How to Handle a Hypertension Crisis
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10:45 – 11:45 am Presenter Disclosure Information How to Handle Hypertension The following relationships exist related to this presentation: Crisis ► Karol E. Watson, MD, PhD, FACC: Advisory Board for AstraZeneca; Daiichi Sankyo; Merck & Co., Inc.; and Quest Diagnostics. SPEAKER Karol E. Watson, MD, PhD, FACC Off-Label/Investigational Discussion ►In accordance with pmiCME policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Learning Objectives How to handle a Define hypertensive crises: Hypertension urgency Hypertension Crisis and hypertension emergency Outline the pathophysiology of hypertensive urgencies and emergencies Karol Watson, MD, PhD Identify treatment goals and treatment options for Professor of Medicine hypertensive crises. David Geffen School of Medicine at UCLA Los Angeles, California Current State of Hypertensive Crisis Acute Severe Hypertension Management Epidemiology and Mortality • Hypertensive crises are among the most misunderstood and mismanaged of acute medical Historical Study problems seen in clinical practice • 1939: First study of the natural history of • Delays in initiating therapy can cause severe complications in target end organs hypertensive emergencies published • Overzealous therapy resulting in a too-rapid • Untreated hypertensive emergencies had a 1- reduction in blood pressure is equally damaging year mortality rate of 79%, with median survival of 10.5 months • Consideration of the pathophysiologic principles involved in hypertensive crises is of utmost importance Varon J, Marik PE. Chest. 2000;118:214-227. Varon J. CHEST 2007; 131:1949–1962. Epstein M. Clin Cornerstone. 1999;2:41-54. Hypertension Emergencies in context Severe hypertension is relatively common Chronic Hypertension There are ~100,000 ER ~15,000 of those Hypertension visits each year visits are for Urgencies for hypertension severely high BP Hypertension Emergencies Pitts et al. Natl Health Stat Report 2008;7:1-38. Terminology and Definitions Epidemiology (JNC 7) Urgency Emergency • You will almost certainly see a hypertensive SevereThe Hypertension diagnosisplus of hypertensiveEnd-organ Damage urgency in your career • You will also likely see a hypertensive ► BPemergencies > 180/110 mm Hg depends► CHF on the ► ACS/AMI emergency clinical manifestations rather - Occur in 1-2% of the hypertensive population ► Renal failure than only on the absolute level of - But, 50 million hypertensive Americans ► Stroke and ICH - 500,000 hypertensive emergencies/year the blood pressure.► Encephalopathy • Higher in the elderly and African Americans ► Aortic dissection • Incidence is twice as high in men as ► Pre-eclampsia compared to women ► Other? Hypertensive Urgencies / Classification of Severe Hypertension Emergencies: (Hypertensive Crises) Urgencies • Classification / Definition Severe HTN with NO evidence of • Etiology / Pathophysiology acute end organ damage • Evaluation Can be treated as an outpatient • Management Emergencies • Follow up Severe HTN WITH evidence of acute end organ damage Requires hospitalization and parenteral (IV) medication Hypertensive Urgencies / Most Hypertensive Crises are Emergencies: caused by: • Sodium excess • Classification / Definition • Extracellular volume expansion • Etiology / Pathophysiology • Sympathetic overactivation • Evaluation • Management Too Much Salt • Follow up Too Much Water Too Much Sympathetic Activity Pathophysiology of Hypertensive Hypertensive Urgencies / Emergencies: Emergencies: a Vicious Cycle Common Etiologies Hypertensive Emergency Vasoconstriction, often Circulating . Accelerated hypertension in a patient with intravascular vasoconstrictors hypovolemia causes: with preexisting hypertension End organ - Increased circulating ischemia Abrupt SVR catecholamines . Medication noncompliance - Activation of renin- Loss of angiotensin-aldosterone . Acute antihypertensive drug withdrawal Abrupt BP system Autoregulatory - Altered autoregulatory function . Renovascular hypertension Endothelial function damage . Acute glomerulonephritis Ault NJ, et al. Am J Emerg Med. 1985;3(6 suppl):10-15. 2. Wallach R, et al. Am J Cardiol. 1980;46:559-565. Varon J, et al. Chest. 2000;118:214-227. 4. Kincaid-Smith P. J Hypertens. 1991;9:893-899. Hypertensive Urgencies / Emergencies: LESS Common Etiologies How do patients with hypertensive Sympathomimetic drug poisonings crises present? Pre-eclampsia Pheochromocytoma MAO inhibitor interactions Signs and Symptoms Hypertensive Urgencies / Emergencies: Signs and HTN Urgency (%) HTN Emergency (%) Symptoms Common Clinical Precipitants Headache 22 3 . Myocardial Ischemia Epistaxis 17 0 . Hypercarbia / Hypoxemia Chest Pain 927 . Inappropriate vascular clamping (afterload) Dyspnea 922 . Malignant Hyperthermia Faintness 10 10 . Pain Agitation 10 2 . Anxiety Neurologic Deficit 321 . Distended Bladder Vomiting 23 . Hypervolemia Arrhythmia 60 Zampaglione B, et al. Hypertension 1996;27:144-147. Signs and Symptoms Hypertensive Urgencies / Signs and HTN Urgency (%) HTN Emergency (%) Symptoms Emergencies: Headache 22 3 • Classification / Definition Epistaxis 17 0 • Etiology / Pathophysiology Chest Pain 927 • Dyspnea 922 Evaluation Faintness 10 10 • Management Goals of evaluation Agitation 10 2 • Outcomes are to determine Neurologic Deficit 321 etiology, and rapidly Vomiting 23 assess for end organ damage Arrhythmia 60 Zampaglione B, et al. Hypertension 1996;27:144-147. End-Organ Damage Characterizes Initial Evaluation Hypertensive Emergencies • Symptoms Brain • Medical History Hypertensive Retina - Episodic palpitations and perspiration? encephalopathy Hemorrhages Stroke Exudates • Medications Papilledema - MAO inhibitors Cardiovascular - Clonidine System Unstable angina Kidney • Social History Acute heart failure Hematuria - Recreational Drugs Acute myocardial Proteinuria infarction Decreasing renal Amphetamines Acute aortic dissection function Cocaine Dissecting aortic aneurysm Phencyclidine Adapted from Varon J, Marik PE. Chest. 2000;118:214-227. Physical Exam Hypertensive Retinopathy • Blood pressures must be taken in both arms Grade 1 – mild narrowing or sclerosis of retinal - If the cuff is too small, the BP will be falsely elevated arteries (arteriolar narrowing) - If the cuff is too low (below the level of the heart), the BP will be falsely elevated Grade 2 – moderate to marked arteriolar • Pulses should be checked in upper and lower narrowing with A-V crossing changes (AV extremities nicking) • Neuro exam Grade 3 – All the above + hemorrhages or • Cardiac exam cotton-wool spots • Pulmonary exam Grade 4 – All the above + additional swelling of • Ocular exam: only happens in 13% of pts the optic disk (papilledema) Labs / Imaging to consider Hypertensive Encephalopathy • Comprehensive Metabolic Panel PRES: • CBC with peripheral smear (which may suggest Posterior reversible microangiopathic hemolytic anemia). encephalopathy syndrome • Urinalysis • EKG Typically symmetrical white • Chest X-ray matter edema in the • Head CT posterior cerebral • Echocardiogram hemispheres Cerebral Autoregulation Is Central to Autoregulation Treatment of Hypertensive Crises • In the uninjured, normotensive brain, Normal Regulatory autoregulation is effective over MAP ranging Cerebral Blood Flow Range(BP ~ 120/70 to 240/150) from about 50 – 150 (BP ~ 80/40 to 190/130) (BP ~ 80/40 to 190/130) Increasing risk of hypertensive • In chronic hypertension, this range can be encephalopathy Normotensive shifted upwards to MAP 80 – 180 (BP ~ 120/70 to 240/150) Chronic hypertensive Increasing risk of ischemia • So, in the patients with out of control 0 50 100 150200 250 hypertension, if BP falls too rapidly to below MAP (mm Hg) ~120/70 cerebral perfusion can be compromised Adapted from Varon J, Marik PE. Chest. 2000;118:214-227. Hypertensive Urgencies / Emergencies: • Classification / Definition Management of Hypertensive • Etiology / Pathophysiology Urgencies • Evaluation • Management (BP > 180/110 mm Hg with NO end organ damage) • Outcomes Hypertensive Emergencies Are More Goals of Therapy of Hypertensive Crises Than Blood Pressure Measurement • Hypertensive urgencies can generally be managed with oral medications as an • Hypertensive emergencies generally occur outpatient. BP should be lowered over 24-48 with DBP 120 mm Hg, BUT there is no strict hours cutoff and BP can be much lower - Important to prevent too-rapid lowering due to • Baseline level of hypertension and rate of autoregulation of flow by pressure in brain, heart, rise are also very important and kidneys • Hypertensive emergencies must be treated as • There is tremendous overlap between groups and categories, i.e., cannot be defined by BP an inpatient, usually in the ICU with parenteral alone medications. Goal is to reduce MAP by ~ 20% within one hour - Aortic dissection requires even more rapid lowering Adapted from Kincaid-Smith P. Aust N Z J Med 1981;11(Suppl 1):64-68 JNC 7, JAMA 2003; 289:2560-2572 How Low Should You Go? • Simple answer - 20-25% reduction in MAP within 1st hour Management of Hypertensive Emergencies • Better answer - It really depends on clinical condition (BP > 180/110 mm Hg WITH end organ damage Less aggressive with ischemic stroke More aggressive with hemorrhagic stroke, acute HF and aortic dissection Marik and Varon. Critical Care 2003, 7:374-84. Hypertensive Emergency: Goals of Goals of Therapy of Hypertensive Crises Therapy • Hypertensive urgencies can generally be managed with oral medications as