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Acute Hypertension

Acute Hypertension. Jay Patel, MD CR FIRM C. Initial Evaluation. What are the vitals? EKG Is this new or old? What has the rate of increase been? Is the patient mentating well? Are there signs of acute end-organ damage?. Acute Hypertension. Is it urgent or emergent?

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Acute Hypertension

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  1. Acute Hypertension Jay Patel, MD CR FIRM C

  2. Initial Evaluation • What are the vitals? • EKG • Is this new or old? • What has the rate of increase been? • Is the patient mentating well? • Are there signs of acute end-organ damage?

  3. Acute Hypertension • Is it urgent or emergent? • Urgent  SBP >180 or DBP >120 • Emergent  Urgent + End-organ damage • End-organ damage • Cardiac: pulmonary edema, ACS, aortic dissection • Renal: ARF, proteinuria, hematuria ATN • Neuro: cerebral edema, CVA, TIA, ICH • Many patients will have headache from hypertensive urgency but no other end organ damage. • Ophtho: retinal hemorrhage/exudate, papilledema

  4. Acute Hypertension • Presentations c/w hypertensive emergency: • BP >180/100 • AND • Encephalopathy • Dyspnea • Chest pain

  5. Things Not to miss… • Aortic Dissection • Intracranial Bleeding • Acute Coronary Syndromes

  6. Treatment: Hypertensive urgency • Titrate up current medications, Q2H BP checks until <160/100 • Add rapid onset/rapid offset oral medications to assess response • Captopril: ~6.25-12.5mg • Clonidine: ~0.2mg • In this situation, try to avoid starting IV drips • DO NOT USE HYDRALAZINE • The goal is BP <160/100 in HOURS to DAYS

  7. Physiology: Hypertensive Emergency • As blood pressure rises, arterial/arteriolar vasoconstriction occurs (autoregulation) to protect distal arterioles and maintain perfusion. • With increasing blood pressure, autoregulation fails. The vascular endothelium loses integrity, and plasma contents enter the vessel wall. • The vascular lumen is narrowed or obliterated, leading to ischemia.

  8. Treatment: Hypertensive Emergency • Use IV bolus/drips to rapidly correct blood pressure • Labetalol: 20mg initially, with repeat boluses (20-80mg) Q10min to total 300mg. Then gtt 0.5-2mg/min. • Nitroprusside: 0.25-0.5mcg/min, titrate to goal BP with max rate 10mcg/min. • Nitroglycerin: 5-100+mcg/min. • Nicardipine: 5-15mg/hr. • DO NOT USE HYDRALAZINE • The goal is to decrease diastolic BP to 100-105mmHg with initial MAP decrease no greater than 25% in MINUTES to HOURS

  9. Nitrates • Nitroglycerin • Good for pulmonary edema and angina • Preload/afterload reduction • Tachyphylaxis occurs quickly • Need high doses to reduce BP • Will cause headache • Nitroprusside • Do not use in renal failure, due to cyanide metabolite

  10. Beta-blockers • Labetolol • Good for rapid onset of action (<5 minutes) • Limited by bradycardia, can cause heart block • Do not use in acute CHF • Caution with underlying COPD/Asthma

  11. Calcium channel blockers • Nicardipine • Effective, use if contraindications to other agents • Do not use in acute CHF, ACS

  12. Case 1 • J.B. is a 55 y.o. AAM with hx of HTN, GERD, in the ER with chest pain and dyspnea • The patient looks extremely uncomfortable but is able to answer questions appropriately… pain is 10/10 and ‘going right through’ his chest • 195/120 105 24 96% RA • What is your initial DDx?

  13. Case 1 • Get BP in BOTH arms • R 190/100, L 165/95 • What therapy do you start empirically? • What imaging/labs do you want?

  14. Case 1

  15. Case 1

  16. Case 1 • Therapy: IV labetalol and IV nitrate • Goal SBP <100, goal HR 60s • DO NOT USE HYDRALAZINE • Imaging: • Dissection protocol CT • TEE • Labs: • BMP, CBC, troponin, CK-MB, type/cross, PT, PTT • Consult vascular surgery

  17. CT

  18. Aortic Dissection • Types: • Type A/Proximal  ascending aorta • Type B/Distal  descending aorta only • Complications: • Valvular insufficiency • CVA/TIA • Tamponade • Renal/bowel ischemia • MI

  19. Case 2 • F.M. is a 84 y.o AAF with hx of HTN, DM2, CHF, and CKD in the ER with chest pain and dyspnea • She missed several doses of medication (BB, ACE-I, CCB, ASA) while out of town at a Ham Eating Festival • 205/115 105 24 87% RA • What is your initial DDx?

  20. Case 2 • Get BP in BOTH arms • R 205/110 L 210/105 • What therapy do you start empirically? • What imaging/labs do you want?

  21. Case 2

  22. Case 2

  23. Case 2 • Therapy: IV furosemide, IV nitroglycerin, O2 • Goal: improvement in dyspnea, O2 requirement • Avoid beta-blocker in this patient • DO NOT USE HYDRALAZINE • Imaging: • CXR • Labs: • BMP, CBC, troponin, CK-MB, BNP

  24. Case 3 • A.C. is a 76 y.o WF with history of HTN, DM2, CAD admitted for hypertension and headache • Initial workup including EKG, Trop, BMP, and CXR are unremarkable… The patient’s HTN remains difficult to control with oral agents. • On HD#1, you are called to see patient for “garbled speech” • What is your initial DDx?

  25. Case 3 • BP 220/135 in both arms, HR 90, SaO2/RR stable • Exam notable for inability to follow commands and agitation, no cranial nerve deficits, moving all four extremities • What imaging/labs do you want?

  26. Case 3

  27. Case 3

  28. Case 3 • Therapy: IV labetalol or nicardipine • Goal: improvement in mental status, airway protection, seizure precautions • DO NOT USE HYDRALAZINE • Imaging: • Brain MRI to follow up • Labs: • BMP, CBC, troponin, CK-MB

  29. RPLE/RPLS/PRES • Results from disordered cerebral autoregulation, endothelial dysfunction, and ischemia • Hypertensive encephalopathy, eclampsia, and immunosuppressive drugs (esp. cyclosporine) are associated conditions • Therapy involves control of blood pressure, removal of offending agents (delivery, cyclosporine), and management of seizures if they occur

  30. CVA/Hemorrhage • Ischemic CVA: • Do not treat HTN unless BP >220/120 OR the patient has concomitant ACS, CHF, aortic dissection, eclampsia • IV labetolol is drug of choice • If lytics are being used, BP has to be <180/105 and maintained there for 24 hours post lytics • Intracranial/subarachnoid hemorrhage • Goal is SBP <200 or MAP <150, use IV labetalol • Call neurosurgery for ICP monitoring

  31. Case 4 • D.Y. is a 52 y.o male with history of HTN, DM2, admitted for community acquired pneumonia • You are on night float and get a call that the patient’s BP is 175/95. • How do you approach this?

  32. Case 4 • A) Review the patient’s medication list • B) Review the patient’s BP trends • C) A and B • D) Give 5mg IV hydralazine

  33. Case 4 • Inpatient hypertension that is not urgent or emergent should be treated like outpatient hypertension. • Add appropriate anti-hypertensives as you would in clinic and don’t aggressively add multiple agents. • Remember, amlodipine, lisinopril, etc. often take several days to reach their effect.

  34. Summary • Any patient with hypertension and chest pain or dyspnea needs blood pressure measured BY YOU in both arms. • Evaluate the hypertensive patient for signs of end-organ damage with EKG, troponin, and neurologic exam. • Hypertensive urgency: Oral medications. • Hypertensive emergency: IV medications and consider ICU transfer. • Inpatient hypertension: Treat like you would in clinic.

  35. Why Hydralazine is Terrible • Reflex tachycardia can increase myocardial oxygen demand and cause ischemia in patients with CAD. • Unpredictable hypotension can ensue, especially in patient with pulmonary hypertension. • Patient with low GFR may have several dips in blood pressure, resulting in drug stacking—hydralazine is renally cleared. • Drug-induced lupus and neuropathy are long-term risks, but those with HLA-DR4 genotype may be at risk with IV dosing.

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