Hypertensive Crisis and Scenario in Nepal

1. Hypertensive crisis
Pratap Sagar Tiwari, MD, Internal Medicine, NGMC

2. HTN ….global issue
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Worldwide, noncommunicable diseases (NCDs)
surpass CD as causes of death. 1
Nearly 2/3rd of the 57 mill deaths globally in 2008
were due to NCDs. 2
Of the NCD risk factors, the % of deaths attributable
to HTN globally is the highest (13%).2
Ref:
1.
World Health Organization. Disease and injury regional mortality estimates for 2008. Geneva:
WHO, 2011.
http://www.who.int/healthinfo/global_burden_disease/estimates_regional/en/index.html - acessed
9th feb 2014.
2.
World Health Organization. Global status report on noncommunicable diseases 2010. Geneva:
WHO, 2011.
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3. HTN…Scenario in Nepal
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1.
In 2008, nearly 50% of total deaths in Nepal were
estimated to be due to NCDs, and CVD accounted
for 25% of these deaths. 1
Hypertension, one of the major RFs for CVD, was
estimated to be present in 26.6/28.6 %(m/f) of
Nepalese adults aged 25 yrs and above.1
Ref:
World
Health
Organization.
Global
health
observatory.
th feb 2014.
http://apps.who.int/gho/data/?theme=main# - accessed 9
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Geneva.

4. HTN…Scenario in Nepal
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Other studies, which were heterogeneous in
design, showed variable results, with prevalence
estimates ranging from 18.8% to 41.8% .(table)
A study comparing the prevalence of hypertension in
the same community in 1981 and 2006 reported a
threefold increase in prevalence, confirming the
trend of a dramatic increase in CVD risk factors in
Nepal.1

Ref:
1.
Vaidya A, Pathak RP, Pandey MR. Prevalence of hypertension in Nepalese community triples in
25 years: a repeat cross-sectional study in rural Kathmandu. Indian Heart J. 2012;64(2):128–
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131.

5. S05/21

6. References to the Prevalence table
(5) Sharma SK, Ghimire A, Radhakrishnan J, Thapa L, Shrestha NR, Paudel N, et al. Prevalence of
hypertension, obesity, diabetes, and metabolic syndrome in Nepal. Int J Hypertens. 2011;2011:821971.
(6) World Health Organization, Society for Local Integrated Development Nepal, Ministry of Health, Nepal. Bagmati:
STEPs noncommunicable disease risk factors survey 2003. Geneva, 2003.
(7) Vaidya A, Pokharel PK, Karki P, Nagesh S. Exploring the iceberg of hypertension: a community based study in an
eastern Nepal town. Kathmandu Univ Med J. 2007;5(3):349-359.
(8) World Health Organization, Society for Local Integrated Development Nepal, Central Bureau of
Statistics, Nepal, Government of Nepal. Nepal STEPS noncommunicable disease risk factors survey 2005.
Geneva, 2005.
(9) Sharma D, Bkc M, Rajbhandari S, Raut R, Baidya SG, Kafle PM. Study of prevalence, awareness,and control of
hypertension in a suburban area of Kathmandu, Nepal. Indian Heart J. 2006;58(1):34–37.
(10) Shrestha UK, Singh DL, Bhattarai MD. The prevalence of hypertension and diabetes defined by fasting and 2-h
plasma glucose criteria in urban Nepal. Diabet Med. 2006;23(10): 1130–1135.
(11) Vaidya A, Pathak RP, Pandey MR. Prevalence of hypertension in Nepalese community triples in 25 years: a repeat
cross-sectional study in rural Kathmandu. Indian Heart J. 2012;64(2):128–131.
(12) World Health Organization, Society for Local Integrated Development Nepal, Ministry of Health and
Population, Government of Nepal. Noncommunicable disease risk factors survey 2007/2008: Nepal. Geneva, 2009.
http://www.who.int/chp/steps/Nepal_2007_STEPS_Report.pdf - accessed 22 March 2013.
(13) Chataut J, Adhikari RK, Sinha NP. The prevalence of and risk factors for hypertension in adults living in central
development region of Nepal. Kathmandu Univ Med J. 2011;9(33):13–18.
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7. HTN…Scenario in Nepal
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In 19811, only 4.8% of the HTN people were aware of
their high BP status while almost 1/3rd (31.8%) of HTN in
20062 and 60 % were aware in 20113 . In 2006, BP was
under control in 9.5% of the hypertensives.
According to Statistical Fact Sheet 2013 Update from
AHA In the United States, 1 out of every 3 adults have
high BP and 47.5 % do not have it controlled and almost
50 % of death was attributable to high bp.
Ref:
1.
2.
3.
Pandey MR and Hypertension Study Group. Hypertension in Nepal—a Scientific Epidemiological
Study. Mrigendra Medical Trust: Kathmandu 1983.
Sharma D, Bkc M, Rajbhandari S, et al. Study of prevalence, awareness, and control of
hypertension in a suburban area of Kathmandu, Nepal. Indian Heart J 2006;58:34–7.
Chataut J, Adhikari RK, Sinha NP. The Prevalence of and Risk Factors for Hypertension in Adults
Living in Central Development Region of Nepal. Kathmandu Univ Med J 2011;33(1)13-8.
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8. Scenario A
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A 50 yrs old obese Male who is a chronic smoker
comes to ER with c/o palpitation and headache.
There is no H/o HTN in the past.
O/E Bp is 210/120 mmhg.
Acute severe
Hypertension
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9. Scenario B
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A 40 yrs old obese F was planned for
Cholecystectomy .
On PAC, Bp was 190/110 mmhg.
Acc to pt, she was diagnosed previously as HTN but
she noncompliant to drugs.
Uncontrolled
Hypertension
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10. Scenario C
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A 40 yrs old M with a history of HTN and BPH had a
recurrence of head and neck cancer.
Two hours after undergoing a modified radical neck
dissection and tracheostomy.
BP was recorded to be 200/110 mmhg.
Acute Postoperative
Hypertension
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11. Scenario D
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A 55 yrs old Male came to ER complaining of
headache and blurring of vision .
He is a known c/o HTN since 4 years and has been
taking 3 different antihtn drugs that includes a
diuretic.
His bp was found to be 190/126mmhg.
Accelerated
hypertension
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12. Scenario E
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A 55 yrs old Male went to other center with same
compaints of headache and blurring of vision .
He is a known c/o HTN since 4 years and has been
taking 3 different antihtn drugs that includes a
diuretic.
His bp was found to be 190/126 mmhg. Pt is
confused and hematuria is present.
Malignant hypertension
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13. Acute postop
Hypertension
Uncontrolled
Hypertension
Malignant Hypertension
Accelerated
Hypertension
Hypertensive urgency
Hypertensive emergency
Acute severe
Hypertension
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14. 
Systolic BP >180 mmhg /or Diastolic BP>120 mmhg
Hypertensive crisis
End organ
damage
????????
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15. End organ Damage
Neurological Deficit
(Htn encephalopathy, cerebral
infarction/hemorrhage)
Features of Acute LV Heart failure
Coronory insufficiency
Aortic Dissection
Acute Kidney failure
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16. Hypertensive Crisis
>180/120
>180/120
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E
O
D
Hypertensive
Emergency
Hypertensive
Urgency

17. Terminologies..continue
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Malignant hypertension and accelerated hypertension are both
hypertensive emergencies, with similar outcomes and
therapies.
In
order
to
diagnose
malignant
hypertension, papilledema must be present.1

Note:
Preexisting Essential HTN: Essential Malignant hypertension
Preexisting
Secondary
HTN:
Secondary
Malignant
hypertension
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Ref:
1.
Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev. Mar-Apr 2010;18(2):102-7.
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18. Terminologies..continue
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Acute elevations in blood pressure (>20 %) in the
intraoperative period are typically considered
hypertensive emergencies during surgery. 1
Postoperative hypertension is defined as systolic
BP≥ 190 mmhg and/or diastolic BP ≥ 100 mmhg on
2 consecutive readings following surgery . 2,3
Ref:
1.
GOldberg
ME,
Larijani
Phasrmacotherapy, 18:911-14.
2.
Plets C. 1989. Arterial hypertension in neurosurgical emergencies. Am J Cardiol, 63:40C42C.
3.
Chonanian AV, Bakris GL, Black HR, et al. 2003b. The Seventh Report of the Joint
National COmmittee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure: the JNC 7 report. JAMA,289:2560-72.
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GE.
1998.
Perioperative
hypertension.

19. Terminologies..continue
Acute onset, persistent (lasting ≥15 min), severe
systolic (≥ 160 mmhg) or severe diastolic
hypertension (≥ 110 mmhg) or both in pregnant or
postpartum women with preeclampsia constitutes a
hypertensive emergency 1,2,3
Major risk factors : H/o HTn for atleast 4 yrs, h/o htn in
previous pregnancy and Renal insufficiency
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Ref:
1.
Diagnosis, evaluation and management of the hypertensive disorders of pregnancy. SOGC
Clinical Practice Guideline No. 206. Society of Obstetricians and Gynaecologists of Canada. J
Obstet Gynaecol Can 2008;30(Suppl 1):S1-S48.
2.
COnfidential Enquiries into Maternal Deaths. why mothers die 1997-1999. The fifth report of the
COnfidential Enquiries into Maternal Deaths in the United Kingdom. London (UK): RCOG
Press;2001.
3.
Emergent Therapy for Acute onset, Severe Hypertension with Preeclampsia or Eclampsia.
Committee opinion. The American College of Obstetricians and Gynaecologists. December
2011.
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20. Causes of hypertensive emergencies
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Essential hypertension
Renal
disease:
Acute
GN, Vasculitis, HUS, TTP, RAS
Pregnancy: Eclampsia
Endocrine:
Pheochromocytoma,
Cushing’s
syndrome
Drugs:
Cocaine, sympathomimmetics, erythropoietin, cyclos
porin, antihypertensive withdrawal, Interactions with
monoamine-oxidase inhibitors, amphetamines, lead
intoxication
Others:
Head
injury,
cerebral
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infarction/hemorrhage, brain tumors

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