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Hypertension. Dr. Stella Yiu Staff Emergency Physician. LMCC objectives: Hypertension. Diagnose and determine severity Investigate target organ damage and 2 nd causes List medical management ( po and iv). 1. Diagnosis. Cdn 2012 guidelines. > 160 or > 100 x 3 Or > 140 or > 90 x 5 .
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Hypertension Dr. Stella Yiu Staff Emergency Physician
LMCC objectives: Hypertension • Diagnose and determine severity • Investigate target organ damage and 2nd causes • List medical management (po and iv)
Cdn 2012 guidelines • > 160 or > 100 x 3 • Or • > 140 or > 90 x 5
Most HTN = Essential HTN • 5-10% 2nd – curable • More demand on pump • or • Stiff pipes
2nd Causes: Cardiac output (pump demand) • Renal failure + fluid overload • ++ aldosterone • Aortic coarctation
2nd Causes: Vascular resistance (stiff pipes) • Renal artery stenosis • Pheochromocytoma • Drugs • Brain (CVA, ICH, SAH)
MCQ 8: What is the most common treatable 2nd cause for HTN? • Hyperaldosteronism • Renal artery stenosis • Pheochromocytoma • Aortic coarctation • Sympathomimetic use
CDMQ: What are the clinical clues and investigations for 2nd causes?
Cardiac output (pump stress) • Renal failure + fluid overload • ++ Aldosterone • Aortic coarctation
Vascular resistance (stiff pipes) • Renal artery stenosis • Pheochromocytoma • Drugs • Brain (CVA, ICH, SAH)
Investigations • Renal failure + fluid overload • Creatinine, CXR
Investigations • ++ aldosterone • High Na, Low K • Cushingoid on exam
Investigations • Aortic coarctation • HTN in Upper extremity • Systolic murmur over back • Delayed Femoral Pulse • Echo, Angio
Vascular resistance (stiff pipes) • Renal artery stenosis • Young female + fibromusculardysplasia • Resistant to HTN meds • Most common treatable cause • Abdobruits, low K, Abdo US
Vascular resistance (stiff pipes) • Pheochro-mocytoma • Episodes of • HTN + HA + palp +diaphoresis • Urine catecholamines, metanephrines
Vascular resistance (stiff pipes) • Drugs • Amphetamines, sympathomimetics • MAOI • Clinical exam: toxidrome • Urine tox • ECG
Vascular resistance (stiff pipes) • Brain • (CVA, ICH, SAH) • CT head
MCQ 9: Which is not an HTN emergency? • 35 M 220/140, dizzy, normal neuro exam • 50 M 200/120, chest pain, CXR wide mediastinum • 25 F 28 wks pregnant, 150/80, seizure • 80 F 220/120, left arm weakness • 45 F 200/120, crackles to apex, JVP 6cm
Aortic Dissection Pulmonary edema ACS
Bleeds, seizures Encephalopathy (not just headache, dizzy) Acute renal failure
Investigations for HTN emergency Aortic Dissection ARF Pulmonary edema ACS Bleeds, seizure, encephalopathy
Treat HTN emergency: General • BP: Reduce MAP by 25% • Iv medications: • Labetolol • Nitroprusside • Hydralazine
CDMQ: 45 F 220/120, bilateral crackles, JVP 6cm, Sat 80%, treatment?
Specific Treatment: Pulmonary Edema • BiPAP • Nitrates iv • Furosemide iv
Specific Treatment: ACS • ASA • NTG • Beta-blockers
Specific Treatment: Dissection • Iv Nitroprusside + beta-blocker • Iv labetolol • Surgery if ascending aorta
Specific Treatment: Seizure+ preg (Eclampsia) • MgSO4 • Iv Hydralazine • Delivery
Diagnosis • > 160 or > 100 x 3 or • > 140 or > 90 x 5
MCQ 10: What test is not needed in ambulatory testing for HTN? • Urine, urine albumin (DM) • Lytes+ creatinine • Fasting glucose + cholesterol • CBC + diff • ECG
Treatment HTN ambulatory • Non-pharmacological management
First line med, dosage and side effects? • No other comorbidities? • CAD? • Diabetes? • Asthma? • Renal failure?
No co-morbid – 1st line • Thiazide (HCTZ 251) • Beta-blocker (Metoprolol 252) • CCB (Amlodipine 51) • ARB (Losartan 25mg )
DM • + Renal: ACEI/ARB • CCB • Thiazide
Asthma • Avoid beta-blocker
CRF (non-DM) • ACEI/ARB • Thiazide
CAD • ACEI /ARB • Angina/recent MI: Beta-blocker
Improving compliance • Fit daily routine • Once daily dosing • Single pill combination • Dosette
LMCC objectives: Hypertension • Diagnose and determine severity • Investigate target organ damage and 2nd causes • List medical management (po and iv)