hp crisis

1. Hypertensive Crisis Yuan Zhiming Department of Emergency Medicine The General Hospital Tianjin Medical University

2. Contents ● Introduction ● Epidemiology ● Etiology ● Pathogenesis ● Diagnosis ● Treatment ● Prognosis

4. Stage 3 hypertension has also been called severe hypertension or accelerated hypertension 1. Classification of hypertension systolic BP or diastolic BP （ mmHg ） （ mmHg ） Stage 1 140 ~ 159 90 ~ 99 Stage 2 160 ~ 179 100 ~ 109 stage 3 ≥180 ≥110

5. Hypertensive crisis refers to elevated blood pressure coupled with progressive or impending organ damage due to high blood pressure, usually characterized by a rise in DBP to greater than 120 to 130 mmHg. Hypertensive crisis comprises a spectrum of conditions, including hypertensive urgency and hypertensive emergency. 2. Hypertensive crisis

6. defined as an elevation of SBP (>220mmHg) and/or DBP (>125mmHg) without evidence of acute end-organ damage. 3. Hypertensive urgency

7. defined as a sudden increase in systolic and/or diastolic BP associated with end-organ damage of the CNS, the heart, or the kidneys. 4. Hypertensive emergency

8. The clinical differentiation between hypertensive emergency and hypertensive urgency depends on the presence of target organ damage, rather than the level of BP

10. What is an aneurysm ? An aneurysm is a dilation (ballooning) of part of the blood vessel . It usually causes no symptoms unless it ruptures. A ruptured aneurysm is often fatal.

12. Hypertensive Urgencies Upper levels of stage 3 hypertension Papilledema Headache Shortness of breath Pedal edema

13. Hypertensive Emergencies Hypertensive encephalopathy Acute aortic dissection Acute pulmonary edema with respiratory failure Acute myocardial infarction/unstable angina Eclampsia Acute renal failure Microangiopathic hemolytic anemia

14. What is aortic dissection ? An aortic dissection begins with a tear in the inner layer of the aortic wall.When a tear occurs in the innermost layer of the aortic wall, blood is then channeled into the wall of the aorta, separating the layers of tissues. It is a life-threatening emergency .

15. (A) Normal blood flow. (B) Dissection occurs when the inner lining of the aorta tears and the blood flow ‘dissects’ between the layers of the aortic wall.

20. Etiology Hypertensive crisis may occur in patients with no history of the condition or can be precipitated by noncompliance with medical therapy or diet, or both; or by inadequate treatment.

21. Common causes include 1. ARF 2. Acute CNS events 3. Drug-induced hypertension 4. Ingestion of tyramine-containing foods or beverages during treatment with a monoamine oxidase inhibitor (MAOI) 5. Pregnancy-induced epilepsia 6. Pheochromocytoma

22. Pathogenesis The exact mechanism of hypertensive crisis is not known. The majority of patients have known hypertension before the crisis, and the sudden rise in BP is often related to the underlying disease process as described above.

23. The pathophysiology humoral vasoconstrictors release systemic vascular resistance increases severe elevations of BP endothelial injury, fibrinoid necrosis of the arterioles deposition of platelets and fibrin, a breakdown of the normal autoregulatory function ischemia vicious cycle

29. The diagnosis is based on altered end-organ function and the rate of the rise in BP, not the level of BP

30. 2. Initial Evaluation of the Patient With Hypertensive Crises (1) The key to successful management of patients with severely elevated BP is to differentiate hypertensive emergencies from hypertensive urgencies

35. In many instances, these tests are performed simultaneously with the initiation of antihypertensive therapy

42. Oral drugs can be prescribed Such as (1) ACEI: Captopril (2) β-blockers: labetalol. (3) Clonidine guanabenz, prazosin, and minoxidil. (4) Loop diuretic: is generally prescribed in addition to the antihypertensive agents.

47. Triage Evaluation: Algorithm Group I-High BP Group II-Urgency GroupIII-Emergency BP >180/110 >180/110 Usually >220/140 Symptoms Headache, anxiety; often asymptomatic Severe headache, shortness of breath Shortness of breath, chest pain, nocturia, dysarthria, weakness, altered consciousness Examination No target organ damage, no clinical cardiovascular disease Clinical cardiovascular disease present/stable Encephalopathy, pulmonary edema, renal insufficiency, cerebrovascular accident, cardiac ischemia Therapy Observe 1-3 hrs; initiate/resume medication; increase dosage of inadequate agent Observe 3-6 hours; lower BP with short acting oral agent; adjust current therapy Baseline laboratory tests; intravenous line; monitor BP; may initiate parenteral therapy in emergency room Plan Arrange follow-up <72 hours; if no prior evaluation, schedule appointment Arrange follow-up evaluation <24 hours Immediate admission to ICU; treat to initial goal BP; additional diagnostic studies

48. Oral agents for treatment of hypertensive crisis Agent Dose Onset/Duration of Action Precautions Captopril 25 mg PO repeat as needed; SL, 25 mg 15-30 min/6-8 hr SL 10-20 min/2-6 hr Hypotension, renal failure in bilateral renal artery stenosis Clonidine 0.1-0.2mg PO, repeat hourly as required to total dose of 0.6 mg 30-60 min/8-16 hr Hypotension, drowsiness, dry mouth Labetalol 200-400mg PO, repeat every 2-3 hr 1-2 hr/2-12 hr Bronchoconstriction, heart block, orthostatic hypotension Prazosin 1-2 mg PO, repeat hourly as needed 1-2 hr/8-12hr Syncope (first dose), palpitations, tachycardia, orthostatic hypotension Min=minutes; hr=hour(s); PO=by mouth; SL=sublingual

49. Parenteral drugs for treatment of hypertensive emergency Agent Dose Onset/Duration of Action Precautions Parenteral Vasodilators Sodium nitroprus-side 0.25-10 µg/kg/min as IV infusion Immediate/2-3 min after infusion Nausea, vomiting; with prolonged use may cause thiocyanate intoxication, methemoglobinemia, acidosis, cyanide poisoning; bags, bottles, and delivery sets must be light resistant Nitroglyc-erin 5-100µg as IV infusion 2-5 min/5-10 min Headache, tachycardia, vomiting, flushing, methemoglobinemia; requires special delivery system due to drug binding to PVC tubing

50. Nitroglycerin 5-100µg as IV infusion* 2-5 min/5-10 min Headache, tachycardia, vomiting, flushing, methemoglobinemia; requires special delivery system due to drug binding to PVC tubing Nicardipine 5-15 mg/hr IV infusion 1-5 min/15-30 min, but may exceed 12 hr after prolonged infusion Tachycardia, nausea, vomiting, headache, increased intracranial pressure; hypotension may be protracted after prolonged infusions Diazoxide 50-150 mg as IV bolus, repeated or 15-30 mg/min by IV infusion 2-5 min/3-12 hr Hypotension, tachycardia, aggravation of angina pectoris, nausea and vomiting, hyperglycemia with repeated injections

51. Fenolda-pam mesylate 0.1-0.3 µg/kg/min IV infusion <5 min/30 min Headache, tachycardia, flushing, local phlebitis, dizziness Hydrala-zine 5-20 mg as IV bolus or 10-40 mg IM; repeat every 4-6 hr 10 min IV/>1hr (IV) 20-30 min IM/4-6 hr (IM) Tachycardia, headache, vomiting, aggravation of angina pectoris, sodium & water retention and increased intracranial pressure Enalapr-ilat 0.625-1.25 mg every 6 hr IV Within 30 min/12-24 hr Renal failure in patients with bilateral renal artery stenosis, hypotension

52. Parenteral Adrenergic Inhibitors Labetalol 20-40 mg as IV bolus every 10 min; up to 2 mg/min as IV infusion 5-10 min/2-6 hr Bronchoconstriction, heart block, orthostatic hypotension, bradycardia Esmolol 500µg/kg bolus injection IV or 50-100µg/kg/min by infusion. May repeat bolus after 5min or increase infusion rate to 300 µg/kg/min 1-5 min/15-30 min First-degree heart block, congestive heart failure, asthma Phentolam-ine 5-10 mg as IV bolus 1-2 min/10-30 min Tachycardia, orthostatic hypotension hr=hour(s); min=minute; IV=intravenous; IM=intramuscular; PVC=polyvinyl chloride

58. ● Hypertensive crisis that is not managed over the long term is associated with a 25% mortality 1 yr after the event, and 50% mortality 5 yr after the event. ● The most common causes of death are uremia, AMI, HF, cerebrovascular accident. Prognosis

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