HYPERTENSIVE CRISISBy Group 6 2015/2016

Epidemiology of Hypertension

• NHMS 2011 reported,• Prevalence HPT Malaysian adults ≥ 18 years

has increased from 32.2 % in 2006 to 32.7 in 2011

• >30 years old, prevalence 42.6% - 43.5%• 60.6% of total hypertensive were undiagnosed• No gender predilection• Malay 34%, Chinese 32.3%, Indians 30.6%

Classification & Prevalence

Definition

Hypertension• Persistent elevation of systolic BP of

140mmHg or greater and/or diastolic BP of 90mmHg or greater

Severe Hypertension• Persistent elevation SBP >180 mmHg and/or

DBP >110 mmHg

Criteria for staging HPT

Clinical Presentation

• Incidental finding in asymptomatic patient• Non-specific symptoms: Headache, dizziness,

lethargy• Symptoms and signs of acute target organ

damage; Acute heart failure, ACS, Acute renal failure, dissecting aneurysm, SAH & Hypertensive encephalopathy

Severe Hypertension Categories

• Asymptomatic severe hypertension• Hypertensive crisis: “Acute increase in BP usually diastolic BP >120 mmHg, with or without end-organ damage.” Adapted from Sarawak Handbook of medical emergencies

-Hypertensive urgencies -Hypertensive emergencies

Definition

• Hypertensive emergencies“ Increase BP with evidence of end-organ damage or dysfunction”

• Hypertensive urgencies“Elevation of BP to a level, which may be potentially harmful, but without signs, symptoms or other evidence of end-organ dysfunction”

End-Organ manifestation

1. Retinal: Papilloedema2. Cardiac: Pulmonary oedema, Myocardial

ischemia3. Neurological: Severe headache, mental status

changes, seizure, coma, hypertensive encephalopathy

4. Renal: Acute Renal Failure

Common Causes:

Investigations

• BUSE• Creatinine• Urinalysis• Chest X-ray • ECG• Toxicology profile

Management

Asymptomatic Severe Hypertension:

May required admission in newly diagnosedReviewed drug regime in patient with previous

anti-hypertensive treatmentOral combination therapy should be preferredSubsequent follow up

Hypertensive Urgencies

• Admit patient• Repeat BP measurement after 30 mins of bed

rest• Aim 25% reduction in BP over 24 hours to a

diastolic level of 100-110 mmHg BUT not lower than 160/90mmHg

• BP control using oral anti-hypertensive drug• Combination therapy is necessary• Sublingual Nifedipine SHOULD BE AVOIDED!

Hypertensive Urgencies

Combination Therapy is necessary for most cases when diastolic BP >110mmHg

• Beta-blocker with or without diuretics OR• ACE Inhibitor/ ARB with or without diuretics

Hypertensive Emergencies

• All patient should be admitted• ABC : IV access, O2 support, cardiac monitor• BP need to be reduce rapidly (to reduce the

risk of permanent damage/death)• Aim reduce BP 25% over 3-12 hours but not

lower than 160/90mmHg• Best achieve with parenteral drugs

Drug choice for management:Condition Drug of Choice

Coronary Artery Disease and Heart Failure

IV NitroglycerinDiuretics and morphine can be added

Pheochromocytoma IV phentolamine or alpha-blocker eg. Prazosin

Aortic dissection IV beta blocker or labetalol +/- nitroprusside

Pulmonary oedema IV Nitroglycerin, IV frusemide, IV nitroprusside, ACE inhibitor/ARB

HPT in pregnancy Hydralazine, Labetalol and magnesium sulphate

Stroke Beta blocker, CCB, diuretic or ACE inhibitor/ ARB

Subsequent Therapy

• Investigate for underlying cause• If parenteral agents are used initially, oral

medication should be administered in combination shortly thereafter to facilitate weaning from parenteral therapy (over 1-2 days)

Reference

• CPG Management of Hypertension (4th edition)

• Sarawak Handbook of Medical Emergencies• Emergency Medicine, companion Handbook.

By Cline, Ma, Tintinalli, Kellen, Stapczynski