الرحيم الرحمن الله بسم

Hypertensive Emergencies and Urgencies

Dr Nahed Sherbini ,Consultant Internist ,Head of Internal Medicine Department

2010 KFH, Medina

Uncontrolled Hypertension: May Occur Throughout the Hospital

ED Medical & Surgical Wards MICU SICU OR

Varon J, Fromm RE. Postgrad Med. 1996;99:189-203.

What I Will Talk About?

Hypertensive Emergencies

Hypertensive Urgencies

An Approach to Drug Treatment of HU and HE

Hypertension — An Epidemic

Affects at least 1 BILLION individuals worldwide.

Most current (2003) evidence basis for chronic management— (JNC 7)—lacks guidance for acute management of patients presenting with severe acute elevations of BP.

JNC 7, JAMA 2003; 289:2560-2572.

Hypertensive Urgenciesand Emergencies

Data are largely lacking.

In a single-center Italian study, HU or HE

HU:HE ratio of 3:1 in that study

Zampaglione et al, Hypertension 1996;27:144.

ED Hypertensive Emergencies

Hypertensive emergencies and urgencies Account for 3% of all ED visits1

An “Internal Medicine” ED N=14,209 1634 had a medical urgency or

emergency2▪ 27.4% of these were hypertensive crises

1. Kitiyakara C, Guzman N. J Am Soc Nephrol. 1998;9:133-142. 2. Zampaglione B, et al. Hypertension. 1996;27:144-147.

Blood Pressure Classification

JNC7

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension 140–159 or 90–99

Stage 2 Hypertension >160 or >100

BP Classification SBP mmHg DBP mmHg

JNC 7 Nomenclature

Stage 3 hypertension (JNC 6): Systolic > 180, Diastolic > 110 Functionally, this is “hypertensive

urgency”

What about “crisis,” “emergency,” and “urgency”?

JNC 7, JAMA 2003; 289:2560-2572.

JNC 7 Nomenclature

“hypertensive crisis” is an acute, severe, stage 2 or 3 elevation BP.

Crisis is then differentiated into hypertensive “emergencies” &“urgencies”.

JNC 7, JAMA 2003; 289:2560-2572.

Hypertensive Crisis: JNC-7 definitions

Hypertensive emergency

Severe elevation in BP (>180/120 mmHg) complicated by evidence of impending or progressive target organ dysfunction

Hypertensive urgency

Severe elevation in BP without progressive target organ dysfunction

Chobanian AV et al. Hypertension. 2003;42:1206-1252.

Hypertensive Crisis

Hypertensive

urgency

Hypertensive

emergency

Perioperative

hypertension

Operating roompost-

anesthesia care

Emergencydepartment

Intensive care unit

End-Organ Damage Characterizes Hypertensive Emergencies

BrainHypertensive encephalopathyStroke

RetinaHemorrhagesExudatesPapilledema

Cardiovascular SystemUnstable anginaAcute heart failureAcute myocardial infarctionAcute aortic dissection Dissecting aortic aneurysm

KidneyHematuriaProteinuriaDecreasing renal function

Adapted from Varon J, Marik PE. Chest. 2000;118:214-227 .

Causes of Hypertensive Crises Essential hypertension

Medication noncompliance

Secondary hypertension Aortic coarctation Cushing’s syndrome Elevated ICP Renal dysfunction Pregnancy Hyperparathyroidism Hyperthyroidism Pheochromocytoma Primary aldosteronism

JNC 7, JAMA 2003; 289:2560-2572.

Severe Hypertension: Etiologies

Medical Uncontrolled HTN

▪ Noncompliance Drug-induced HTN

▪ Cocaine, amphetamines

▪ Drug withdrawal▪ Drug-drug

interactions Endocrine disorders

●Surgical– Cardiac surgery

– Major vascular surgery

- Carotid endarterectomy

- Aortic surgery

– Neurosurgery

– Head and neck surgery

– Renal transplantation

– Major trauma – burns or head injury

Varon J, Fromm RE. Postgrad Med. 1996;99:189-203.

Medications That May PrecipitateHypertensive Emergencies / Urgencies

• Oral contraceptives

• Steroids

• NSAIDs

• Nasal decongestants

• Appetite suppressants

Presenting Symptoms

Hypertensive Urgencies Arrhythmia Epistaxis Headache Psychomotor agitation

Usual Primary ED Diagnosis Hypertension

Hypertensive Emergencies Chest pain Dyspnea Neurologic deficits

Usual Primary ED Diagnosis CVA Acute pulmonary edema Hypertensive encephalopathy Acute heart failure

Zampaglione et al, Hypertension 1996;27:144.

Hypertension in presentation

Four Categories of Presentation1. Mild, uncomplicated2. Transient3. Emergencies4. Urgencies

Definitions of Hypertension

Mild, Uncomplicated HTN Diastolic BP <115 mmHg without end

organ symptoms Educate, do not treat, arrange follow up

Transient HTN A reaction to some condition

▪ Pain, fright, epistaxis, drug OD

Treat the condition

SevereHTN

CHF andPulmonary

Edema

Renal

Dysfunction

Myocardial

Infarction

Stroke,Encepha-lopathy

AorticDissectio

n

Severe Hypertension: Clinical Outcomes

Benefits of Lowering BP JNC7

Average Percent Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

Treatment Guidance

Goals of Emergency Therapy of Hypertensive Crises

Goal in hypertensive urgency is to reduce MAP (MAP= ( 2 Diastolic + systolic) / 3) by 10-15% and/or to a DBP of 110 . . . within hours.

HU can generally be managed with oral medications and requires BP lowering over 24-48 h.

JNC 7, JAMA 2003; 289:2560-2572.

Algorithm for Treatment of Hypertension JNC7

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed .

With Compelling Indications

Lifestyle Modifications

Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)

2-drug combination for most (usually thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg)

Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB,

or combination.

Without Compelling Indications

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.

Consider consultation with hypertension specialist.

Compelling Indications for Individual Drug Classes

Compelling Indication Initial Therapy Options Clinical Trial Basis

ACC/AHA Heart Failure Guideline, MERIT-HF, COERNICUS, RALES

ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn,

ALLHAT, HOPE, ANBP2, LIFE, CONVINCE

THIAZ, BB, ACEI, ARB, ALDO ANT

BB, ACEI, ALDO ANT

THIAZ, BB, ACE, CCB

Heart failure

Post MI

High CAD risk

Diabetes

Chronic kidney disease

Recurrent stroke prevention

Compelling Indications for Individual Drug Classes

Compelling Indication Initial Therapy Options Clinical Trial Basis

NKF-ADA Guideline, UKPDS, ALLHAT

NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK

PROGRESS

THIAZ, BB, ACE, ARB, CCB

ACEI, ARB

THIAZ, ACEI

Treatment Goals for Hypertensive Emergency

Reduce MAP by ≤ 25% during the 1st minutes to 1 h.

If stable, reduce BP to 160/100-110 mmHg in next 2-6 h.

Conditions requiring special management Aortic dissection

Stroke eligible for thrombolytic agents Ischemic stroke

Chobanian AV et al. Hypertension. 2003;42:1206-1252.

Cerebral Autoregulation Is Central to Treatment of Hypertensive Crises

100 200

Normotensive

Chronic hypertensive

Increasing risk of hypertensive

encephalopathy

Increasing risk of ischemia

50 150 250

Patients with cerebral ischemia lose their ability to autoregulate

Ischemia

Cerebral Blood Flow

Adapted with permission from Varon J, Marik PE. Chest. 2000;118:214-227.

MAP (mm Hg)

0

Patients with chronic hypertension autoregulate cerebral blood flow

around higher set points

PATHOPHYSIOLOGY

NORMAL AUTOREGULATION

RISE IN BP

ARTERIAL AND ARTERIOLAR CONSTRICTION

Normal flow.(flow=P/r)

RISE IN BP

FAILURE OF VASOCONSTRICTION

ENDOTHELIAL DAMAGE

(due to shear stress on the wall)

AUTOREGULATION FAILURE

JNC 7: Special Considerations in Hypertensive Emergencies

Patients with marked BP elevations and acute target-organ damage

Admitted to an ICU for continuous monitoring of BP.

Should receive parenteral antihypertensive therapy with an agent appropriate for the individual patient.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. US Dept of HHS; NIH publication No. 04-5230; 2004:54.

Ref : CHEST 2007 ; 131 : 1949-1962 : Hypertensive crises : challenges and management

Ref : CHEST 2007 ; 131 : 1949-1962 : Hypertensive crises : challenges and management

47- Year-OldComplains Of Chest Pain

47-Year-Old Complains Of Chest Pain

BP 162/110BP 162/110

Acute Myocardial Infarction

NTG Relieves only chest pain No mortality difference in 77,000 patients

-blockers

Antiplatelets: ASA, clopidogrel

Anticoagulants: LMWH, UFH

GP IIb/IIIa antagonist or DTI w/clopidogrel

NTG Relieves only chest pain No mortality difference in 77,000 patients

-blockers

Antiplatelets: ASA, clopidogrel

Anticoagulants: LMWH, UFH

GP IIb/IIIa antagonist or DTI w/clopidogrel2007 AHA/ACC Guidelines

NitrovasodilatorsNitroprusside versus Nitroglycerin

Drug Nitroprusside NitroglycerinRapid onset of peak effect ++++ +++

Afterload reduction ++++ +

Preload reduction ++ ++++

Coronary steal reported + 0

Coronary dilation – large vessel + ++++

Coronary dilation – small vessel +/- +/-

Tachycardia ++ ++

Potential for symptomatic hypotension ++ +++

Ease of administration ++ +++

Cyanide toxicity ++++ 0

Pepine CJ. Clin Ther. 1988;10:316-325.

54-Year-Old Male, Collapsed At Work

Aortic Dissection — Strategy

Must decrease shear forces Do not use inotropics

Esmolol

Labetolol

Must decrease shear forces Do not use inotropics

Esmolol

Labetolol

Tintinalli, 4th ed.

-Blocker vs Combined - and -Blocker

Esmolol -Blocker

Labetalol

- and -Blocker

Administration BolusContinuous infusion

BolusContinuous infusion

Onset Rapid (60 s)2 Intermediate (peak 5-15 min)2

Offset (Duration of action) Rapid (10-20 min)2 Slower (2-4 h)2

HR Decreased +/-

SVR 0 Decreased

Cardiac output Decreased +/-

Myocardial O2 balance Positive Positive

Contraindications Sinus bradycardiaHeart block >1°

Overt heart failureCardiogenic shock

Severe bradycardiaHeart block >1°

Overt heart failureCardiogenic shock

1. Hoffman BB. In: Hardman JG, Limbird LE, eds. Goodman and Gilman’s Pharmacological Basis of Therapeutics. 10th ed. New York, NY: McGraw-Hill; 1997:215-268.

2. Varon J, Malik PE. Chest. 2000;118:214-227.

Calcium Channel Blockers

Nicardipine(dihydropyridine)

Diltiazem(benzothiazepine)

Verapamil(phenylalkylamine)

Peripheral Vasodilation1 +++++ +++ +++

CoronaryVasodilation2 +++++ +++ ++++

Suppressionof SA Node2 + +++++ +++++

Suppressionof AV Node2 0 ++++ +++++

Suppressionof Cardiac

Contractility20 ++ ++++

.1Frishman WH, et al. Med Clin North Am. 1988;72:523-547 .

.2Adapted from Goodman and Gilman’s: The Pharmacologic Basis of Therapeutics. 9th ed. 2001.

IV Antihypertensive Utilization Trends

1,200,4441,133,717

8,288

139,104

240,785

735,647

502,518

312,432

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

Nitroglycerin Labetalol Hydralazine Enalaprilat Esmolol SNP Nicardipine Fenoldopam

2004 2005 2006

All Patients Treated with Drug

Thomson Patient Level Data. 2006

Finally,

HTN is extremely prevalent & hypertensive crises will become increasingly common in the ED.

So, What is new?

http://www.nhlbi.nih.gov/guidelines/hypertension/jnc8/index.htm

Coming up next year!

The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8)

Update of the JNC 7 ReportExpected Availability for Public

Review and Comment:  Spring 2011

Expected Release Date:  Fall 2011

Thank you for your attention