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Hypertensive Emergency & Urgency

Hypertensive Emergency & Urgency. TREAT THE PATIENT! (Not the BP Reading and not the Nurses). Introduction. ~70 Million in USA have chronic HTN Most HTN crisis patients have chronic HTN Only a few well done controlled trials Insufficient outcome data to chose best treatment

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Hypertensive Emergency & Urgency

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  1. Hypertensive Emergency & Urgency TREAT THE PATIENT! (Not the BP Reading and not the Nurses)

  2. Introduction • ~70 Million in USA have chronic HTN • Most HTN crisis patients have chronic HTN • Only a few well done controlled trials • Insufficient outcome data to chose best treatment • Far different entity than chronic HTN

  3. Definitions • Hypertensive emergency: • End organ damage caused by high BP • Generally: SBP>180 and DBP>120 (110) • Hypertensive urgency: • No end organ damage • Headache maybe present • Generally: SBP>180 and DBP>120 (110) • Malignant Hypertension:

  4. BP Measurement • Technique is important! • Calm patient (pain, anxiety, anger) • Sitting • Cuff Size • Automated devices

  5. Mean Arterial Blood Pressure • MAP = (CO x SVR) + CVP • MAP ~ DBP + 1/3 (SBP-DBP) • In words: MAP is approximately the diastolic BP plus one third of the pulse pressure.

  6. Evaluation • Do not evaluate the Pt. over the phone! • Look for an underlying cause • Noncompliance • Pain, anxiety • EtOH withdrawal • Cocaine, Amphetamine use • Inappropriate measurement

  7. Evaluation (cont) • Is end organ damage present • Encephalopathy, Retinal hemorrhages • Pulmonary edema • ACS • Renal failure (proteinuria) • ICB • Aortic dissection • Stroke

  8. Evaluation (cont) • Directed history • Directed exam • Directed testing

  9. Treatment Concepts • In true hypertensive emergencies: • Lower BP in the time frame of a minutes to a few hours • BP goal depends on the situation • IV medications are used • Choice of medication is made on based pathophysiology of the condition but there is little outcome data

  10. The Medications • Esmolol: IV short acting cardioselctive beta-blocker (half-life of 9 minutes) Dose is 150 to 300 mcg/kg/min • Nicardipine: PO or IV Ca blocker. IV Dose 5mg/hr to 15mg/hr • Lebatolol: Alpha and beta blocker. Dose 20mg to 80mg boluses q10 to total dose of 300mg. IV drip can be used at 0.5mg to 2mg/min. • Nitroprusside: Arteriole and venous dilator. Start 0.25mcg/kg/min IV and titrate to BP. Max dose 10mcg/kg/min. x10 min. Dose above 2mcg/kg/min risk cyanide accumulation. Generally need to use for less than <48hrs.

  11. The Medications • Hydralazine: Direct arteriolar vasodilator. Response to IV doses is not predictable. Causes reflex tachycardia. Best avoided unless there is no other alternative. • Nitroglycerine: Primarily venous dilation. Dose: 5mcg/min to 100mcg/min IV • Fenoldopam: peripheral dopamine-1 receptor agonist. Preserves renal blood flow. Start 0.1 mcg/kg/min IV and titrate Q15 min up to control BP. Max dose 1.6 mcg/kg/min • Clevidipine: Ca blocker. Short acting dihydropyridine. IV dose 1 mg/hr to 21 mg/hr. Titrate up to control BP

  12. The Medications • Enalaprilat: IV ACEI. Response is not predictable. Dose is 1.25mg q6hrs to 5mg q6hrs. • Phentolamine: IV Alpha blocker. Given 5 to 10 mg q5-15 min IVP prn half-life 19 min • Furosemide: IV loop diuretic. Useful if patient is fluid overloaded. • Clonidine: Oral central alpha agonist. 0.2mg x1 and then 0.1 q 30 to 60 minutes to total dose of 0.8 mg • ACEI: lisinopril, enalopril, captopril

  13. Neurologic Emergencies • Hypertensive encephalopathy • Reduce MAP by 25% over 4 to 8 hours • Lobetolol, Esmolol and Nicardipine are the preferred agents • Avoid: Hydralazine & Nitroprusside • Acute Ischemic stroke • Treat if SBP>220 or DBP>120 • If getting TPA then goal: SBP<185 & DBP<110

  14. Neurologic Emergencies (cont) • ICB • If signs of increased ICP then MAP goal is about 130 • If no signs of increased ICP then MAP goal is about 110

  15. Neurologic Emergencies (cont) • SAH • Nicardipine, Labetalol, Esmolol • Oral nicardipine not used for BP control • Goal SBP<160

  16. Cardiovascular Emergencies • Aortic Dissection • Combination: Laebetalol, nicardipine, nitroprusside (with beta-blocker), esmolol, morphine. • Preload and afterload reduction to reduce shear stress on the aortic wall. • Goal: SBP<110 and maintain organ perfusion. • If tamponade or AI present beta-blockers are problematic

  17. Cardiovascular Emergencies(Cont) • ACS • Nitroglycerin, ACEI, Beta-blockers • Generally lower BP if >160/100 • Goal to reduce BP by about 20% • CHF • Nitroglycerin IV or SL, ACEI, Furosemide • Goal: SBP of about 140

  18. Cocaine Intoxication • Phentolamine, Diazepam, Nitroglycerin, Nitroprusside

  19. Hypertensive Urgencies • BP lowered over several days • Consider if the elevation is chronic • Oral agents are best approach • Procardia-XL, ACEI/ARB, Metoprolol, Clonidine • Amlodipine, HCTZ • Avoid being too aggresive

  20. Take Home Messages • Treat the patient NOT the numbers • Treat the patient NOT the nurses • Little out come data exits • Attendings/experts will therefore have preferred approaches largely based the pathophysiology of the situation • Don’t be dogmatic

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