Severely Increased Blood Severely Increased Blood Pressure In The ED: Treating The Pressure In The ED: Treating The

Mercury?Mercury?

Rick Blubaugh, D.O.Rick Blubaugh, D.O.Cornerstone Physician’s Management GroupCornerstone Physician’s Management Group

Skaggs Community Health CenterSkaggs Community Health Center

Branson, MOBranson, MO

Case HistoryCase History

50 y/o male50 y/o male History of hypertensionHistory of hypertension Hasn’t taken meds in 1 yearHasn’t taken meds in 1 year C/O headache & malaise for 2 daysC/O headache & malaise for 2 days Exam: remarkable only for BP Exam: remarkable only for BP

210/120 & grade I retinopathy210/120 & grade I retinopathy

Questions For EPQuestions For EP

Is patient stable?Is patient stable? Is further WU indicated? & if so, Is further WU indicated? & if so,

what?what? Does pt require immediate Does pt require immediate

intervention? & if so, what?intervention? & if so, what? Does pt require admission or Does pt require admission or

monitoring, or if D/C’d, how soon monitoring, or if D/C’d, how soon should he be seen in follow up?should he be seen in follow up?

BackgroundBackground

Prolonged & severely increased BP Prolonged & severely increased BP causes cerebral, cardiovascular, and causes cerebral, cardiovascular, and renal disease (Target Organs). renal disease (Target Organs).

Morbidity & mortality can be Morbidity & mortality can be improved with treatmentimproved with treatment

Limited data concerning acutely Limited data concerning acutely elevated blood pressureelevated blood pressure

PhysiologyPhysiology

Affects heart, brain, kidneys, & large Affects heart, brain, kidneys, & large arteriesarteries

Chronic HTN causes right shift in Chronic HTN causes right shift in pressure flow autoregulation curvepressure flow autoregulation curve

When BP decreases, cerebral When BP decreases, cerebral vasodilation occursvasodilation occurs

When BP increases, constriction occursWhen BP increases, constriction occurs Cerebral perfusion pressure remains Cerebral perfusion pressure remains

constant despite fluctations in MAPconstant despite fluctations in MAP

Normal individuals: cerebral blood flow Normal individuals: cerebral blood flow remains constant for MAP of 60-150remains constant for MAP of 60-150mmmmHgHg

When MAP decreases to less than lower When MAP decreases to less than lower limits of autoregulation, the brain becomes limits of autoregulation, the brain becomes hypoperfused & cerebral hypoxia occurs.hypoperfused & cerebral hypoxia occurs.

MAP = Diastolic + 1/3 (Systolic – Diastolic)MAP = Diastolic + 1/3 (Systolic – Diastolic) Cerebral perfusion pressure = MAP – Cerebral perfusion pressure = MAP –

Intracranial pressureIntracranial pressure Chronic hypertension: lower limit of Chronic hypertension: lower limit of

autoreguation is increasedautoreguation is increased Autoregulation might fail at MAPs well Autoregulation might fail at MAPs well

tolerated in normotensive individualstolerated in normotensive individuals

Lower limit of autoregulation is Lower limit of autoregulation is approximately 25% of MAPapproximately 25% of MAP

Therefore, MAP should not be Therefore, MAP should not be lowered by more than 20-25%lowered by more than 20-25%

Copyright ©1998 American Physiological Society

Gao, E. et al. Am J Physiol Heart Circ Physiol 274: H1023-H1031 1998

Fig. 4.Autoregulation CurveAutoregulation Curve

Clinical EvaluationClinical Evaluation

BP 180/110: immediate or evaluation BP 180/110: immediate or evaluation within 1 week (Joint National within 1 week (Joint National Committee-VI Guidelines)Committee-VI Guidelines)

Recheck BP: many spontaneously Recheck BP: many spontaneously reducereduce

Seated, arm at level of heart, both armsSeated, arm at level of heart, both arms Automated cuff inaccurate in A-Fib or Automated cuff inaccurate in A-Fib or

irregirreg Manage pain or underlying causesManage pain or underlying causes

Fundoscopic exam: retinal hemorrage Fundoscopic exam: retinal hemorrage or papilledemaor papilledema

Cardiovascuar exam: Identify heart Cardiovascuar exam: Identify heart failurefailure

Neuro exam: LOC, visual fields, motor Neuro exam: LOC, visual fields, motor & sensory deficits& sensory deficits

Serum creatinineSerum creatinine ECGECG Med History including OTCMed History including OTC Urine drug screen: cocaine, Urine drug screen: cocaine,

amphetamineamphetamine

Stratification of Hypertensive Stratification of Hypertensive EventsEvents

EmergentEmergent UrgentUrgent Uncontrolled hypertensionUncontrolled hypertension

Hypertensive EmergencyHypertensive Emergency

Rapid, progressive decompensation or Rapid, progressive decompensation or damage of target organsdamage of target organs

Hypertensive encephalopathy, or brain Hypertensive encephalopathy, or brain hemorragehemorrage

Acute aortic dissection, acute LV Acute aortic dissection, acute LV failure, AMI, unstable angina, failure, AMI, unstable angina, symptomatic aortic aneurysm.symptomatic aortic aneurysm.

Acute glomerulonephritis,kidney Acute glomerulonephritis,kidney transplanttransplant

Hypertensive EmergencyHypertensive Emergency

PheochromocytomaPheochromocytoma Sympathomimetic useSympathomimetic use Severe burnsSevere burns Severe epistaxisSevere epistaxis Eclampsia/preeclampsiaEclampsia/preeclampsia

Requires immediate (1-2 hours) BP Requires immediate (1-2 hours) BP reductionreduction

Parenteral agentParenteral agent Nitroprusside – most eventsNitroprusside – most events Labetalol – intracranial disorders Labetalol – intracranial disorders

(does not dilate cerebral vessels)(does not dilate cerebral vessels) B- blockers – aortic dissection (blocks B- blockers – aortic dissection (blocks

reflex tachycardia)reflex tachycardia) Oral agents – should not be used Oral agents – should not be used

(limited data, high failure rates, not (limited data, high failure rates, not titratable, uncontrolled hypotension)titratable, uncontrolled hypotension)

Emergent Blood Pressure Emergent Blood Pressure ReductionReduction

Should not exceed 20%-25% of Should not exceed 20%-25% of pretreatment BPpretreatment BP

11stst 30-60 Min: Reduce MAP to 110- 30-60 Min: Reduce MAP to 110-115115

Further reduction over next 24 hoursFurther reduction over next 24 hours

Hemorrhagic & Ischemic CVAHemorrhagic & Ischemic CVA When systolic BP is reduced, cerebral When systolic BP is reduced, cerebral

autoregulation might fail leading to autoregulation might fail leading to extension of CVAextension of CVA

Some believe that elevated MAP is Some believe that elevated MAP is protective in CVAprotective in CVA

AHA: reduce BP in CVA only when AHA: reduce BP in CVA only when MAP is > 130mm Hg or SBP > 220 MAP is > 130mm Hg or SBP > 220 mm Hgmm Hg

Esmolol & labetalol are good choicesEsmolol & labetalol are good choices Nipride – cerebral vasodilationNipride – cerebral vasodilation

Cardiovascular EmergenciesCardiovascular Emergencies

CHF – nitroprusside & ACE inhibitorCHF – nitroprusside & ACE inhibitor ACS – nitroglycerine – reduce BP to ACS – nitroglycerine – reduce BP to

normal levelsnormal levels Aortic Dissection – nitroprusside + B- Aortic Dissection – nitroprusside + B-

blocker.blocker.

Hypertensive UrgencyHypertensive Urgency

ControversialControversial History of prior target organ disease History of prior target organ disease

(CHF, CAD, angina, renal insuff, TIA, or (CHF, CAD, angina, renal insuff, TIA, or CVA)CVA)

Treatment strategy should be initiated Treatment strategy should be initiated in ED, although BP does not in ED, although BP does not necessarily need to be reduced in EDnecessarily need to be reduced in ED

Reliance on specific numbers is Reliance on specific numbers is inadequateinadequate

Hypertensive UrgencyHypertensive Urgency

VA Cooperative Study: no adverse VA Cooperative Study: no adverse outcomes within first 3 months in outcomes within first 3 months in patients who had DBP 115-130mm Hgpatients who had DBP 115-130mm Hg

No evidence to support practice of No evidence to support practice of treating hypertension by reducing BP treating hypertension by reducing BP acutely in EDacutely in ED

Numerous reports of adverse outcomes Numerous reports of adverse outcomes with acute, rapid reduction of BP in ED.with acute, rapid reduction of BP in ED.

Uncontrolled HypertensionUncontrolled Hypertension

Asymptomatic elevated BP without Asymptomatic elevated BP without evidence of target organ diseaseevidence of target organ disease

Represents majority of patients with Represents majority of patients with elevated BP in EDelevated BP in ED

Goal: lifelong BP controlGoal: lifelong BP control Treat pain or infectionTreat pain or infection Refer for recheck after primary Refer for recheck after primary

problem resolved ( 1 week)problem resolved ( 1 week)

Uncontrolled HypertensionUncontrolled Hypertension

If patient has quit taking If patient has quit taking antihypertensive meds – then restart antihypertensive meds – then restart themthem

1/3 of patients in ED with DBP > 95 1/3 of patients in ED with DBP > 95 mmHg were normotensive at follow-mmHg were normotensive at follow-upup

Initial Oral Drug ChoicesInitial Oral Drug Choices

Case RevisitedCase Revisited

Tx: analgesia for headacheTx: analgesia for headache Lab: Serum creatinine, UA, ECGLab: Serum creatinine, UA, ECG CT: if findings on H&P suggest CNS CT: if findings on H&P suggest CNS

involvementinvolvement

If history or CT scan shows prior CVA, If history or CT scan shows prior CVA, then patient qualifies as then patient qualifies as hypertensive urgency – justifying hypertensive urgency – justifying initiation of maintenance treatmentinitiation of maintenance treatment

Best regimen is one that previously Best regimen is one that previously workedworked

Otherwise – diuretic & B-blockerOtherwise – diuretic & B-blocker Follow up in 1 week or observationFollow up in 1 week or observation

CaseCase

If clinical exam & work up is negative If clinical exam & work up is negative & BP remains elevated after & BP remains elevated after resolution of headache, then patient resolution of headache, then patient is stratified as uncontrolled is stratified as uncontrolled hypertensionhypertension

Follow –up with PCPFollow –up with PCP

SummarySummary

Hypertensive EmergencyHypertensive Emergency – rapidy, – rapidy, progressive end-organ damage. progressive end-organ damage.

Needs parenteral meds & ICU Needs parenteral meds & ICU Caution in cerebrovascular eventsCaution in cerebrovascular events

SummarySummary

Hypertensive UrgencyHypertensive Urgency – BP – BP elevated > 180/110 elevated > 180/110 && history of end- history of end- organ disease. organ disease.

Initiate oral meds & short term Initiate oral meds & short term follow up or observationfollow up or observation

Uncontrolled Hypertension Uncontrolled Hypertension – – asymptomaticasymptomatic

Referral to PCP & educationReferral to PCP & education