2. OBJECTIVES
• 1. What is Hypertensive Crisis ?
• 2. Size of the problem
• 3. Clinical presentation
• 4. Management
3. CASE SCENARIO
• 69/M
• Chest tightness and shortness of breath
• Diabetes – 10 years. Chronic smoker
• Not known hypertensive
• BP 230/120 mmHg HR 110/mt
• CVS – S3 gallop, No murmur.
• Chest – Bi-basal fine inspiratory crackles
• P/A – Kidneys not ballotable. No RA bruit.
• Neuro – fully consciouss , No neuro deficits.
7. What would you do next?
• 1. 24 hour urinary protein.
• 2. 24 hour ambulatory BP
• 3. Renal Ultrasound
• 4. Fundoscopy
8.
9. What targets organs are Involved?
• 1. Brain
• 2. Heart
• 3.Retina
• 4. Kidneys
10. What targets organs are Involved?
• 1. Brain
• 2. Heart
• 3.Retina
• 4. Kidneys
11. What is the diagnosis?
• 1. Accelerated Hypertension
• 2.Malignant Hypertension
• 3. Hypertensive Urgency
• 4. Hypertensive Emergency
12. Answer
Hypertensive Emergency
Severe Hypertension where BP is > 180/110
mmHg with evidence of target organ damage.
1.Retinopathy / Retinal hemorrhage
2.Encephalopathy/I.C hemorrhage/ IC tension
3.Acute Pulm. Oedema, Myocardial
ischaemia/Aortic dissection.
4. Acute Renal Failure
13. HYPERTENSIVE CRISIS
• Approximately 25% of emergency room visits
are due to hypertensive crisis.
• BP > 180/110 mmHg
• Emergency : Target organ damage.
• Urgency : No target organ damage.
14.
15.
16. Common precipitating factors
• 1. No regular health checks
• 2. Age - elderly
• 3.Sub therapeutic treatment
• 4. Non adherence to medication.
• 5. Lack of family care physician.
17. Signs and Symptoms
Symptoms specific to target organ damage
• Headache
• Neck pain
• Blurring of vision
• Chest tightness
• Shortness of breath
• Anuria
23. Medication of choice
• Myocardial Ischemia/ LVF : NTG, Esmolol
• Aortic Dissection : Labetalol
• Acute Renal Failure : Fenoldopam /
Nicardipine
• Hyper-adrenergic states : due to sympatho-
mimetic drugs : Benzodiazepines.
Pheo chromocytoma : Phentolamine
24. • Eclampsia : Labetalol /Magnesium
ACEI and ARB contra-indicated
Intracranial Heamorrhage: Aim MAP 130
mmHg
First : Labetolol
Second : Sodium Nitroprusside if no raised ICP
If ICP raised : Use Nicardipine.
25. • Labetalol : Alpha selective, Beta non selective
• oral/ intravenous
• Nicardipine : second generation
dihydropyridine.Onset of action 5-20 minutes
• Nitroglycerine :
• More of Venodilator than arterial dilator.
• SE: Headache, Flushing, Tachycardia
•
26. • Nitro prussside :
Strong veno and arterial vasodilator.
rapid onset of action.
Risk of thiocyanide toxicity : Hyperreflexia
delerium , psychosis
28. Use of Captopril
• Short acting ACEI
• Hypertensive Urgency
• Oral and sublingual : 6.25-50 mg
• Effect seen within 5-15 minutes
• Max reduction of BP in 30 mins
• Duration of effect 2-6 hours
• S/E : Hyperkalaemia / Angio-edema/dry cough
37. How will you manage the patient?
• 1.Admit and start intravenous
antihypertensive medication
• 2. Treat as OP clinic with orally
antihypertensive
• 3. Treat if patient is symptomatic
• 4. Just Observe
38. How will you manage the patient?
• 1.Admit and start intravenous
antihypertensive medication
• 2. Treat as OP clinic with orally
antihypertensive
• 3. Treat if patient is symptomatic
• 4. Just Observe
39.
40. What do the guidelines say?
Joint National Committee
•Seventh report on Prevention, Detection,
Evaluation and Treatment of Hypertension
states ‘’ Initial goal of therapy in hypertensive
emergencies is to reduce MAP by no more than
25% - minutes to 1 hour
160/100-110 - 2 to 6 hours
<140/90 - 24 to 48 hours
42. Acute Ischemic Stroke
• If BP < 220/120 mmHg – only observe
Unless end organ damage
concurrent hemorrhage
If SBP > 220 and DBP 120-140 : Labetalol
/Nicardipine
If DBP > 140 : Nitroprusside
Aim for 10 – 15% reduction over 24 hours
43. Aortic Dissection
• BP should be lowered quite aggressively
• Goal : systolic BP 100-120 mmHg within 20
minutes
• Aim
a. lower BP
b. decrease LV contraction so as to decrease
Aortic shear stress
DOC : labetalol or Esmolol