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CRISIS

HYPERTENSION
dr. Isra Sukhraini Nst
How blood pressure regulated?

Lilly Leonard S. Pathophysiology of Heart Disease. 6th Edition


Organ Damage Caused by Hypertension

Lilly Leonard S. Pathophysiology of Heart Disease. 6th Edition


Hypertensive crisis
(acute increasing of BP >180/120
mmHg)

Hypertensive Emergencies
Hypertensive Urgency
Markedly elevated BP
Markedly elevated BP
With acute or progressing
Without severe symptoms or
target organ damage
progressive target organ damage
BP should be reduced immediate
BP should be reduced within hours
PARENTERAL AGENTS
ORAL AGENTS

Kaplan, NM. Clinical Hypertension 11th Ed: 263, JNC7 report:54


Sign and symptom Hypertensive Crisis
Hypertensive Urgency Hypertensive Emergency
• Asymptomatic • Chest pain
• Severe Headache • Back pain
• Dyspnea • Dyspnea
• Nose bleeding • Seizure
• Anxiety • Visual disturbunces
• Altered level of consciousness
• Nausea-vomiting
HBP Sign:
• Myocardial infarction
• Aortic dissection
• Pulmonary edema
• Acute Kidney Injury
• Malignant Nephroscerosis
• Retinal Hemorrhage or Papiledema
• Hypertensive Encephalopathy
• Hemorrhagic Stroke
• Lacunar Infarct
End- Organ Damage in Hypertensive Emergencies

• Brain • Retina
• Hypertensive • Hemorrhage
Encephalopathy
• Stroke • Exudates
• Lacunar Infarct • Papiledema

• Cardiovascular system
• Unstable angina • Kidney
• Acute heart failure • Hematuria
• Acute Myocardial • Proteinuria
infraction • Decreasing renal
• Acute aortic dissection function
• Aneurysm
Laboratory Evaluation
• Complete Blood Count
• Urine analysis
• Ureum/creatinine
• Electrolytes
• Electrocardiogrphy
• Chest radiograph
• Plasma renin activity and aldosterone
• Plasma for metanephrine
Management Of Hypertensive Crisis
Management of Hypertensive Urgency
• Hypertensive urgencies can generally be managed with oral
medications as an outpatient. BP should be lowered over 24-
48 hours
• Important to prevent too-rapid lowering due to
autoregulation of flow by pressure in brain, heart, and
kidneys
• Treat with oral agent
• Agents: Nitrates, Captopril, Clonidine, Labetalol
Hypertensive Crises: Emergencies and Urgencies
COR LOE Recommendations for Hypertensive Crises and Emergencies
In adults with a hypertensive emergency, admission to an intensive care unit is
recommended for continuous monitoring of BP and target organ damage and
I B-NR for parenteral administration of an appropriate agent.

For adults with a compelling condition (i.e., aortic dissection, severe


preeclampsia or eclampsia, or pheochromocytoma crisis), SBP should be
I C-EO reduced to less than 140 mm Hg during the first hour and to less than 120 mm
Hg in aortic dissection.

For adults without a compelling condition, SBP should be reduced by no more


than 25% within the first hour; then, if stable, to 160/100 mm Hg within the
I C-EO next 2 to 6 hours; and then cautiously to normal during the following 24 to 48
hours.

Whelton PK et al, High Blood Pressure Clinical Guideline , ACC/AHA 2017, (17)41519-1 : 143
Diagnosis and Management of a Hypertensive Crisis
SBP >180 mm Hg and/or
DBP >120 mm Hg

Target organ damage new/


progress ive/worsening

Yes No

Hypertensive
Markedly elevated BP
emergency

Admit to ICU
(Class I) Reinstitute/intensif y oral
antihypertens ive drug therapy
and arrange fo llow-up

Cond itions:
• Aortic dissecti on
• Severe preeclampsia or eclampsia
• Pheochromocytoma crisis

Yes No

Reduce SB P to <140 mm Hg Reduce BP by max 25% over first h†, then


during first h* and to <120 mm Hg to 160/100–110 mm Hg over next 2–6 h,
in aortic dissection† then to normal over next 24–48 h
(Class I) (Class I)
Whelton PK et al, High Blood Pressure Clinical
Guideline , ACC/AHA 2017, (17)41519-1 : 144
Recommended antihypertensive Agents for Hypertensive Crisis
Conditions Prefered Antihypertensive Agents
Acute Pulmonary Edema/ systolic disfunction Nicardipin, Fenoldapam, or Nitropruside in combination
with Niroglyserin and loop diuretic
Acute Pulmonary Edema/ diastolic dysfunction Esmolol, Metoprolol, Labetalol, or verapamil in combination
with low dose nitroglycerin and loop diuretic

Acute myocard Ischemia Labetalol or Esmolol combination with Nitroglyserin


Hypertensive Encephalopaty Nicardipine, Labetalol or Fenoldapam
Acute aortic dissection Labetalol or combination Nicardipine and Esmolol or
combination of Nitropruside with either Esmolol or IV
Metoprolol
Pre eclmapsia- Eclampsia Labetalol or Nicardipine
Acute Renal Failure/ Microangiopathic anemia Nicardipine, Fenoldapam
Sympatetic crisis Verapamil, Diltiazem, or Nicardipine in combination with a
benzodiazepine
Acute Ischemic Stroke/Intracerebral bleed Nicardipine,Labetolol, or Fenoldapam
Acute Posoperative Hypertension Esmolol, Nicardipine, or Labetolol
Marik Paul E, Varon Joseph, CHEST 2007;131:1949-62
Kaplan, NM. Clinical Hypertension 11th Ed: 270
Kaplan, NM. Clinical Hypertension 11th Ed: 271
Classification of Channel Blocker
Nicardipine
• Dihydropiridine Channel Blocker
• Potent arteriodilator penurunan afterload/SVR
• Particularly useful in neurological scenarios, as it doesn’t raise ICP and
directly reduce cerebral ischemia
• Has mild negative inotropic effect
• Contraindicated advanced Aorta Stenosis
• Doses: Initial 5 mg/h, increasing every 5 min by 2.5 mg/h to maximum 15
mg/h.

Katzung BG et al, Basic & Clinical Pharmacology 10th Ed


Whelton PK et al, High Blood Pressure Clinical Guideline , ACC/AHA 2017, (17)41519-1 : 142
block inward movement
of calcium ions in the
heart and in smooth
muscle of the peripheral
vasculature
Nicardipine

Perifer resistance

Blood Pressure
Differences of tissue selectivity between dihydropiridines (nicardipine
and others), diltiazem and verapamil:
Peripheral and Depression of Depression of Depression of
coronary cardiac SA node AV node
vasodilation conteractility

+++++ + + 0
Nicardipine

+++ ++ +++++ ++++


Diltiazem

++++ ++++ +++++ +++++


Verapamil

Kerins DM. Goodman Gilman’s.10th ed.2001:843-70


Nitroglyserine (NTG) iv

• Primarily a venodilator, has modest effect on afterload at high dose

• Drug of choice in setting of myocardial ischemia, acute Myocard


Infarct and Congestive Heart Failure

• NTG directly increase cerebral blood flow and riase ICP

• Doses: Initial 5 mcg/min; increase in increments of 5 mcg/min every


3–5 min to a maximum of 20 mcg/min
Katzung BG et al, Basic & Clinical Pharmacology 10th Ed
Whelton PK et al, High Blood Pressure Clinical Guideline , ACC/AHA 2017, (17)41519-1 : 142