Urgent and Emergency Hypertension

Urgency and Emergency
Hypertension
Ika Prasetya Wijaya
Cardiology Division, Internal Medicine Department
Cipto Mangunkusumo Hospital
Faculty of Medicine, Universitas Indonesia
Presenter Disclosure Information
• Ika Prasetya Wijaya
– Urgent and Emergency Hypertension
• FINANCIAL DISCLOSURE
– None to declare
BP refers to Blood Pressure in this slide presentation

Definition
• Hypertension is defined as office systolic
blood pressure (SBP) values ≥140 mmHg
and/or dyastolic blood pressure (DBP) values
≥90 mmHg
1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

Classification
ESC JNC 8
Category Systolic Dyastolic Category Systolic Dyastolic
Blood Blood Blood Blood
Pressure Pressure Pressure Pressure
(mmHg) (mmHg) (mmHg) (mmHg)
Optimal <120 and <80 Normal <120 and <80
Normal 120-129 and/or 80-84 Pre 120-139 or 80-89

hypertension
High Normal 130-139 and/or 85-89
Stage 1 140-159 or 90-99
Grade 1 140-159 and/or 90-99 hypertension
hypertension Stage 2 ≥160 or ≥100
Grade 2 160-179 and/or 100-109 hypertension
hypertension
Grade 3 ≥180 and/or ≥110
hypertension
Isolated ≥140 and <90
systolic
hypertension
2. JNC 8. JAMA 2014; 310(12)
Screening and Detection of
Hypertension
• Screening and hypertension detection are
recommended for all patients aged >18 years
– In patients aged >50 years, the frequency of
screening for hypertension is increased due to an
increase in the prevalence of systolic blood
pressure
– The difference in systolic blood pressure >15
mmHg between the two arms is suggestive of a
vascular disease and is closely related to the high
risk of cerebrovascular disease

Screening and Detection of
Hypertension
Optimal BP Normal BP High BP Hypertension
<120/80 120-129/80-84 130-139/85-89 ≥140/90
Consider Masked Out-of-office BP

measurement
Hypertension
(ABPM or HBPM)
Use either
to confirm
diagnosis
Repeat BP at Repeat BP at Out-of-office BP

Repeat BP at Repeated visits
least every 5 measurement
least every 3 for office BP
least annually (APBM or
years years measurement HBPM)
Indications for
ABPM or HPBM
Blood Pressure Limits for the
Diagnosis of Hypertension
Category Systolic Blood Dyastolic Blood
Pressure (mmHg) Pressure (mmHg)
Clinic BP ≥140 and/or ≥90
ABPM
• Morning-afternoon ≥135 and/or ≥85
(or wake up) average
• Night (or sleep) ≥120 and/or ≥70
average
• 24 hour average ≥130 and/or ≥80
HBPM average ≥135 and/or ≥85
ABPM: Ambulatory blood pressure monitoring

HBPM: Home blood pressure monitoring

Routine Workup for Evaluation of
Hypertensive Patients
Routine Laboratory Tests
Haemoglobin and/or haematocrit
Fasting blood glucose and glycated HbA1c
Blood lipids: total cholesterol, LDL cholesterol, HDL cholesterol
Blood triglycerides
Blood potassium and sodium
Blood uric acid
Blood creatinine and eGFR
Blood liver function tests
Urine analysis : microscopic examination; urinary protein by dipstick test or, ideally,
albumin:creatinine ratio
12-lead ECG

Assessment of Hypertension-
mediated Organ Damage (HMOD)
Basic Screening Tests Indication and Interpretation
12-lead ECG LVH screening and other cardiac disorders,
and arrhythmias atrial fibrillation
Albuminuria Qualitative urine protein for detection of
kidney damage
Funduscopy Detection of hypertensive retinopathy,
especially in grade 2-3 hypertension

Advanced Screening Tests Indication and Interpretation
Echocardiography Detection of cardiac structural and functional
abnormalities, if they have an impact on
management
Carotid Ultrasonography Measure intima media thickness and carotid
plaque
Abdominal Doppler Ultrasonography Evaluation of kidney size and structure,
evaluation of aneurysms or dilatation of
abdominal aorta, evaluation of adrenal glands
(CT/MRI if facilities are available)
Pulse wave velocity (PWV) As an index of arterial stiffness and
arteriosclerosis:
- Pulse pressure (at elderly) ≥60 mmHg
- Carotid-femoral PWV >10 m/s
Ankle-brachial index (ABI) Screening for the presence of leg blood vessel
disease (ABI <0.9)
Cognitive function test Evaluation of cognitive function in patients
with symptoms of cognitive impairment
Brain imaging Evaluation of ischemic or cerebral hemorrhage,
especially in patients with a history of stroke or
cognitive decline
Risk Classification of Hypertension
• Based on blood pressure level, cardiovascular risk factors,
HMOD, or comorbidity
Hypertension Other Risk Grade of Blood Pressure
Disease Staging Factors, High Grade 1 Grade 2 Grade 3
HMOD, or Normal
Disease
Stage 1 No other risk Low risk Low risk Moderate High risk
(uncomplicated) factors risk
1 or 2 risk Low risk Moderate Moderate- High risk
factors risk high risk
≥ 3 risk factors Low- Moderate- High risk High risk
moderate high risk
risk
Stage 2 Moderate- High risk High risk High-very high
(asymptomatic high risk risk
disease)
Stage 3 (establised Very high risk Very high risk Very high Very high risk
disease) risk
Management of Hypertension
1. Lifestyle Interventions
Lifestyle Interventions Note
Restrictions on salt consumption Sodium use should be no more than 2 grams/day
(equivalent to 5-6 grams of NaCl per day or 1
teaspoon of salt)
Changes in diet Consume balanced foods containing vegetables, nuts,
fresh fruits, low-fat dairy products, wheat, fish, and
unsaturated fatty acids (especially olive oil), and limit
the intake of red meat and saturated fatty acids
Weight loss and maintaining ideal Prevent obesity (BMI >25 kg/m2) and target ideal
body weight body weight (BMI 18.5-22.9 kg/m2) with waist
circumference <90 cm (male) and <80 cm (female)
Regular exercise Exercise at least 30 minutes of moderate intensity
dynamic aerobic exercise (such as: walking, jogging,
cycling or swimming) 5-7 days per week
Stop smoking
2. Summary of Office BP Thresholds for Treatment
ESC JNC 8
Age SBP (mmHg) DBP Age Group SBP DBP
Group (mmHg)
(mmHg) (mmHg)
Hyper- +Diabe +CKD +CAD +Stroke
tension tes / TIA
General population (no diabetes or CKD)
18-65 ≥140 ≥140 ≥140 ≥140 ≥140 ≥90
years <60years ≥140 or ≥90
65-79 ≥140 ≥140 ≥140 ≥140 ≥140 ≥90 ≥60 years ≥150 or ≥90
years
Diabetes or CKD present
≥80 ≥160 ≥160 ≥160 ≥160 ≥160 ≥90
years ≥18 years ≥140 or ≥90
with CKD
DBP ≥90 ≥90 ≥90 ≥90 ≥90
(mmHg) ≥18 years ≥140 or ≥90
)
with
diabetes

2. JNC 8. JAMA 2014; 310(12)
Initiation of BP-Lowering Treatment at
Different Initial Office BP Levels
Grade 1 Grade 2 Grade 3
High Normal BP
Hypertension Hypertension Hypertension
Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle advice
Consider drug Immediate drug Immediate drug Immediate drug

treatment in very treatment in high or very
high risk patients with
treatment in all treatment in all
high risk patients CVD, renal disease or patients patients
with CVD, especially HMOD
CAD
Drug treatment in low-
moderate risk patients Aim for BP control Aim for BP control
ESC without CVD, renal disease
or HMOD after 3-6 months
within 3 months within 3 months
of lifestyle intervention if BP
not controlled 1. ESC/ESH. European Heart Journal 2018; 39:3021-3104
JNC 8
1. JNC 8. JAMA 2014; 310(12)

3. Hypertension Treatment Target
ESC JNC 8
Age SBP Target (mmHg) DBP Age Group SBP Target DBP Target
Group Target
Hyper- +Diabete +CKD +CAD +Stroke/ (mmHg) (mmHg) (mmHg)
tension s TIA
18-65 Target Target Target Target Target 70-79
General population (no diabetes or CKD)
years ≤130 if it ≤130 if it ≤130 if it ≤130 if it ≤130 if it
can be can be can be can be can be <60 years <140 <90
tolerated tolerated tolerated tolerated tolerated
but not but not but not but not but not ≥60 years <150 <90
<120 <120 <120 <120 <120
65-79 Target Target Target Target Target 70-79 Diabetes or CKD present
years 130-139 130-139 130-139 130-139 130-
if it can if it can if it can if it can 139* if it ≥18 years with <140 <90
be be be be can be
tolerated tolerated tolerated tolerated tolerated CKD
≥80 Target Target Target Target Target 70-79 ≥18 years with <140 <90
years 130-139 130-139 130-139 130-139 130-
if it can if it can if it can if it can 139* if it diabetes
be be be be can be
tolerated tolerated tolerated tolerated tolerated
DBP 70-79 70-79 70-79 70-79 70-79
Target
(mmHg)
2. JNC 8. JAMA 2014; 310(12)
*For lacunar strokes: the target of decreasing SBP is 120-130 mmHg
4. Drug Therapy
5 main classes of antihypertensive drugs that
are routinely recommended, that is:
• ACE inhibitor
• ARB
• Beta blocker
• CCB
• Diuretic

Contraindications of Antihypertensive Drugs
Drug Contraindications
Compelling Possible
Diuretics (Thiazides/thiazide-like, • Gout • Metabolic syndrome

eg chlortalidone and • Glucose intolerance
indapamide) • Pregnancy
• Hypercalcaemia
• Hypokalaemia
Beta Blocker • Asthma • Metabolic syndrome
• Any high-grade sinoatrial or • Glucose intolerance
atrioventricular block • Athletes and physically active
• Bradycardia (HR <60 patients
beats/min)
Calcium Channel Blocker • Tachyarrhythmia
(Dihydropyridines) • Heart failure (HFrEF, class III or
IV)
• Pre-existing severe leg
oedema
Contraindications of Antihypertensive Drugs
Drug Contraindications
Compelling Possible
Calcium Channel Blocker (Non- • Any high-grade sinoatrial or • Constipation

Dihydropyridines) atrioventricular block
• Severe LV dysfunction (LV
ejection fraction <40%)
• Bradycardia (HR <60
beats/min)
ACE Inhibitor • Pregnancy • Women of child-bearing

• Previous angioneurotic potential without reliable
oedema contraception
• Hyperkalaemia (potassium
>5.5 mEq/L)
• Bilateral renal artery stenosis
Angiotensin Receptor Blocker • Pregnancy • Women of child-bearing
• Hyperkalemia (potassium >5.5 potential without reliable
mEq/L) contraception
• Bilateral renal artery stenosis

Oral Antihypertensive Drugs
Class Drugs Dosis Frequency per Day
(mg/day)
First Line Drugs
Thiazide or thiazide-type Hydrochlorothiazide 25-50 1
diuretics
Indapamide 1.25-2.5 1
ACE inhibitor Captopril 12.5-150 2 or 3
Enalapril 5-40 1 or 2
Lisinopril 10-40 1
Perindopril 4-16 1
Ramipril 2.5-10 1 or 2

(mg/day)
First Line Drugs
ARB Candesartan 8-32 1
Eprosartan 600-800 1 or 2
Irbesartan 150-300 1
Losartan 50-100 1 or 2
Olmesartan 20-40 1
Telmisartan 20-80 1
Valsartan 80-320 1
CCB – Dihidropiridine Amlodipin 2.5-10 1
Felodipin 5-10 1
Nifedipin LA 60-120 1
(mg/day)
First Line Drugs
CCB – Nondihidropiridine Diltiazem SR 180-360 2
Diltiazem CD 100-200 1
Verapamil SR 120-480 1 or 2
Second Line Drugs
Loop duretic Furosemide 20-80 2
Torsemide 5-10 1
Potassium saving kalium Amilorid 5-10 1 or 2
diuretic
Triamteren 50-100 1 or 2
Aldosteron antagonist Eplerenon 50-100 1 or 2
diuretic
Spironolactone 25-100 1

(mg/day)
Beta blocker – Atenolol 25-100 1 or 2
Cardioselective
Bisoprolol 2.5-10 1
Metoprolol 100-400 2
tartrate
Beta blocker – Nebivolol 5-40 1
Cardioselective and
vasodilator
Beta blocker – Propranolol IR 160-480 2
noncardioselective
Propranolol LA 80-320 1
Beta blocker – Cardivelol 12.5-50 2
Combination of α and β
receptors

(mg/day)
Alpha-1 blocker Doxazosine 1-8 1
Prazosine 2-20 2 or 3
Terazosine 1-20 1 or 2
Central alpha-1 agonist Metildopa 250-1000 2
and other central drugs
Clonidine 0.1-0.8 2
Direct vasodilator Hydralazine 25-200 2 or 3
Minoxidil 5-100 1-3

Side Effects of Antihypertensive Drugs
Class Side Effects
ACE inhibitor Cough, hyperkalemia
Angiotensin receptor blocker Hyperkalemia is less common than ACEi
Calcium channel blocker
• Dihidropiridine Foot edema, headache
• Non-dihidropiridine Constipation (verapamil), headache (diltiazem)
Diuretic Frequent urination, hyperglycemia, hyperlipidemia,
hyperuricemia, sexual dysfunction
Alpha-agonist center Sedation, dry mouth, rebound hypertension, sexual
dysfunction
Alpha blocker Foot edema, ortostatic hypotension, dizziness
Beta blocker Weakness, bronchospasm, hyperglycemia, sexual
dysfunction

5. Drug Therapy Algorithm for Hypertension
Main recommendation:
• Treatment initiation in most patients with a combination of
2 drugs
• Combination 2 drugs that are often used are RAS blockers,
namely ACEi or ARB, with CCB or diuretics
• Combination of beta blockers with diuretics or other groups
is recommended if there are specific indications, such as
angina, post-AMI, heart failure, and heart rate control
• Consider monotherapy for stage 1 hypertensive patients
with low risk (SBP <150 mmHg), patients with high-normal
BP and very high risk, elderly (≥80 years) or fragile patients

5. Drug Therapy Algorithm for Hypertension
Main recommendation:
• Use of a combination of 3 drugs consisting of RAS
blockers (ACEi or ARB), CCB, and diuretics if BP is not
controlled by a combination of 2 drugs
• Addition of spironolactone for the treatment of
resistant hypertension, unless there are
contraindications
• Addition of other drugs in certain cases if BP has not
been controlled by the above combination of drugs
• Combination of 2 RAS blockers is not recommended

Core Drug Treatment Strategy for Uncomplicated Hypertension
ESC
Consider monotherapy in
Initial therapy low-risk grade 1 hypertension
Dual combination ACEi or ARB + CCB or diuretic (SBP <150 mmHg, or in very
old (≥80 years) or frailer
patients
Step II
ACEi or ARB + CCB or diuretic
Triple combination
Consider referral to a
Step III Resistant Hypertension specialist centre for further
Triple combination + Add spironolactone (25-50 mg investigation
spironolactone or other o.d.) or other diuretic, alpha-
drug blocker or beta-blocker 1. ESC/ESH. European Heart Journal 2018;
39:3021-3104
Beta-blockers
Consider beta-blockers at any treatment, when there is a specific indication for their use, e.g.
heart failure, angina, post-MI, atrial fibrillation, or younger women with, or planning pregnancy
JNC 8
1. JNC 8. JAMA 2014; 310(12)

Guideline Population Initial Drug Treatment
Options
ESH/ESC 2018 General non-elderly ACEi or ARB + CCB or
General elderly <80 years diuretic
General very old ≥80 years Diuretic, BB, CCB, ACEi, or

ARB
JNC 8 2014 General ≥60 years Nonblack: Thiazide-type

General <60 years diuretic, ACEi, ARB, or CCB
Black: Thiazide-type
Diabetes diuretic or CCB
CKD ACEi or ARB

2. JNC 8. JAMA 2014; 310(12)
Drug Treatment Strategy for Hypertension and
Coronary Artery Disease Consider monotherapy in
ACEi or ARB + beta-blocker or CCB low-risk grade 1 hypertension
Initial therapy or CCB + diuretic or beta-blocker (SBP <150 mmHg, or in very
Dual combination or beta-blocker + diuretic old (≥80 years) or frailer
patients
Consider initiating therapy

Step II when SBP is 130 mmHg in
Triple combination of above these very high risk patients
Triple combination
with established CVD
Step III Resistant Hypertension

Consider referral to a
Triple combination + Add spironolactone (25-50 mg specialist centre for further
spironolactone or other o.d.) or other diuretic, alpha- investigation
drug blocker or beta-blocker
Chronic Kidney Disease
ACEi or ARB + CCB Beta-blockers
Initial therapy or ACEi or ARB + diuretic (or loop Consider beta-blockers at any
Dual combination diuretic) treatment step, when there ais
a specific indications for their
use, e.g. heart failure, angina,
post-MI, atrial fibrillation, or
Step II ACEi or ARB + CCB + diuretic young women with, or planning
Triple combination (or loop diuretic) pregnancy
Step III Resistant hypertension

Triple combination + Add spironolactone (25-50 mg
spironolactone or other o.d.) or other diuretics, alpha-
drug blocker or beta-blocker
A reduction in eGFR and rise in serum creatinine is expected in patiensts with CKD who receive
BP-lowering therapy, especially in those with an ACEi or ARB but a rise in serum creatinine of
>30% should prompt evaluation of the patient for possible of renovascular disease
Heart Failure with Reduced Ejection Fraction
ACEi or ARB + diuretic (or loop
Initial therapy
diuretic) + beta-blocker
ACEi or ARB + diuretic (or loop

Step II
diuretic) + beta-blocker + MRA
When antihypertensive therapy is not required in HFrEF, treatment should be prescribed

according to the ESC Heart Failure Guidelines

Atrial Fibrillation
ACEi or ARB + beta blocker
Initial therapy
Or CCB non-DHP,
Combination of 2 drugs or beta blocker + CCB
ACEi or ARB + beta blocker + CCB

Step II
DHP or diuretic
Combination of 3 drugs Or beta blocker + CCB DHP + diuretic
Add oral anticoagulants if there are indications according to the CHA2DS2-VASc score, unless
there are contraindications.
Routine combinations between beta blockers and CCB non-DHP (eg verapamil or diltiazem) are
not recommended because the risk of a significant decrease in heart rate

6. Device-based Hypertension Treatment
• Especially for types of hypertension that are
resistant to drugs
• Example:
– Carotid baroreceptor stimulation (pacemaker and
stent)
– Renal denervation
– Creation of an arteriovenous fistula

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Urgency and Emergency

BP refers to Blood Pressure in this slide presentation

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

Normal 120-129 and/or 80-84 Pre 120-139 or 80-89

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

Consider Masked Out-of-office BP

Repeat BP at Repeat BP at Out-of-office BP

ABPM: Ambulatory blood pressure monitoring

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle advice

Consider drug Immediate drug Immediate drug Immediate drug

1. JNC 8. JAMA 2014; 310(12)

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

Diuretics (Thiazides/thiazide-like, • Gout • Metabolic syndrome

Calcium Channel Blocker (Non- • Any high-grade sinoatrial or • Constipation

ACE Inhibitor • Pregnancy • Women of child-bearing

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. JNC 8. JAMA 2014; 310(12)

General very old ≥80 years Diuretic, BB, CCB, ACEi, or

JNC 8 2014 General ≥60 years Nonblack: Thiazide-type

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

Consider initiating therapy

Step III Resistant Hypertension

Step III Resistant hypertension

ACEi or ARB + diuretic (or loop

When antihypertensive therapy is not required in HFrEF, treatment should be prescribed

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

ACEi or ARB + beta blocker + CCB

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

1. ESC/ESH. European Heart Journal 2018; 39:3021-3104

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