Hypertensive crisis

1. Dr Maged Abulmagd,MD,EDIC
Consultant intensivist,EBGH
Hypertensive Crisis

2. Hypertensive Crisis
• Hypertensive Urgency
SBP >180 or DBP>110 w/o TOD
• Hypertensive Emergency
SBP >180 or DBP>110 (esp >120) +TODs

3. • What is the primary reason for
hypertensive emergencies in the USA
today?
1. A-Renovascular Disease
2. B-Pheochromocytoma
3. C-Non-adherence to anti-hypertensive
medication
4. D-Hyperaldosteronism
5. E-Erythropoeitin

4. The commonest cause of hypertensive emergency in
2011 is undiagnosed,untreated,or undertreated
essential hypertension

5. Epidemiology
Hypertensive emergencies are common
50 million hypertensive Americans
500,000 hypertensive emergencies/year
Higher in the elderly and African Americans
Incidence in men 2 times higher than in women

6. Urgency
• Rapid reduction in BP >>>> significant
morbidity; organ hypoperfusion
– Ischemia
– Infarction
• Lower gradually over 24 – 48 hours
• Oral medications
• pressure induced natriuresis>>> volume
repleting

7. Emergency
• Reduce DBP by 10 – 15%, or to ~ 110
mm Hg over 30 – 60 minutes
• Aortic Dissection
– Rapid lowering over 5 – 10 minutes
– SBP < 120 and MAP < 80

8. Threshold BP
There is no specific BP where
hypertensive emergencies occur
Organ dysfunction is rare with diastolic
BPs < 120 mm Hg
Encephalopathy will occur at lower BPs in
pregnancy and in children

9. Vaughan and Delanty Lancet 2000; 356:411

10. Cerebral Autoregulation

12. Questions
• Define hypertensive urgency and
hypertension emergency?
• What are clinical findings associated with
hypertensive emergenices?

13. Question
• What is the most common complaint in
hypertensive emergency?
1. Neurologic defect
2. Gross Hematuria
3. Chest pain
4. Headache
5. Epistaxis

14. Clinical Presentation
Frequency of signs and symptoms
Chest Pain 27%
Dyspnea 22%
Neuro defect 21%
Zampaglione et al (Hypertension 27:144, 1996)

15. Clinical Findings
• Predisposing disease
– Thyrotoxicosis/Thyroid storm, Hypothyroidism/Myxedema, goiter
– HPT: hypercalcemia (psychosis, constipation,cataract,
nephrocalcinosis, N-DI, dystrophic calcifications of soft tissue (X-
ray)
– Cushing’s: Cushinoid
– Conn’s: hypokalemic metabolic alkalosis
– Pheochromocytoma: perspiration, palpitation, pain (chest, AP),
labile pressure (+/- orthostatic hypotension), pallor
– RAS: Renal bruits
– OSA/Pickwikian Syndrome: day time somnolence, apnea attacks
– Pregnancy: HELLP, Ecclampsia (edema, protienuria, sz)

16. Clinical Findings
• Complications/TOD
– Brain: meningism, FND, delirium, decreased LOC,
seizures, coma.
– Retina: blurred vision, papilledema (IV) +/- cotton
wool exudate, flame shape hg.
– CVS: chest pain, ACS (MR, ECG, trop), CHF,
pulse/BP bi limbs deficit (AD).
– Kidneys: active sediment, proteinuria, hematuria,
tubular casts.

17. A rare tumor of catecholamine-secreting
chromaffin cells, 80% to 90% of which are
located in the adrenal medulla.
10% to 20% are located extra-adrenal, usually
throughout the sympathetic chain in the
thorax, abdomen, and pelvis,are referred to
as paragangliomas.
Pheochromocytoma

18. Hypertensive crisis is managed with
intravenous nitroprusside, labetalol or
phentolamine
Diagnostic tests
24-hour urine metanephrines and
plasma fractionated metanephrines
Pheochromocytoma

19. Preeclampsia/Eclampsia
• Diastolic pressure should be reduced to 90-100
mmHg.
• Precipitous drops should be avoided as they
may compromise placental circulation.
• Hydralazine and labetalol are the usual agents
of choice. Nifedipine can also be used.
• ACE inhibitors should not be used due to
adverse fetal effects.

20. Acute Post Operative Hypertension
Frequent in post-operative state (20-75%)
Hyper-responsiveness to surgical trauma
Increased stress hormones
Activation of RAA
Hypothermia, hypoxia, carbon dioxide
retention, bladder distention

21. Acute Post Operative Hypertension
Prevention
 Preoperative antihypertensives
 Hold diuretics
Treatment
• Control pain and anxiety
• While NPO use nicardipine, esmolol or
labetolol
• Resume oral medications when possible

22. CARDIOVASCULAR
SYSTEM
Cardiac failure
Pulmonary edema
Myocardial ischemia, or Myocardial
infarction
Aortic dissection

23. Aortic dissection
• Goal is to reduce the shear force, and therefore
the dP/dt.
• Goal is an SBP of 100-110 achieved with a
beta-blocker and an easily titratable vasodilator
if necessary.
• A vasodilator should not be used alone

24. All initial treatment is medical
Decrease pulse rate and BP
Goal is systolic 100-120 mmHg & HR 50-60
Esmolol & Nitroprusside combination
Labetolol single agent
 Ascending require medical stabilization & then surgery
 Descending require medical stabilization & monitoring
Aortic dissection

25. Renal Artery Stenosis
What people should be screened for renal
artery stenosis?
1-Patients who have uncontrolled blood pressure
despite 3 or more medications at maximal dosages
2--people who are younger than 35 or older than 65
who develop sudden or new onset hypertension

26. Renal Artery Stenosis
The diagnosis is made with
ultrasound dopplers to check
blood flow rates
Arteriograms are more accurate,
but only show an anatomic
blockage, and don't help with
functional testing

27. A diagnosis of exclusion. Cerebral oedema
may be present on a CT scan but
haemorrhage or infarction are absent.
Immediate blood pressure reduction is
mandatory.
Hypertensive
Encephalopathy

28. CVA’s
• Ischemic CVA
– Protective physiologic response to maintain
CPP
– Impaired auto-regulation
– Some evidence for induced HTN
– Treat if:
• Thrombolysis (SBP/DBP < 185/110)
• End organ damage
• SBP > 220, DBP >120 .

29. CVA’s
• Hemorrhagic CVA
– No evidence HTN leads to increased size
of ICH, but there is an association
– Evidence suggests lowering BP rapidly
leads to increased mortality
– Maintain SBP < 200, DBP < 130
– Lowering MAP ~ 15% does not seem to
reduce CBP

30. Hypertensive Retinopathy
 Fundoscopy used to be considered a
definitive tool in diagnosing HTN
encephalopathy.
 Usefull in recognizing acute EOD as in HTN
encephalopathy.
 Absence of retinal exudates, hemorrhages, or
papilledema does not exclude the diagnoses.

31. HPT Retinopathy

32. Reversible posterior leukoencephalopathy
syndrome
A clinical radiographic syndrome of
heterogeneous etiologies.
 Characterized by
Headaches
Altered consciousness
Visual disturbances
Seizures

33. A/W hypertensive encephalopathy, eclampsia,
and the use of cytotoxic and
immunosuppressant .
 It is related to disordered cerebral
autoregulation and endothelial dysfunction
Reversible posterior
leukoencephalopathy syndrome

34. Profile of an ideal IVProfile of an ideal IV
antihypertensiveantihypertensive
Preserves GFR and renal blood flow
Few or no drug reactions
Little or no potential for exacerbation of co-morbid
conditions
Rapid onset and offset of action
Minimal hypotension “overshoot”
Minimal need for continuous BP monitoring and frequent
dose titration
No acute tolerance
Ease of use and convenience
Safe and no toxic metabolites
Multiple formulations for short and long term use
Minimal symphathetic activation

35. Case Based Presentation:
Hypertension in the ICU

36. Nitroprusside
• A short-acting easy-to-titrate arteriolar and
venous vasodilator.
• Most common adverse effect is hypotension
which can be treated by reducing dosage and
administering fluids if needed (lasts 1-2 min)
• Other adverse effects include reflex
tachycardia and cyanide/thiocyanate
toxicity

37. Nitroprusside
• Nitroprusside is metabolized through combination
with hemoglobin to produce
cyanomethemoglobin.
• Thyocyanate is then excreted in the urine
• Hepatic insufficiency leads to cyanide accumulation
• renal insufficiency leads to thiocyanate
accumulation

38. Nitroprusside
• Cyanide toxicity manifests as lactic acidosis,
confusion, and hemodynamic instability.
• Cyanide toxicity is prevented by avoiding large
doses (>3mcg/kg/min) for greater than 72h,
especially in patients with hepatic or renal
dysfunction.
• Maximal doses of 10 mcg/kg/min should not be
administered for more than 10 minutes

39. Labetalol
• A non-selective β-blocker with associated α-
blocking activity, in a 7 to 1 ratio in i.v. formulation.
• Contraindicated in reactive airway disease or
second to third degree heart block.
• Caution in patients with second to thir degree heart
block.

40. Nitroglycerin
• A venous and coronary artery dilator.
• Indicated in acute coronary syndromes; has also
used in perioperative hypertension.
• Side effects include headache, nausea,
bradycardia, hypotension, and
methemoglobinemia.
• Prlonged use may cause tachyphylaxis.

41. Nicardipine
• A dihydropyridine CCB with systemic
and coronary vasodilating effects.
• No negative inotropic or a-v conduction
effects.
• Used in perioperative hypertension and
eclampsia/preeclampsia.

42. Esmolol
• Short-acting cardioselective β-blocker
that can be used in perioperative
hypertension and tachycardia.
• A prolonged esmolol infusion is a
relatively expensive means of blood
pressure control

43. Enalaprilat
• Its long duration of action and variable
response, do not make it an ideal
candidate for hypertensive
emergencies.
• Contraindicated during preganancy, and
in renal failure, esp. in renal artery
stenosis.

44. Hydralazine
• An arteriolar vasodilator.
• Difficult to use due to its variable magnitude and rate of
response.
• Improves placental blood flow so good for
preeclampsia/eclampsia
• Should therefore not be used in aortic dissection or
myocardial ischemia.

45. Rhoney and Peacock. Am J Health-Syst Pharm. 2009; 66:1343-52.
Specific Indications

46. A 76-year-old male is admitted to the ICU for recovery after lung volume
reduction surgery for severe emphysema. He is alert and his BP is
168/96 mmHg. All of the following are appropriate EXCEPT?
A. Assess for pain
B. Start an antihypertensive treatment with a β-blocker
C. Reassess the patient later since there is no end-organ damage
D. Fundoscopic examination is not indicated for the transient, postoperative,
acute hypertensive episode
E. Recommend the consultation of a hypertensive specialist once the patient
is transferred to the ward if the blood pressure remains high

47. Which of the following is correct in regard to measurement of blood
pressure in severe hypertension?
A. Automated oscillometric monitors are adequate for blood pressure
measurement in the critically ill patient
B. A blood pressure cuff that is too small for the patient may result in a
falsely decreased blood pressure measurement
C. Hypothermia causes hypotension; it does not increase blood pressure
D. Intra-arterial pressure monitoring provides the most accurate blood
pressure measurement
E. A blood pressure cuff that is wrapped too loosely on the arm may
result in a falsely low blood pressure

48. An acute hypertensive episode (190/110 mmHg), in a known
hypertensive patient, is associated with acute congestive heart
failure (HR 95/min). All of the following are true EXCEPT
A. Is a medical emergency requiring IV antihypertensive therapy
B. Is a medical urgency requiring oral antihypertensive therapy
C. Could be appropriately treated with a labetalol infusion
D. Requires caution with diuretics in case of diastolic dysfunction
E. Is most likely due to diastolic dysfunction

49. SummarySummary
HPT crisis - serious condition - associated
with EOD, if left untreated
High mortality - untreated
Main causes – non-compliance and poorly
controlled chronic hypertension.
Urgency vs emergency
Treatment should be tailored to the
individual’s condition
HPT urgency – initial goal max 25% drop in
MAP in first hours
Precipitous drop just as bad –continuous
monitoring essential