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Hypertensive Emergencies

Hypertensive Emergencies. Phillip D. Levy, MD, MPH, FACEP Associate Professor Associate Director of Clinical Research Wayne State University Department of Emergency Medicine. Relevant Disclosures. Grant/Research Support

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Hypertensive Emergencies

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  1. Hypertensive Emergencies Phillip D. Levy, MD, MPH, FACEP Associate Professor Associate Director of Clinical Research Wayne State University Department of Emergency Medicine

  2. Relevant Disclosures • Grant/Research Support • The Robert Wood Johnson Foundation Physician Faculty Scholars Program, the NIH Loan Repayment Program (Health Disparities Division), and the NIH/NIHMD (1R01 MD005849-01A1) • Consultant • The Medicines Company, EKR Therapeutics

  3. Purpose of This Lecture • To provide an overview of the “what” and “why” of contemporary ED management of acute HTN • Utilize an evidence-based discussion format • Focus on differentiation between simple BP elevation and true hypertensive emergency

  4. Why This Topic? Nawar et al. Adv Data 2007; 386:1-32.

  5. Why This Topic? Pitts et al. Natl Health Stat Report 2008;7:1-38.

  6. Based on JNC VII Class http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm

  7. Reflects the General Population Prevalence Lloyd-Jones et al. Circulation 2010;121;e1-e170.

  8. As Well As Racial and Ethnic Demographics Lloyd-Jones et al. Circulation 2010;121;e1-e170.

  9. And Low Levels of Awareness, Treatment and Control Lloyd-Jones et al. Circulation 2010;121;e1-e170.

  10. So The BP is High - Now What ? http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm

  11. So The BP is High - Now What ? http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm

  12. So The BP is High - Now What ? http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm

  13. Shayne and Pitts. Ann Emerg Med. 2003;41:513-29.

  14. Are All of These Patients the Same? Kessler and Joudeh. Am Fam Physician. 2010;81:470-76.

  15. Clearly Not! Kessler and Joudeh. Am Fam Physician. 2010;81:470-76.

  16. What Constitutes a Hypertensive Emergency? 1,2 1 Varon and Marik. Chest 2000;118:214-27. 2 Rynn et al. J Pharm Prac 2005;18:363-76.

  17. Pathophysiology of aHypertensive Emergency1,2 1 Ault and Ellrodt. Am J Emerg Med 1985; (suppl 6):10-15. 2 Varon and Marik. Chest. 2000;118:214-27.

  18. Chirinos and Segers. Hypertension 2010;56:563-70.

  19. Macrocirculatory:Arterial Impedance Kawaguchi et al. Circulation 2003;107:714-20.

  20. What End-Organs Are Typically Involved? Zampaglione et al. Hypertension 1996;27:144–7.

  21. Katz et al. Am Heart J 2009;158:599-606.

  22. Patient Outcomes Katz et al. Am Heart J 2009;158:599-606.

  23. Szczech et al. Circulation 2010;121:2183-91.

  24. Deshmukh et al. Am Heart J. 2011 [epub ahead of print].

  25. Stead et al. Neurology 2005;65:1179-83.

  26. Gheorghiade et al. JAMA 2006;296:2217-26.

  27. Perez et al. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD003653.

  28. Perez et al. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD003653.

  29. Treatment Typically Parenteral • Adrenergic receptor blockers • Esmolol (β1) • Labetalol (α1 and β) • Phentolamine (α1) • Urapidil (α1) • Ca2+ channel blockers • Nicardipine • Clevidipine • ACE inhibitors • Enalaprilat • NO donors • Nitroprusside • Nitroglycerin • Isosorbidedinitrate • NP analogue • Nesiritide • Dopamine agonist • Fenoldopam • Direct vasodilator • Hydralazine

  30. What Is Used Most Commonly? Katz et al. Am Heart J 2009;158:599-606.

  31. How Well Does That Work? Katz et al. Am Heart J 2009;158:599-606.

  32. Differential Antihypertensive Response Katz et al. Am Heart J 2009;158:599-606.

  33. Blood Pressure Dynamics • MAP = DBP + ([SBP - DBP]/3) • MAP = (CO x SVR) + CVP • CO = HR x SV

  34. Reference: Peacocket al. Peacock et al. Critical Care 2011 [epub ahead of print].

  35. CLUE Study Evaluation of Intravenous niCardipine and LabetalolUse in the Emergency Department Reference: Peacocket al. Peacock et al. Critical Care 2011 [epub ahead of print].

  36. CLUE Study Evaluation of Intravenous niCardipine and LabetalolUse in the Emergency Department Final multivariable logistic regression model†* for “met target SBP within first 30 minutes” Reference: Peacocket al. Peacock et al. Critical Care 2011 [epub ahead of print].

  37. Specific Indications Rhoney and Peacock. Am J Health-Syst Pharm. 2009; 66:1343-52.

  38. How Low Should You Go? • Simple answer • 25% reduction in MAP within 1st hour • Target ~ 160/100 mm Hg by 2-6 hours Marik and Varon. Critical Care 2003, 7:374-84.

  39. How Low Should You Go? • Better answer • It really depends on clinical condition • Less aggressive with ischemic stroke • More aggressive with hemorrhagic stroke, acute HF and aortic dissection

  40. AHA/ASA Recommendations for BP Management in AIS Aiyagari and Gorelick. Stroke 2009;40:2251-56.

  41. AHA/ASA Recommendations for BP Management in AIS Aiyagari and Gorelick. Stroke 2009;40:2251-56.

  42. AHA/ASA Recommendations for BP Management in AIS Aiyagari and Gorelick. Stroke 2009;40:2251-56.

  43. AHA/ASA Recommendations for BP Management in ICH Aiyagari and Gorelick. Stroke 2009;40:2251-56.

  44. AHA/ASA Recommendations for BP Management in ICH Aiyagari and Gorelick. Stroke 2009;40:2251-56.

  45. Sandset et al. Lancet 2011 [epub ahead of print].

  46. Sandset et al. Lancet 2011 [epub ahead of print].

  47. Sandset et al. Lancet 2011 [epub ahead of print].

  48. Impact of Early Reduction Rhoney et al. Presented at the 2011 Neuro-Critical Care Society Meeting.

  49. Impact of Early Reduction Rhoney et al. Presented at the 2011 Neuro-Critical Care Society Meeting.

  50. Guideline: SBP < 180 mm Hg Intensive: SBP < 140 mm Hg Anderson et al. Stroke 2010;41:307-12.

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