Htn urgency and emg
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Transcript of Htn urgency and emg
Hypertensive Urgency/Emergency
Dr. Sudhir DeoHouse OfficerGPEM, BPKIHS
JNC 7 Classification Of HTN
Evaluation Of Patient’s with HTN
Evaluation of hypertensive patients has three objectives:
(1) to assess lifestyle and identify other
cardiovascular risk factors or associated disorders that may affect prognosis and guide treatment
(2) to reveal identifiable causes of high BP (3) to assess the presence or absence of target
organ damage.
Cardiovascular risk factors
Major Risk Factors
Hypertension*Age (older than 55 years for men, 65 years for women)†Diabetes mellitus*Elevated LDL (or total) cholesterol, or low HDL cholesterol*Estimated GFR <60 mL/minFamily history of premature CVD (men <55 years of age orwomen <65 years of age)MicroalbuminuriaObesity* (BMI >30 kg/m2)Physical inactivityTobacco usage, particularly cigarettes
Identifiable causes of hypertension
Chronic kidney diseaseCushing’s syndrome and other glucocorticoid excess statesincluding chronic steroid therapyDrug induced or drug related (see table 18)Obstructive uropathyPheochromocytomaPrimary aldosteronism and other mineralocorticoid excess statesRenovascular hypertensionSleep apneaThyroid or parathyroid disease
Target Organ Damage
HeartLVHAngina/prior MIPrior coronary revascularizationHeart failure
BrainStroke or transient ischemic attackDementia
CKDPeripheral arterial diseaseRetinopathyPlacenta
Eclampsia
Approach to All Patients With HTN
Look for:• LOC and orientation• Respiratory status• For neurological deficits
Hemiparesis, slurred speech• Baseline
Temperature, HR, RR, BP• Maintain continuous monitoring of BP and HR• ***BP should not only be measured in both the supine
position and the standing position (assess volume depletion), but it should also be measured in both arms (a significant difference may suggest aortic dissection).
• Assess for changes in cardiac rhythm if patient is on a monitor• Monitor I&O
SaO2 via pulse oximetry if available
For associated symptoms Visual disturbance, chest pain, peripheral edema, hematuria
Drug use in Hypertension
Combination drugs
REF: JNC -7 (THE 7TH REPORT OF JOINT NATIONAL COMMITTEE ON PREVENTION, DETECTION, EVALUATION AND TREATMENT OF HIGH BLOOD PRESSURE) PAGE 27, 28,29
HTN URGENCY
Severe elevations in BP (DBP≥120-130mmhg) without evidence progressive target organ dysfunction.
Examples: Severe uncomplicated essential hypertensionSevere uncomplicated secondary hypertensionPostoperative hypertensionDrug-induced hypertensionRebound hypertension (i.e., sudden withdrawal of clonidine)Cessation of prior antihypertensive therapySevere hypertensive crises related to anxiety, panic attacks or pain
Agents that reliably cause an immediate fall in BP include captopril(25-50 mg), central sympatholytics(clonidine0.1–0.2 mg), labetalol(200–400 mg), and amlodipine(2.5–5 mg)• Initiation of therapy with two oral agents is appropriate to lower BP
to an intermediate target over 24 to 72 hours • Appropriate follow-upwithin 3 days.
TREATMENT OF HTN URGENCY:Goals: Lower mean arterial pressure to goal or near goal within several hours. Oral medications can be used.MAP=(2xDP)+SP/3Lower mean arterial pressure by 20- 25% or diastolic pressure to <100 to 110 mmHg within 30–60 minutes. excessive falls in pressure that may precipitate renal, cerebral, or coronary ischemia.
HTN EMERGENCY
Hypertensive EmergenciesSevere elevations in BP (>180/120 mmHg) Complicated by evidence of impending or progressive target
organ dysfunction. Require immediate BP reduction (not necessarily to normal) to
prevent or limit target organ damage.
Exampleshypertensive encephalopathyIntracerebral hemorrhage,acute MIacute left ventricular failure with pulmonary edemaunstable anginadissecting aortic aneurysm,eclampsia
Initial Evaluation of Patients with a Hypertensive
Emergency
History• Prior diagnosis and treatment of hypertension• Intake of pressor agents: street drugs,
sympathomimetics• Symptoms suggesting an acute end-organ
involvement• chest pain –myocardial infarction, thoracic aortic
dissection• back pain –thoracic aortic dissection• dyspnea–acute pulmonary edema• neurological symptoms-hypertensive
encephalopathy
Physical examination
• Blood pressure –both upper limbs• Fundoscopy• Cardiopulmonary status
AR, MR , signs of CHF• Neurologic status
level of consciousness, focal sigh of ischemia
• Body fluid volume assessment• Peripheral pulses
Laboratory evaluation
Hematocrit and blood smear (microangiopathic hemolysis)Urine analysisAutomated chemistry: creatinine, glucose, electrolytesElectrocardiogramChest radiograph (if heart failure or aortic dissection is
suspected)CT brain in patients with neurological symptomsCT chest or MRI in patients with unequal pulses/ an enlarged
mediasternum
Clinical Characteristics HTN Emergency
Blood pressure: usually >140 mm Hg diastolic
Fundoscopic findings : accelerated HT -grade 3 retinopathy ( haemorrhages, exudates) malignant HT -grade 4 retinopathy (papillodema)
Neurologic status: headache, confusion, somnolence, stupor, vision loss, focal deficits, seizures, coma
Renal status: oliguria, azotemia(high levels of nitrogen- containing compounds)
Gastrointestinal status: nausea, vomiting
HTN EMERGENCY TREATMENT
GOALS:
Almost all hypertensive emergencies are caused or exacerbated by intense systemic vasoconstriction, often with profound blood volume reduction
goal of therapy is to reduce vasoconstriction while maintaining adequate perfusion of target organs
Treatment: All HTN Emergencies should be admitted and
treated in ICU/CCU The initial goal of therapy in hypertensive
emergencies is to reduce mean arterial BP by no more than 25 percent (within minutes to 1 hour)
If clinical is stable, reduce BP to 160/100–110 mmHg within the next 2–6 hours
Further gradual reductions toward a normal BP can be implemented in the next 24–48 hours.
Exceptions• acute stroke in evolution (for which no BP
lowering is generally recommended)
• The American Heart Association recommends:
• Treatment with intravenous labetalol or nicardipine
Started when BP values are above 220/120mmHgThe target BP should be a 10–15% lowering of BP
DRUGS FOR HTN EMERGENCY• Nitroprusside — a rapidly acting arteriolar and venous dilator,
given as an intravenous infusion. Initial dose: 0.25 to 0.5 mcg/kg per min; maximum dose: 8 to 10 mcg/kg per min which should be continued for no more than 10 minutes.
• Nitroglycerin — a rapidly acting venous and, to a lesser degree, arteriolar dilator, given as an intravenous infusion. Initial dose: 5 mcg/min; maximum dose: 100 mcg/min.
• Labetalol — an alpha- and ß-adrenergic blocker, given as an intravenous bolus or infusion. Bolus: 20 mg initially, followed by 20 to 80 mg every 10 minutes to a total dose of 300 mg. Infusion: 0.5 to 2 mg/min.
• Nicardipine — a calcium channel blocker, given as an intravenous infusion. Initial dose: 5 mg/h; maximum dose: 15 mg/h.
• Clevidipine — a calcium channel blocker. Initial dose: 1
mg/hour; maximum dose: 16 mg/hour.
DRUGS FOR HTN EMERGENCY• Fenoldopam — a peripheral dopamine-1 receptor agonist, given
as an intravenous infusion. Initial dose: 0.1 mcg/kg per min; the dose is titrated at 15 min intervals, depending upon the blood pressure response.
• Hydralazine — an arteriolar dilator, given as an intravenous bolus. Initial dose: 10 mg given every 20 to 30 minutes; maximum dose: 20 mg.
• Propranolol — a ß-adrenergic blocker, given as an intravenous infusion and then followed by oral therapy. Dose: 1 to 10 mg load, followed by 3 mg/h.
• Phentolamine — an alpha-adrenergic blocker, given as an intravenous bolus. Dose: 5 to 10 mg every 5 to 15 minutes.
• Enalaprilat — an angiotensin converting enzyme inhibitor, given as an intravenous bolus. Dose: 1.25 mg every six hours.
Drugs In HTN Emergency
Drugs of choice and relative contraindications for hypertensive emergencies
References• JNC VII Seventh report of
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
• Manual of Hypertension of the European Society of Hypertension 2008
Thank You!