Slide Ws Htn

8/17/2019 Slide Ws Htn

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COMPLICATIONS OF HYPERTENSION

Acute Complication

- Abruptly

- Related it! accelerated

ele"ation o# $P

- $P mu%t be decrea%ed

a&&re%%i"ely

C!ronic complication

- 'radually

- Related it! duration

o# !yperten%ion

- $P mana&ed %martly


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COMPLICATIONS OF HYPERTENSION

Acute Complication

- Abruptly

- Related it! accelerated

ele"ation o# $P

- $P mu%t be decrea%ed

a&&re%%i"ely

C!ronic complication

- 'radually

- Related it! duration

o# !yperten%ion

- $P mana&ed %martly

Hyperten%i"e Cri%i%


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Hyperten%i"e Emer&encyHyperten%i"e Emer&ency

- A relative increase in blood pressure from baseline- A relative increase in blood pressure from baseline

combined withcombined with Tar&et Or&an (y%#unction )TO(*Tar&et Or&an (y%#unction )TO(*

-

No Defined Pressure MeasurementNo Defined Pressure Measurement

- Target Organ Damage is evidentTarget Organ Damage is evident

- Also known as Hpertensive !risis or Malignant Also known as Hpertensive !risis or Malignant

HpertensionHpertension

- TheThe MOSTMOST "erious form of hpertension"erious form of hpertension


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efinition & Classification

efinition

Hyperten%i"e cri%i%+ %e"ere ele"ation o# blood pre%%ure,

!ic! mu%t be reduced immediately

Classification

# Hyperten%i"e emer&ency +

# accompanied by acute tar&et or&an dama&e

# $P mu%t be reduced it!in minute%

# Hyperten%i"e ur&ency +

# no acute or&an dama&e

# $P mu%t be reduced it!in !our%

Clinical Hyperten%ion, -aplan .//0


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Hyperten%i"e Cri%e%

Hyperten%i"e Emer&encyHyperten%i"e 1r&ency

Mar2edly ele"ated $P

3it!out %e"ere %ymptom% or

pro&re%%i"e tar&et or&an dama&e

$P %!ould be reduced it!in !our%

Oral a&ent%

Mar2edly ele"ated $P

3it! acute or pro&re%%in&

tar&et or&an dama&e

$P %!ould be reduced immediate

Parenteral a&ent%

$aplan NM %Hpertensive !rises in & !linical hpertension ' th (d%

)ippincott *illiams + *ilkins ,.&.'-./


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efinition :

# Not determined by $P le"el, but rat!er t!e imminent

compromi%e "ital or&an #unction

# Formerly !en +

# %y%tolic ≥ 45/ mm H&

# dia%tolic 6 44/ mm H&

)%ta&e III ESH*

T!e -idney and Hyperten%ion, $a2ri%, .//7


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Tar&et Or&an (y%#unctionTar&et Or&an (y%#unction

(vidence of Damage or 0n1ur to 2Target(vidence of Damage or 0n1ur to 2Target

Organs3 such as the Heart% 4rain% )ungs%Organs3 such as the Heart% 4rain% )ungs%

$idnes% or Aorta5$idnes% or Aorta5


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E8ample% o# Tar&et Or&an (y%#unction

Acute M06 7nstable Angina Acute M06 7nstable Angina

!8A!8A

0!H 6 "ubarachnoid Hemorrhage0!H 6 "ubarachnoid Hemorrhage

!H9!H9

Aortic Dissection Aortic Dissection

Acute :enal 9ailure Acute :enal 9ailure

Hpertensive (ncephalopathHpertensive (ncephalopath


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Hi&! blood pre%%ure in a%ymptomatic c!ronic !yperten%ion

IS NOT A HYPERTENSIVE CRISES


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Precipitating factors in hpertensi!e crisis

49 Accelerated %udden ri%e in blood pre%%ure in patient

it! pree8i%tin& e%%ential !yperten%ion

.9 Reno"a%cular !yperten%ion

09 'lomerulonep!riti%:acute

79 Eclamp%ia

;9 P!eoc!romocytoma


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HYPERTENSIVE E"ER#ENCY

Accelerated:mali&nant !yperten%ion it! papilledema

Cerebro"a%cular condition%

Hyperten%i"e brain in#arction it! %e"ere !yperten%ion

Intracerebral !emorr!a&e

Subarac!noid !emorr!a&e

Head trauma

Cardiac condition%

Acute aortic di%%ection

Acute le#t "entricular #ailure

Acute or impendin& myocardial in#arction

A#ter coronary bypa%% %ur&ery

Renal condition%

Acute &lomerulonep!riti%

Reno"a%cular !yperten%ion

Renal cri%e% #rom colla&en:"a%cular di%ea%e%

Se"ere !yperten%ion a#ter 2idney tran%plantation


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Hpertensi!e e$ergenc %cont'(

E8ce%% circulatin& catec!olamine%

P!eoc!romocytoma cri%i%

Food or dru& interaction% it! monoamine o8ida%e in!ibitor%

Sympat!omimetic dru& u%e )cocaine*

Rebound !yperten%ion a#ter %udden ce%%ation o# anti!yperten%i"e dru&%

automatic !yperre#le8ia a#ter %pinal cord in>ury

Eclamp%ia

Sur&ical condition%

Se"ere !yperten%ion in patient% re@uirin& immediate %ur&ey

Po%toperati"e !yperten%ion

Po%toperati"e bleedin& #rom "a%cular %uture line%

Se"ere body burn%

Se"ere epi%ta8i%

T!rombotic t!rombocytopenic purpura


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Si&n and %ymptom in "ariou% type% o# !yperten%i"e emer&ency

Type o#Type o#!yperten%i"e emer&ency!yperten%i"e emer&ency

Typical %ymptom%Typical %ymptom% Typical %i&n%Typical %i&n% CommentComment

Acute %tro2e in e"olutionAcute %tro2e in e"olution)t!rombotic or embolic*)t!rombotic or embolic*

3ea2ne%%, altered3ea2ne%%, alteredmotor %2ill)%*motor %2ill)%*

Focal neruolo&icalFocal neruolo&icalde#icit)%*de#icit)%*

Hyperten%ion notHyperten%ion notu%ually treatedu%ually treated

Suibarac!noid !emorr!a&eSuibarac!noid !emorr!a&e Headac!e,Headac!e,deleriumdelerium

Altered mentalAltered mental%tatu%, menin&eal%tatu%, menin&eal

%i&n%%i&n%

Lumbar punctureLumbar puncturetypically %!o%typically %!o%

8ant!oc!romia or red8ant!oc!romia or redblood cell%blood cell%

Acute !ead in>urytraumaAcute !ead in>urytrauma Headac!e, alteredHeadac!e, altered%en%orium or%en%orium ormotor %2ill%motor %2ill%

Laceration%,Laceration%,ecc!ymo%e%,ecc!ymo%e%,altered mentalaltered mental%tatu%%tatu%

ComputedComputedtomo&rap!ic )CT*tomo&rap!ic )CT*%can i% !elp#ul to%can i% !elp#ul todetermine e8tent o#determine e8tent o#intracranial in>uryintracranial in>ury

Hyperten%i"eHyperten%i"eencep!alopat!yencep!alopat!y

Headac!e, alteredHeadac!e, alteredmental %tatu%mental %tatu%

papilledemapapilledema 1%ually a dia&no%i% o#1%ually a dia&no%i% o#e8clu%ione8clu%ion

Cardiac i%c!emiain#ractionCardiac i%c!emiain#raction C!e%t di%com#ort,C!e%t di%com#ort,nau%ea, "omitin&nau%ea, "omitin&

Abnormal E-'Abnormal E-')e%p9 T:a"e)e%p9 T:a"eele"ation%*ele"ation%*


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Type o#Type o#!yperten%i"e emer&ency!yperten%i"e emer&ency

Typical %ymptom%Typical %ymptom% Typical %i&n%Typical %i&n% CommentComment

Acute le#t "entricularAcute le#t "entricular#ailurepulmonary edema#ailurepulmonary edema

S!ortne%% o#S!ortne%% o#breat!breat!

Rale% au%cultatedRale% au%cultatedin c!e%tin c!e%t

Aortic di%%ectionAortic di%%ection C!e%t di%com#ortC!e%t di%com#ort 3idened aortic3idened aortic2nob on c!e%t 8:2nob on c!e%t 8:rayray

Ec!ocardio&ram,Ec!ocardio&ram,c!e%t CT, orc!e%t CT, oran&io&ram u%uallyan&io&ram u%uallyneeded to con#irmneeded to con#irm

Recent "a%cular %ur&eryRecent "a%cular %ur&ery $leedin&,$leedin&,tenderne%% attenderne%% at%uture line%%uture line%

$leedin& at %uture$leedin& at %utureline%line%

O#ten re@uire %ur&icalO#ten re@uire %ur&icalre"i%ion o# "a%cularre"i%ion o# "a%cularana%tamo%i%ana%tamo%i%

P!eoc!romocytomaP!eoc!romocytoma Headac!e,Headac!e,

%eatin&,%eatin&,palpitation%palpitation%

Pallor, #lu%!in&,Pallor, #lu%!in&,

rare %2in %i&n%rare %2in %i&n%)p!a2omato%e%*)p!a2omato%e%*

P!entolamine i% "eryP!entolamine i% "ery

u%e#ulu%e#ul

(ru& related(ru& relatedcatec!olamine e8ce%%catec!olamine e8ce%%%tate%tate

Headac!e,Headac!e,palpilation%palpilation%

tac!ycardiatac!ycardia Hi%tory re&ardin&Hi%tory re&ardin&dru& e8po%ure i% 2eydru& e8po%ure i% 2ey

Preeclamp%ia eclamp%iaPreeclamp%ia eclamp%ia Headac!e, uterineHeadac!e, uterineirritabilityirritability

Edema,Edema,!yperre#le8ia!yperre#le8ia

Ne treatmentNe treatment&uideline% e8i%t&uideline% e8i%t

Si&n and %ymptom in "ariou% type% o# !yperten%i"e emer&ency )contBd*

http://images.google.co.id/imgres?imgurl=http://dms.dartmouth.edu/news/section_images04h2/icu2.jpg&imgrefurl=http://dms.dartmouth.edu/news/2004_h2/01sep2004_3paintings.shtml&usg=__q0t1UkxXSynpjcaQBx3ESbv860M=&h=398&w=535&sz=57&hl=en&start=8&tbnid=bztzTYKCO7ykSM:&tbnh=98&tbnw=132&prev=/images%3Fq%3DICU%26gbv%3D2%26hl%3Den%26sa%3DG


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Management of Management of

Hpertensive (mergencHpertensive (mergenc ;gener al ;within minutes to ? hour ;within minutes to ? hour


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Management of Management of

Hpertensive (mergencHpertensive (mergenc ;general


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Parenteral Drugs for Treatment ofParenteral Drugs for Treatment of

Hpertensive (mergencies based on CN! Hpertensive (mergencies based on CN!

(ru&%(ru&% (o%e(o%e On%etOn%et (uration o#(uration o#ActionAction

SodiumSodiumnitropru%%idenitropru%%ide

/9.;:4/ u&r2&min/9.;:4/ u&r2&min ImmediateImmediate 4:. minute% a#ter4:. minute% a#terin#u%ion %toppedin#u%ion %topped

Nitro&lycerinNitro&lycerin ;:;// u&min;:;// u&min 4:0 minute%4:0 minute% ;:4/ minute%;:4/ minute%

Labetolol HClLabetolol HCl ./:5/ m& e"ery 4/:4; min./:5/ m& e"ery 4/:4; minor /9;:. m&minor /9;:. m&min

;:4/ minute%;:4/ minute% 0:< minute%0:< minute%

Fenoldopan HClFenoldopan HCl /94:/90 u&2&min/94:/90 u&2&min ; minute%; minute% 0/:


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(ru&(ru& I99 $olu% (o%eI99 $olu% (o%e Continou% In#u%Continou% In#u%RateRate

LabetalolLabetalolNicardipineNicardipine

E%mololE%molol

EnalaprilEnalapril

HydralaGineHydralaGine

NiprideNiprideNT'NT'

; ./ m& e"ery 4;B; ./ m& e"ery 4;BNANA

.;/ u&2& IP loadin& do%e.;/ u&2& IP loadin& do%e

4,.;:; m& IP e"ery < !4,.;:; m& IP e"ery < !

; ./ m& IP e"ery 0/B; ./ m& IP e"ery 0/B

NANANANA

. m&min )ma8 0//m&d*. m&min )ma8 0//m&d*;:4; m&!;:4; m&!

.;:0// u&2&m.;:0// u&2&m

NANA

4,;:; u&2&m4,;:; u&2&m

/,4:4/ u&2&m/,4:4/ u&2&m./:7// u&m./:7// u&m

AHAASA 'uideline, .//= update9 Stroke. 2 //=05+ .//4:./.09

Parenteral Drugs for Treatment of

Hpertensive (mergencies based on

A"A Fuideline

T!i% parenteral dru&% are appro"ed #or !yperten%i"e emer&ency

in acute i%c!emic %tro2e and intracerebral !emmor!a&e


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Parenteral Drugs for Treatment ofParenteral Drugs for Treatment of

Hpertensive (mergencies based on !H("T ,Hpertensive (mergencies based on !H("T ,

Acute Pulmonar edema 6 Acute Pulmonar edema 6"stolic dsfunction"stolic dsfunction

Nicardipine%Nicardipine% fenoldopam% or nitropruside combined withfenoldopam% or nitropruside combined withnitroglicern and loop diureticnitroglicern and loop diuretic

Acute Pulmonar edema6 Acute Pulmonar edema6Diastolic dsfunctionDiastolic dsfunction

(smolol% metoprolol% labetalol% verapamil% combined with(smolol% metoprolol% labetalol% verapamil% combined withlow dose of nitroglicern and loop diureticslow dose of nitroglicern and loop diuretics

Acute 0schemia !oroner Acute 0schemia !oroner )abetalol or esmolol combined with diuretics)abetalol or esmolol combined with diuretics

Hpertensive encephalopatHpertensive encephalopat NicardipineNicardipine%% labetalol% fenoldopamlabetalol% fenoldopam

Acute Aorta Dissection Acute Aorta Dissection )abetalol or combined)abetalol or combined NicardipineNicardipine and esmolol or combineand esmolol or combinenitropruside with esmolol or 08 metoprololnitropruside with esmolol or 08 metoprolol

Preeclampsia% eclampsiaPreeclampsia% eclampsia )abetalol or)abetalol or nicardipinenicardipine

Acute :enal failure 6 Acute :enal failure 6microangiopathic anemiamicroangiopathic anemia

NicardipineNicardipine or fenoldopamor fenoldopam

"mpathetic crises6 cocaine"mpathetic crises6 cocaineoveerdoseoveerdose

8erapamil% diltiaGem% or 8erapamil% diltiaGem% or nicardipinenicardipine combined withcombined withbenGodiaGepinbenGodiaGepin

Acute postoperative Acute postoperativehpertensionhpertension

(smolol%(smolol% NicardipineNicardipine%% )abetalol)abetalol

Acute ischemic stroke6 Acute ischemic stroke6

intracerebral bleedingintracerebral bleeding

Nicardipine%Nicardipine% labetalol% fenoldopamlabetalol% fenoldopam

Marik Paul (% 8aron Coseph% !H("T ,E?/?&?''-.,

Nit l iNit l i


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Nitro&lycerinNitro&lycerin

Nitroglcerin is a potent venodilator and onl at high doses affectNitroglcerin is a potent venodilator and onl at high doses affect

arterial tonearterial tone55 0t reduces 4P b reducing cardiac0t reduces 4P b reducing cardiac

ouput and preload which are undesirable effects in patient withouput and preload which are undesirable effects in patient with

compromised cerebral and renal perfusioncompromised cerebral and renal perfusion

Ni#edipineNi#edipineNifedipine has been widel used via oral or sublingualNifedipine has been widel used via oral or sublingual

administration in the management of hpertensiveadministration in the management of hpertensive

emergenciesemergencies55 This mode of administration has not beenThis mode of administration has not beenapproved b 9DA and since CN! 80 because it ma causeapproved b 9DA and since CN! 80 because it ma cause

sudden uncontrolled and severe reductions in blood pressuresudden uncontrolled and severe reductions in blood pressure

ma precipitate cerebral% renal% and mocardial ischemia thatma precipitate cerebral% renal% and mocardial ischemia that

have been associated with fatal outcomeshave been associated with fatal outcomes


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!lonidine!lonidine

!entral alfa blocker% sedative effect!entral alfa blocker% sedative effect

!0 & in patient with !erebrovascular!0 & in patient with !erebrovascular

accidentaccident

:ebound effect:ebound effect


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# Nicardipine +

9 (i!ydropiridine cla%% o# CC$

# Reduce perip!eral re%i%tance ::: blood pre%%ure

# water soluble! light insensiti"e, :: can be

parenteraly u%ed )de#erence it! ni#edipine %odium nitropru%id*

)SE O* NICAR IPINE


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↓

↓

Ca++ plus Calmodulin

Myosin Kinase

↓

↓ ↓ ↓

↓ ↓

Ca

++

plus Calmodulin

Actin-Myosin Interaction

Contraction

↓

↓ ↓ ↓ ↓ ↓ ↓

↓

Myosin Kinase

Ca++ Ca++Blockingefect o CCB

Ca++ Ca++

Calcium Channel Blocker Mechanism

↓


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# perip!eral "a%odilatation

# pre%er"e or en!anced cardiac pump acti"ity

:::::: impro"e ti%%ue per#u%ion

# #all in %y%temic blood pre%%ure, maintain at de%ired

le"el

# in compari%on it! %odium nitropru%ide e@uallye##ecti"e, but no cyanide to8ic e##ect in lon& term u%e

# not a%%ociated ad"er%e e##ect on cardio"a%cular and

renal #unction

PRI"ARY HE"O YNA"IC O*

NICAR IPINE E**ECT


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NICAR(IPINE

CHARACTERISTIC1.8A"O"()(!T080T

Nicardipine selectivit /5 @ in smooth muscle cells

blood vessels compared with mocardium

,5 Mocardial depression ;-<

/5 Negative inotropic ;-<

5 :apid and stable antihpertensive effects% reduce blood

pressure graduall I ,=> in , hours% minimal effects to

heart rate=5 0ncrease blood flow in ma1or organ & :enal% coroner%

cerebral


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Actions to increase organ blood flow Actions to increase organ blood flow

Perdipine+ 0 &2&min × ./ min

;"ho1i "uGuki% et al5% The ,th Annual "cientific Meeting of the Capanese "ociet of Hpertension& ?''<


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Tissue selectivit betweenTissue selectivit between

!alcium Antagonist!alcium Antagonist

4ristow et al5 4r C Pharmacol?'BE /'&B,


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!omparison between !alcium Antagonist!omparison between !alcium Antagonist

(ru&(ru&CoronaryCoronary

a%odilationa%odilation

Suppre%%ionSuppre%%iono# Cardiaco# Cardiac

ContractilityContractility

Suppre%%ionSuppre%%iono# SA Nodeo# SA Node

Suppre%%ionSuppre%%iono# A Nodeo# A Node

erapamilerapamil)p!enylal2ylamine*)p!enylal2ylamine*

KKKKKKKK KKKKKKKK KKKKKKKKKK KKKKKKKKKK

(iltiaGem(iltiaGem

)benGot!iaGepin*)benGot!iaGepin*KKKKKK KKKK KKKKKKKKKK KKKKKKKK

Nicardipine)di!ydropyridine *

KKKKKKKKKK // KK //

-erin% (M9 'oodman 'ilmanB%94/t! ed9.//4+570:=/


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Compari%on Study it!Compari%on Study it!

Intra"enou% (iltiaGemIntra"enou% (iltiaGem

Sub>ect%+

Patients reJuiring a rapid reduction in 4P ;D4P ≥ ??= mmHg<

Design&

Multicenter% randomiGed% single-blind comparative stud

DosageNicardipine& "tarted at 5= µg6kg6min

→ 0ncreased up to ? µg6kg6min if necessar

DiltiaGem& "tarted at = µg6kg6min

→ 0ncreased up to ?= µg6kg6min if necessar

Duration of drug administration

Dose titration& ? hour

Maintenance infusion& , hours

oshinaga $5 et al5 0gaku no Aumi ?''/& ?.=&/


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ta!ility o anti"ypertensi#eta!ility o anti"ypertensi#e

efectefect better than $iltia%em$iltia%em

oshinaga $5 et al5 0gaku no Aumi ?''/& ?.=&/


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Nicardipine vs NitrovasodilatorsNicardipine vs Nitrovasodilators

Pepine CJ. Intravenous nicardipine: cardiovascular efects and clinical relevance. Clin Ther .1988;1:!1"#$%.

(ru&(ru& NicardipineNicardipine

)Perdipine)Perdipine&& I*I*

Nitropru%%ideNitropru%%ide Nitro&lycerinNitro&lycerin

Rapid On%et o# Pea2 E##ectRapid On%et o# Pea2 E##ect KKKKKKKK KKKKKKKK KKKKKK

A#terload ReductionA#terload Reduction KKKKKKKK KKKKKKKK KK

Preload ReductionPreload Reduction // KKKK KKKKKKKK

Coronary Steal ReportedCoronary Steal Reported // KK

Coronary (ilation+ Lar&e e%%elCoronary (ilation+ Lar&e e%%el KKKKKK KK KKKKKKKK

Coronary (ilation+ Small e%%elCoronary (ilation+ Small e%%el KKKKKK K6-K6- K6-K6-

Tac!ycardiaTac!ycardia KK KKKK KKKK

Potential #or SymptomaticPotential #or SymptomaticHypoten%ionHypoten%ion

KK KKKK KKKKKK

Ea%e o# Admini%trationEa%e o# Admini%tration KKKKKKKK KKKK KKKKKK

Cyanide To8icityCyanide To8icity // KKKKKKKK


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S1MMARYS1MMARY

Hyperten%i"e Cri%e% i% an ur&ent %ituation t!at need rapidHyperten%i"e Cri%e% i% an ur&ent %ituation t!at need rapid

mana&ement to pre"ent or&an dama&emana&ement to pre"ent or&an dama&e

Anti!yperten%i"e a&ent t!at pre##ered in t!i% condition %!ouldAnti!yperten%i"e a&ent t!at pre##ered in t!i% condition %!ould

be #a%t action, parenteral, and titratablebe #a%t action, parenteral, and titratable

Nicardipine i% t!e only Calcium Anta&oni%t recommended byNicardipine i% t!e only Calcium Anta&oni%t recommended by

DNC =, AHA, .//=, CHEST .//= to mana&e !yperten%i"eDNC =, AHA, .//=, CHEST .//= to mana&e !yperten%i"e

emer&encyemer&ency

Nicardipine !a% #a"orable antii%c!emic pro#ileNicardipine !a% #a"orable antii%c!emic pro#ile becau%e o#becau%e o#

an increa%e myocardial , brain, and 2idney o8y&en %upplyan increa%e myocardial , brain, and 2idney o8y&en %upply


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THANK YOU FOR YOUR ATTENTION THANK YOU FOR YOUR ATTENTION

TAKE CARE OF YOUR HEART, BRAIN, AND KIDNE

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Slide Ws Htn