Hijpertensi.Grea Essential Chronic renal disease Primary aldosteronism Renovascular Pheochromocytoma Coarctation of the aorta Cushing syndrome 90% 26% <2%-15% (varies by sensitivity of sereening) 1% 0.2% 0.1% 0.1% © Age of onset: 20-50 years ‘Family history of hypertension ‘= Normal serum K*, urinalysis '* T Creatinine, abnormal urinalysis © L Serum ke ‘Abdominal bruit ‘+ Sudden onset (especialy if age >50 or <20) © 4 Serum Ke ‘+ Paroxysms of palpitations, diaphoresis, ‘and headache + Weight loss * Episodic hypertension in one third of patients + Blood pressure in arms > legs, o right arm > left arm ‘+ Midsystolic murmur between scapulae * Chest xray: aortic indentation, rib- notching due to arterial collaterals ‘+ “*Cushingoid” appearance (e.g, central obesity, hirsutism)Blood Pressure asia ee ES =a in =I = ean = + PSNS (L) “+ Angiotonsin I(T) +c4-Recoptors (P) sion “+ Homatoerit (1) sus (1) “Catecholamines (P)_ +s Receptors (L). +“ Endothain (1) + Catecholaminas (1) (HTL) + Oxygen (7) Adenosine (1) eminaiy] oR *Prosagianins (1) Es + Catecholamines (7) + SNS (1) ae) ae Se eB *SNS (1) + Catacholamines (1) Renal] + Thirst (1) telenion (Ne, HO) + Aldosterone (7) ADHD, #SNS (1) +NPC) Figure 13.2. Regulation of systemic blood pressure. The small avows indicate whether thee is 2 stimulatory (1) or inhibitory (1) effect onthe bowed parameters. ADH, antidiuretic hormone: HR, heart rate: NP, natiretic peptides; PSNS, paresympathetic nervous sytem: SKS, sympathetic nervous system; SY, stoke volume.Blood vessel Functional: + E Nitric oxide secretion + T Endothelin production + Ca®* of Na‘/K" channel defects + Hyperrespansiveness to catecholamines ens + 1 Basal sympathetic tone + Abnormal stress response + Abnormal response to signals from baroreceptors and volume receptors Pressure/volume receptors * Desensitization Structural: + Exaggerated medial hypestoohy { oN ‘are Kidney + Catecholamine leak + RAA dysfunction or malregulation * lon channel defects (e.g., Na‘/K*/2CI- colransporter, basolateral Na“/K= ATPase, Ca®* ATPase) Figure 13.3. Potential primary abnormalities in essential hypertension. These defects are supported by experimental evidence, but their specific contributions to essential hypertenson remain unknown. CNS, central nervous systom; RA, renin-angiotensin-aldosterone system,Co. Peripheral Cardiac ’ sgn eo) po “32 em) and thn arme, respectively. + To have the cuff atthe heart evel, whatever the position of the patient. * When adopting the auscutatory method, use phase | and V (disappearance) Korotkoff sounds to identify systolic and diastolic BP, respectively + To measure BP in both arms at first vst vo detect possible aifferences. In this instance, take the arm with the higher value as she reference. + To measure at the firs vit, BP | and 3 min after assumption of the standing position In elderly subjects, diabetic patents, and in cother conditions in which orchostatic hypotension may be frequent or suspected + To measure, in case of conventional BP measurement, heart rate ‘by pulse palpation (at least 30) after the second measurement in she sitting position {BP = blood pressureClassification of Blood Pressure in Adults Normat <120 And <80 Prehypertension 120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99 Stage 2 hypertension 2160 Or =100 Modif from The seventh report of the Joint Natfonal Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, ‘TAMA. 2003;280:2560-2572Table 3 Definitions and classification of office blood pressure levels (mmHg)* Category systolic Diastolic Optimal <120 and <80 Normal 120-129 and/or 80-84 High normal 130-139 and/or 85-89 Grade | hypertension 140-159 and/or 90-99 Grade 2 hypertension 160-179 and/or | 100-109 Grade 3 hypertension 2180 and/or 2110 Isolated systolic hypertension >140 and <90 *The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated,Table 6 Definitions of hypertension by office and out-of-office blood pressure levels Category Systolic BP Diastolic BP (mmHg) (mmHg) Office BP 2140 and/or | 90 Ambulatory BP Daytime (or awake) 2135 andlor | >85 Nighttime (or asleep) 2120 andlor | >70 24-h >130 andlor | >80 Home BP 2135 and/or >85 BP = blood pressure.Figure, 2014 Hypertension Guideline Management Algorithm Adult age 218 years with hypertension Implement ifestye interventions (continu throughout management. Set bloodpressure goa nd initit blood pressure lowerng- medication bse on age, labetes, and chronic key dsease (CKD) ‘General population (odiabetesor CKD) Diabetes or CKD present ‘Age 260 years ‘Age <60 years ‘Allages Allages Diabetes present KD present with eo lorwithour diabetes Blood pressure goal lod pressure goal ‘lood pressure goal lod pressure goal 8? <150mmtig sap + reamentag onto’ SBP indicates sto blond pressure BP. ast blood pressure ACEI * aces and ARBS should not bo used ncombnacen. nglotersin converting enzyme; ARB, angiotensin eceptr blocker. and¢cB, Pi bloodpressure fal tobe mamntaned at goa rarer the algorthm where ‘alciumerame! beck. ppeopiate based onthe cure ndviualtheapait plan,‘Table 5, Strategies to Dose Antihypertensive Drugs Strategy _ Description Details a Start one drug, titrate to maximum Tf goal BP isnot achieved withthe itil drug, titrate the dose ofthe initial drug upto the maximum ‘dose, and then adda second rug ‘recommended dose to achieve goal BP I goal BP is not achieved withthe use of one drug despite titration to the maximum recommended ‘ose, adda secon drug from the lst (thlazide-type duretc, CCB, ACE, or ARB) and titrate upto the maximum recommended dose of the second drug to achieve goal BP If goat BP isnot achieved with 2 drugs, solecta third rug from the list (thlazde-type diuretic, CCB, [ACEI ARB), avoiding the combined use of ACE! and ARB, Titrat the third drug up t the maximum recommended dose to achieve goal BP 8 Start one drug and then adda second Start with one drug then ada second drug before achieving the maximum recommends dose ofthe ‘rug before achieving maximum dose intial drug, then titrate both drugs upto the maximum recommended doses of both to achieve goal BP ‘ofthe initial drug If goal BP isnot achieved with 2 drugs, select a third rug from the list (thiazde-type cluetic, CB, ‘ACEI, or ARB), avoiding the combined use of ACEI and ARB, Titra the third drug up te the maximum recommended dose to achieve goa BP c Begin with 2 drugs a the same time, _Intate therapy with 2crugs simultaneousy elther as 2 separate drugs ora single pill combination, ‘elther as 2 separate pills or asa single Some committee members recommend stating therapy with 22 drugs when SBP is >160 mm Hg pillcombination| and/or DBP is >100 mm Hg, or SBP Is >20 mun Hg above goal and/or DBP s >10 mm Hg above goa. I ‘goal BP snot achiaved with 2 rugs, select 2 third drug fom the lst (ehazide-type diuretic, CB, ‘ACE, or ARB), avoiding the combined use of ACE|and ARB, Tirate the third drug up t the maximum recommended dose. ‘Abbreviations: CEL angjotensin-converting enzyme: ARB, angiotensin receptor blocker, BP blood pressure; CCB, calcum channel blocer DBP, dastoic blood pressure: SBP systolic blood pressure.‘able 6. Guideline Comparisons of Goal BP and initial Drug Therapy for Adults With Hypertension Goal Guideline Population ‘mmHg nila Drag Treatment Options 2014 Hypertension General =60y 150/90 Nonblack: thiazide-type duretic, ACEI, ARB, ‘guideline orcs General <60y -<140/90 Blac: thazide-type diuretic or CB Diabetes 140/90 Thiaride-type diuretic, ACEI, ARB, oF CCB xo -<140/90 ACEI or ARB. ESH/ESC2013°7 General nonelderly <140/90 Blocker, diuretic, CCB, ACEL, or ARB General elderly <80y 150/90 General 280 150/90 Diabetes 140/85 ACElor ARB (XD proteinuria 140/90 ACElor ARB (KD + proteinuria -<130/90 ‘cHEP 2013°*| General <80y <140/90 Thine blocker (age 603), ACEI onl), 130/90 -<130/80 ACEI or ARB with addtional CVD risk ‘ACEI, ARB, thiaide, or DHPCCB without addi- tional CVD risk xo 140/90 ACElor ARB -apa2013" Diabetes <140/80 ACEIor ARB K0IG0 2012 (KD no proteinuria 5140/90 ACEIor ARB KD + proteinuria 130/80 Nice 2011" General <80y -<140/90 <55,: ACEI or ARB General 280 150/90 255 yorblack- CCB tsi 2010" Black, lower risk 135/85 Diuretic or CCB Target organ damage 130/80 or cvDrisk Abbreviations: ADA, American Diabetes Association: ACEL angiotensin converting enzyme inhibitor ARB, angiotensin receptor blocker: CCE, calcium channel blocker: CHEP, Canadian Hypertension Education Program: (CKD, chronic kidney disease: CVD, cardiovascular disease; DHPCCB, dihydropyridine caleum channel blocker: ESC, European Society of Cardiology ESH, European Society of Hypertension; ISH, international ‘Society for Hypertension in Blacks: INC, Joint National Committe: KOIGO, Kidney Disease: Improving ‘Global Outcome: NICE, National Institute for Health and Clinical, Excelence.HYPERTENSIVE CRISIS Christopher J. Rees, MD and Charles V. Pollack, Jr., MA, MD, FACEP, tela aa What is a hypertensive crisis? The term hypertensive crisis is inclusive of two different diagnoses, hypertensive [Emergency)pnd hypertensive istinguishing between the two is important because they require different intensities of should be noted that older and less specitic terminology, such as “malignant hypertension” and “accelerated hypertension”, should no longer be used. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) defines hypertensive emergency as being “characterized by severe elevations in blood pressure[(more than 180/120 mm Hg], complicated by evidence of impending or progressive target organ dysfunction”. JNC-7 defines hypertensive urgency as “those situations associated with severe elevations in blood pressure without progressive target organ dysfunction”. There is no absolute value of blood pressure that defines a hyperlensive urgency or emergency or separates the two syndromes. Instead, the most important cistinction is whether there is evidence of impending or progressive end-organ damage, which defines an emergency or other symptoms that are felt referable to the blood pressure. How commonly do these situations occur? It is estimated that 50 to 75 million people have hypertension and that 1% of those will have a hypertensive emergency. Hypertension accounts for 110 million emergency department (ED) visits per year, with severe hypertension accompanying as many as 25% of all admissions from the ED.3. What are the causes of hypertensive crisis? The most common cause of hypertensive emergency is an abrupt increase in blood pressure in patients with chronic hypertension, Medication noncompliance is a frequent cause of such changes. Blood pressure control rates for patients diagnosed with hypertension are less than 50%. The elderly and African Americans are at increased risk of developing a hypertensive emergency. Other causes of hypertensive emergencies include stimulant intoxication (cocaine, methamphetamine, and phencyclidine), withdrawal syndromes (clonidine, p-adrenergic blockers), pheachromocytoma, and adverse drug interactions with monoamine oxidase (MAO) inhibitors. 4, What are the common clinical presentations of hypertensive crisis? Typical presentations of hypertensive urgency include severe headache, shortness of breath, epistaxis, or severe anxiety. Clinical syndromes typically associated with hypertensive emergency include hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, pulmonary edema, unstable angina, dissecting aortic aneurysm, or eclampsia. Note ‘hat in hypertensive emergency presentations, there is evidence of impending or progressive ‘target organ dysfunction and that the absolute value of the blood pressure is not pathognomonic5. What historical information should be obtained? A thorough history, especially as it relates to prior hypertension, is important to obtain and document, as most patients with a hypertensive emergency carry a diagnosis of hypertension and are either inadequately treated or are noncompliant with treatment. A thorough medication history is also essential. The patient's current medications need to be reviewed and updated to include timing, dosages, recent changes in therapy, last doses taken, and compliance. Patients should also be questioned about over-the-counter medication usage and recreational drug use because these agents may also affect blood pressure. How should the physical examination be focused? Physical examination should start with recording the blood pressure in both arms with an appropriately sized blood pressure cuff. Direct ophthalmoscopy should be performed with attention to evaluating for papilledema and hypertensive exudates. A brief, focused neurologic examination to assess mental status and the presence or absence of focal neurologic deficits should be performed. The cardiopulmonary examination should focus on signs of pulmonary edema and aortic dissection, such as rales, elevated jugular venous pressure, or cardiac gallops. Peripheral pulses should be palpated and assessed. Abdominal examination should Include palpation for abdominal masses and tenderness and auscultation for abdominal bruits7. What laboratory and ancillary data should be obtained? All patients should have an electrocardiogram performed to assess for left ventricular hypertrophy, acute ischemia or infarction, and arrhythmias. Urinalysis Should be performed to evaluate for Kematuria and proteinuria as signs of acute renal failure. Women of child-bearing age should have @ urine pregnancy test performed. Laboratory studies should include a basic metabolic profile with blood urea nitrogen (BUN) and creatinine and a complete blood cell count (CBC) with a peripheral smear to evaluate for signs of microangiopathic hemolytic anemia. Hf acute coronary syndrome is suspected, cardiac biomarkers should be assessed. Choice of radiographic studies, if any, should be based on the presentation and diagnostic considerations. A chest radiograph is often ordered to evaluate for pulmonary edema, cardiomegaly, and mediastinal widening. If there are any focal neurologic findings, a computed tomography (CT) scan of the brain should be performed to evaluate for hemorrhage. SCS 8. What are the cardiac manifestations of hypertensive emergencies? Cardiac manifestations of hypertensive emergency include acute coronary syndromes, acute cardiogenic pulmonary edema, and aortic dissection. The latter deserves special attention because it has much higher short-term morbidity and mortality, requires more urgent and rapid reduction in blood pressure, and also requires specific inhibition of the refiex tachycardia often associated with blood pressure-lowering agents. It is recommended that patients with aortic dissection have their systolic blood pressure reduced to at least 120 mm Hg within 20 minutes, a much more rapid decrease than is recommended for other syndromes associated with hypertensive emergency.10. 11. 12, What are the renal manifestations of hypertensive emergencies? Renal failure can both cause and be caused by hypertensive emergency. Typically, hypertensive renal failure presents as nonoliguric renal failure, often with hematuria. What are the pregnancy-related issues with hypertensive emergency? Preeclampsia is a syndrome that includes hypertension, peripheral edema, and proteinuria in women after the twentieth week of gestation. Eclampsia is the more Severe form of the syndrome, with severe hypertension, edema, proteinuria, and seizures. What are general issues in the treatment of hypertensive urgency? Patients with hypertensive urgencies often have elevated blood pressure and nonspecific symptoms but no evidence of progressive end-organ damage. These patients do not often require urgent treatment with parenteral antihypertensives. There is no evidence to suggest that urgent treatment of patients with hypertensive urgencies in an emergency department setting reduces morbidity or mortality. In fact, there is evidence that too-rapid treatment of asymptomatic hypertension has adverse effects. Rapidly lowering blood pressure below the autoregulatory range of an organ system (most importantly the cerebral, renal, or coronary beds) can result in reduced perfusion, leading to ischemia and infarction. It is usually appropriate in these situations instead to gradually reduce blood pressure over 24 to 48 hours. Most patients with hypertensive urgency can be treated as outpatients, but some may need to be admitted as dictated by symptoms and situation and to ensure close follow-up and compliance. The most important intervention for hypertensive urgency is to ensure good follow-up, which helps to promote ongoing, long-term control of blood pressure. No guidelines and no evidence support a specific blood pressure target number that must be achieved in order to safely discharge a patient with hypertensive urgency.13. What are general issues in treating hypertensive emergencies? JNC-7 recommends that patients with hypertensive emergencies be treated as inpatients in an intensive care setting with an initial goal of Jand then] This requires parenteral agents. Aortic dissection is a special situation that requires reduction of the systolic blood pressure to at least 120 mm Hg within 20 minutes. Treatment is also required to help blunt the reflex tachycardia associated with most antihypertensive agents. Ischemic stroke and intracranial hemorrhage are also special situations, and guidelines exist for the treatment of hypertension in these settings from multiple experts, including guidelines from the American Stroke Association/American Heart Association (ASA/AHA). These guidelines state that “there is little scientific evidence and no clinically established benefit for rapid lowering of blood pressure among persons with acute ischemic stroke.” Too rapid a decline in blood pressure during the first 24 hours after presentation of an intracranial hemorrhage has been independently associated with increased mortality. The overall weight of evidence currently supports only judicious use of antihypertensive agents in the treatment of acute ischemic or hemorrhagic stroke. Expert Guidance is recommended, especially if fibrinolytic therapy is being considered for acute ischemic stroke.TABLE 44-12 Intravenous Drugs for Treatment of Hypertensive Emergencies DRUG oi fred Gass Labetall 5 0.5 maikg, 2-4 marin unt goal BPs Second-degre of third-degree AV block; reached, thereafter 5-20 mg/h ‘systolic heart flue, COPD (eltire) bradycardia Nicardipine 5.15mi «30-40 min_5-15 mafhr as continuous infusion, starting dose of Liver faire 5 maj, increase q15-30 min with 2.5 mg unt ‘goa BP achieved, thereafter decrease to 3 mgfhr Nivoprusside immediate 1-2 min (03-10 ug/kgfnin, increase by 0.5 jgikghin Livery flue (relative. cyanide toxcty ‘@5 min until goal BP achieved Nitrogen 1-5 min 25 min 5.200 ahnin, S-ughmin increase a min Urapiat 3.5 min 46h 12.5.25 mg as bolus injections, §-40 mgr as «continuous infusion Esmolo! 12min 10:30 min 015-10 mg/g as bolus, 50-300 jg/kgfnin 2s, Second-degree of third-degree AV block, ‘continuous infusion ‘sjstolic hear flue, COPD (eltire bradyeard Phentolamine 12 min 3.5 min 1-5 ma, repeat after $-15 min unt goal BPs Tactyarrhythmia, angina pectoris reached: 05-1 mgr as continuous infusion ‘AV = atioventicular, COPD = chronic obstructive urronary cease. ‘Moaiisa trom van den Bam Bl euter 1) Gallo CA. et at Dutch guideline forthe management of hypertensive crsi-2010 revlon Neth J Med 69:48, 20ttLabetall Labetall Niroprussde + metoproil ‘Ntzoprusside with loop divetc Ntroglycerin Labetall Labetall ‘TABLE 44-13 Recommended Treatment of Hypertensive Emergencies by End-Organ Involved ere) = Mim pee pene cs wih eto Several hous, MAP 20% to -25% Tmcroangopsty, of 3c rel 3 insuicieney 3 syperense encephatopty mee, MAP-20% 19-25% 8 E acute artic dissection Immediate, SBP < 110 men Hg & acute pulmonary edema Immediate, MAP 60 t 100 mmHg ‘Acute coronary syndrome Immediate, MAP 60 t0 100 mm Hi Acute scheme stoke and 8° 1 hour, MAP 15% 220/120 mm Hg Cerebral hemorrhage and $8 1 hou $82 < 180 mm Hg and 180 mm Hg oF MAP>130 mm Hg AP ci30 mm Hg ‘Acute ischemic stoke wth indication 1 hou, MAP ss than 15%, for thrombolyte therapy and BP >18S/110 mm Hg CCocaine/XTC intoxication Several hours, SBP.< 140 mm Hg Pheochromocytoma criss Immediate Perioperative hypertension during or Immediate ater CABG During of after craniotomy mediate Severe preeclampsiaveclampsia Immediate, 8P < 160/105 mm Ha Labetall Phentolamine (after benzodiazepines) Phentolamine Ncaripine Nceripine| Labetalol (pls MgSO. and ‘ofa antinypertensives) ‘ALTERNATIVE ‘THERAPY Nittoprussice | Nearapine | Urapial Nicercipine Nittoprusside Labetall Nitroglycarn rapid with loop disetic Labetaal Ncardipine Nitoprusside Neardipine Nitroprussie Neardipine Nitoprussie Nitroprusside Nitrous | Urania Urapil Nitroglycarn Labetall Ketanserin Nicardipine CCARG = coronary atary bypass gat; MAP = mean arterial pressure; M950, pes slate; XIC = Ecstasy. ‘Moafed trom van dan Born, Beutler, Glfard CA, et ak Dutch gue forthe management of hypertensive crl—2010 revbon. Neth J Med 69:248, 2011.Trimss..