hypertensive Urgency • Hypertensive Emergency • Accelerated Hypertension • Malignant Hypertension • Accelerated-Malignant Hypertension

  23. Definitions • Hypertensive Crisis • Urgency or Emergency

  24. Hypertensive Urgency • “Severe elevation of blood pressure” • Generally DBP >115-130 • No progressive end organ damage

  25. Hypertensive Emergency • “Severe elevation of blood pressure” • Generally occurs with DBP >130 • WITH significant orprogressive end organ damage • Hypertensive Encephalopathy • CVA – Ischemic versus hemorrhagic • Acute Aortic Dissection • Acute LVF with Pulmonary Edema • Acute MI / Unstable Angina • Acute Renal Failure • Eclampsia

  26. Urgency vs. Emergency • Urgency • No need to acutely lower blood pressure • May be harmful to rapidly lower blood pressure • Death not imminent • Emergency • Immediate control of BP essential • Irreversible end organ damage or death within hours

  27. Approach to Patients

  28. Approach to patients • Recheck blood pressure! • Appropriate size cuff. • Cuff not over clothing • Check in all limbs • History • Prior crises • Renal disease • Medications • Compliance • MAO inhibitors • Recreational drugs

  29. Approach to patients • Physical Exam • What do you see? • Signs of end organ damage?

  30. End organ damage • Neuro • Cardiac • Renal

  31. Neuro • Hypertensive encephalopathy • Severe Headache • AMS • Nausea/Vomiting • Papilledema • Visual Changes • Seizures • Focal Neurological Deficits • Ischemic vs hemorrhagic CVA

  32. Fundoscopy

  33. Fundoscopy/ Neuro

  34. Fundoscopy/ Vascular

  35. Fundoscopy/ Vascular

  36. Cardiac • Cardiac ischemia • Chest pain • EKG for ischemic changes • Acute left ventricular failure • Pulmonary edema • Rales • Hypoxia • SpO2 • EKG for left ventricular strain pattern • Aortic regurge murmur • CXR?

  37. Renal • Electrolytes • BUN/Cr • Chronic failure/insufficiency vs acute failure • Cause vs effect • UA with micro • Protein • Blood • Casts

  38. Goals of Treatment

  39. Goals of Treatment • Prevent end organ damage • NOT normalize BP • Exceptions?? • IV fluids • Forced natriuresis • Saline may help blunt renin-angiotensin response

  40. Goals of Treatment • Harington, et al, BMJ: 1959 • 94 cases over 7 years • Immediate normalization of BP • 12 not included in study • 30 / 82 with significant neurologic sequelae • Ledingham, et al, QJM: 1979 • Case series of 10 patients • All with papilledema • All with neurologic sequelae • 3 deaths during treatment

  41. Goals of Treatment WHY ?

  42. Cerebral Autoregulation • Strandgaard, et al. BMJ: 1973 Lancet, Hpertensive Emergencies, 2000; 356(9227):411-417

  43. Cerebral Autoregulation • Strandgaard, et al. BMJ: 1973 Cerebral blood flow 60 mmHg 120 mmHg 160 mmHg MAP Adapted from: Chest, 2000; 118:214-227

  44. Goals of Treatment • Within 1-2 hrs • Lower MAP 20-25% • CONTROLLED • IV titratable meds • Sublingual Nifedipine • Too effective • Hydralazine • Not titratable • Eclampsia

  45. Pharmacotherapy

  46. Pharmacotherapy • Nitroprusside • Arterial & venous dilator • Decreases afterload and preload • No direct negative inotropy or chronotropy • Kinetics • Onset: seconds • Duration: 1-2 min • 1/2 life: 3-4 min • Increased ICP (?) • Toxic metabolites • Takes days to accumulate

  47. Pharmacotherapy • Nitroglycerine • Weak anti-hypertensive • Vasodilator • At high doses dilates arteriolar smooth muscle • Better dilation of coronary conductance arteries • Kinetics • Onset: 1-2 min • Duration: 3-4 min • Tolerance • Headache, Tachycardia, Nausea, Vomiting, Hypotension

  48. Pharmacotherapy • Enalaprilat • IV ACE inhibitor • Improves cardiac index and stroke volume without affecting HR • Degree BP reduction associated with pretreatment plasma renin activity • Kinetics • Onset: 15 min • Duration: 6 hours

  49. Pharmacotherapy • Esmolol • Ultra-short acting • Cardioselective β1-blocker • Rapidly metabolized by plasma esterase • Negative chronotropy/inotropy • Kinetics • Onset: 1-5 min • Duration: 10-20 min

  50. Pharmacotherapy • Labetolol • Selective Post-synaptic α blockade • Non-selective β blockade • α: β = 1:7 • Maintains cardiac output • Decreased PVR without reflex tachycardia • Maintains cerebral, renal & coronary blood flow • Kinetics • Onset: 2-5 min • Peak: 5-15 min • Duration: 4-8 hrs

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