and
HYPERTENSION URGENCIES
Case based approach and management
Introduction
• It includes
– Hypertensive Emergency
– Hypertensive Urgency
Hypertensive Emergency
• Characterised by severe increase in systolic and/or diastolic blood pressure
assosciated with signs or symptoms of acute end-organ damage.
• IV drugs
Hypertensive Emergencies
Hypertensive encephalopathy
Hypertension assosciated with acute cerebrovascular disease
Hypertension assosciated with pulmonary edema
Hypertension assosciated with acute coronary syndromes
Hypertension assosciated with dissecting aortic aneurysm
Pheochromocytoma
Hypertension associated with acute renal failure
Eclampsia
Microangiopathic anemia
What is the primary reason for hypertensive
emergencies ?
1. Renovascular Disease
2. Pheochromocytoma
3. Non-adherence to anti-hypertensive medication
4. Hyperaldosteronism
5. Erythropoeitin
Hypertensive Urgency
Increase in
PRESSURE Increase in SVR
NATRIURESIS BP
Mechanical stress
Endothelial injury
RAAS IL-6
Activation of
coagulation
End organ cascade,platelets
hypoperfusion, Increased
ischemia, permeability
dysfunction Deposition
of fibrin
ischemia Fibrinoid
necrosis
Vaughan and Delanty Lancet 2000; 356:411
Vaughan and Delanty Lancet 2000; 356:411
CASE 1
• A 65 yr old male, hypertensive, chronic smoker, driver by
occupation admitted in ED with c/o headache since 3 days,increased
in severity over the past one day, associated with vomitings and
altered sensorium.
• Admit ?/ OPD Rx ?
• IV drugs / oral?
CASE 3
• A 28 yr old female, primi (6 months amenorrhea) was referred to
physician with
c/o headache,vomitings,decreased urine output.
her BP was recorded to be 170/100 mm Hg
• What to do ?
• Admit ?
• Normalize BP ?
CASE 4
• What to do ?
• Normalize BP?
CASE 5
• What to do ?
• Normalize BP ?
CASE 6
• A 23 yr old male,degree student, was brought to casualty with
sudden onset of SOB since 2 hours,saturations at room air
were normal.
• BP – 180/100 mm Hg
• CVS/RS –NAD
• What to do ?
• IV/oral/reassurance
Clinical assessment
• Grade 1 Grade 3
– Mild narrowing of the arterioles Severe Narrowing -
– “Copper Wire” Silver wire changes,
hemorrhage, cotton wool
• Grade 2 spots, hard exudates
– Moderate narrowing – Grade 4
– Copper wire and AV nicking Grade 3 + Papilledema
• Blood electrolytes
• Creatinine
• Urea nitrogen
• Cell count
• Smear (microangiopathic hemolysis)
• ECG
• CXR
• CT Brain
• CT chest/MRI
Management
Normalisation of BP is usually not
recommended*
How fast and how much BP to be lowered to be given importance.
Why ??
Vasculature - aortic
dissection, eclampsia
• GOAL reduce MAP by no more than 20-25%,
DBP to 100-110mm Hg within few minutes to 2 hours.
Easily titratable
Impaired
Lesions in
neurogenic HIGH BP
cerebral area
control of CVS
• IV Labetalol or Nicardipine .
• IV tPA (if to be given) BP <185/110mm Hg.
Stroke 2003;34:1056-83
IC bleed
reduction in BP.
Nimodipine, a dihydropyridine calcium blocker,is effective
Excessive
HIGH
increase LOCALISED
OR
BLOOD in HYPERFILTRATION
WIDESPREAD
PRESSURE EDEMA
cerebral
blood flow
Circulation,2004;110:2241-5
Eclampsia
Pheochromocytoma
Cocaine intoxication
Abuse of sympathomimetics
Post operative Hypertension
• IV labetalol
• Pheochromocytoma crisis (IV alpha blocker phentolamine)
followed by B blocker(for tachycardia or VPCs).
ORAL DRUGS FOR HTN URGENCIES
Drug Initial dose Onset duration Adverse effects
Acute and transient BP elevations
• Anxiety
• Panic attacks
• Pain
Rx - Administration of anxiolytic or analgesic drugs.