- 1. Hypertensive Urgency and EmergencyThe ApproachBy Dr Nurul
AthirahMO KK Tandek
2. The Basic (JNC 7)*The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood PressureRisk of CV event increase with 20/10mmHgDm and
kidney dss < 130/180/>120mmHg) ofBP without target end-organ
damage Emergency Severe elevations of BP with targetend- organ
damage or dysfunction. Younger pts mayhave lower BP 4. Preeclampsia
/ EclampsiaA syndrome;-preeclampsia : HTN+ proteinuria +
pulmonaryedema + proteinuria > 20w POG without seizures-
eclampsia : .... with seizures 5. Clinical
manifestationsFatigueHeadacheRestlessConfuseVisual
disturbanceSeizureDyspnoeTachy/bradycardiaPedal edemaChest
painDizzinessnausea,vomitting 6. 3. Investigationsi. Bloods-RP,
LFT, lipid profilecardiac bloodsii. ECG-LVH, ischemia, MI ,
arrythmiaiii. UFEME- hematuria or proteinuriaiv. radiologic- CXR ;
pulmo edema/mediastinal widening or (v)- CT ( if mental
status/altered neurological status) 7. General principle1.1
H'emergency BP control accomplished within few hours (reducerisk of
permanent damage/ death)-diastolic 100-110mmHg adequate for first
24hr-use IV antihypertensive1.2.H'urgency-BP control , slow with
oral aHTN (24-48hr), to adiastolic 100-110mmHg-excesive decrease
should be avoided (minimise riskof cerebral hypoperfusion/ coronary
insuff) 8. JNC7 guidelines- Reduce SBP by 10-15% , and not more
than25% within the first hour-if pt is stable, to 160/ 100-110mmHg
over 2 6hours-in case of aortic dissection ; reduce SBP at atleast
120mmHg within 20minutes-too rapid reduction will reduce tissue
perfusion( ischmemia , infarction) 9. An aortic dissectionis a tear
in the innerlayer of the aortic wall,which allows blood toenter
into the wallof the aorta (AHA) 10. 1.1 Oral antihypertensive
agents( only for urgent / not rapid reductions)- combinations
therapy necessary when diastolic> 110mmHgACEi ; captopril 12.5
to 25mg (w/wo diureticsBB ; atenolol 50-100mg or labetolol
200-400mg(with / wo diuretics) or,CCB can also be used. 11. Drugs
of choicei. CAD (coronary artery disease) and HF (heartfailure) ;
IV NTG or nitroprussideii. Pulmonary edema ; IV frusemide,
IVnitroprusside, or ACEi/ ARBiii. HTN in pregnancy ; MgSO4,
hydralazine orlabetololiv. stroke ; BB, CCB, diuretic or ACEi/ ARB
12. Common drugs used in our settings1. Captopril (ACEi)/ 25mg
poonset 15-30mins,duration action6-8hours ; effect the
renin-angiotensin (inhibit angiotensin I II)**Ag II regulates BP2.
Labetolol (combined alpha , beta adrenergic inhibitor).
Controlsreflex tachcyardia as BP drops. Does not effect cardiac/
renal3. Nifedipine (CCB) ; dilate coronary artery, and relaxation
ofperipheral arterioles smooth muscle, reduce peripheral
vascularresistance. Onset 5-10mins , peak15-30mins, duration
6-8hrs4. Mgso4 (inorganic salt) ; replace Mg , decrease nerve
impulse tomuscles5. Nitroglycerin ; rx acute cardiac ischemia.
direct vasodilator ,reduce preload and cardiac output 13. Having
difficulties ?- ?incomplete history-?complex comorbiditiesRx choose
aHTN with limited side effectsand broad applicability , with
limited renal /cardiac/ hepatic contraindications 14. Sources1.
Sarawak Handbook of MedicalEmergencies 3rd edition2.Hypertensive
emergencies : acute careevaluation and management ;
emergencymedicine cardiac research and emergencygroup ( dec 2008,
vol 3)3. American Heart Association (AHA)
