Hypertension in the ED - management tips that will bring down your own BP

Transcription

1 27th Annual Update in Emergency Medicine Hypertension in the ED - management tips that will bring down your own BP February 24, 2014 Clare Atzema, MD MSc FRCPC Staff Physician, Sunnybrook Health Sciences Centre Core Scientist, ICES Annals of Emergency Medicine Decision Editor

2 Disclosures No industry funding Funded by several Canadian federal research agencies Heart and Stroke Foundation of Canada CIHR

3 Objectives 1) To review the myriad of ways that hypertension can present in the ED 2) To revisit your drug armamentarium for managing hypertension in the ED 3) To examine how the latest evidence impacts the ED management of these patients

4 Working in the ED Which of these 5 patients require BP treatment? VS: hr 100, BP 209/105, RR 20, temp 36.9 o C 1) Patient A: 65 y o!with n/v & confusion 2) Patient B: 73 y o"with sudden onset SOB, pink sputum & chest pressure 3) Patient C: 56 y o!with sharp chest & back pain 4) Patient D: 64 y o"with a 6-hr of right-sided weakness 5) Patient E: 51 y o" with a mild headache, concerned about her BP level

5 Patient A 1) Patient A: 65 y o!with n/v & confusion VS: hr 100, BP 209/105, RR 20, temp 36.9 o C CINETVDATE / VINDICATE Infectious? DKA? Tox? Post-ictal? Intracranial goober? Hypertensive Encephalopathy

6 Patient A Hypertensive Encephalopathy A diagnosis of exclusion Intracranial etiology? Imaging to r/o ischemic CVA Triad: Usually focal signs & sx 1. severe hypertension 2. altered mental status 3. papilledema

7 Patient A Hypertensive Encephalopathy What is it? Cerebral hyperperfusion, increased vascular permeability, resultant edema Early (24-48 hrs): Headache (anterior, constant), n/v, +/- visual disturbances Stage II/III retinal findings Cotton-wool spots: fluffy white-ish lesions (nerve fiber layer infarcts) Exudates: well-defined yellow patches (lipids, from basement membrane leakage) Flame hemorrhages

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11 Retinopathy in hypertensive crisis

12 Patient A Hypertensive Encephalopathy Early (24-48 hrs): Headache (anterior, constant), n/v, +/- visual disturbances Stage II/III retinal findings Cotton-wool spots: fluffy white-ish lesions (nerve fiber layer infarcts) Exudates: well-defined yellow patches (lipids, from basement membrane leakage) Flame hemorrhages Late (48 hrs +): Confusion, lethargy, LOC, seizures Papilledema (stage IV retinal findings)

13 Patient A Hypertensive Encephalopathy Treatment Lower the BP (confirms diagnosis) Goal 20-25% reduction / 2-6 hrs " DBP goal mm Hg / 2-6 hrs Labetalol 20 mg slow push (2 minutes) Based on result, repeat or double (20/40/80/160) q10min Max 300mg No Nitroprusside May increase cerebral blood flow

14 Patient B Patient B: 73 y o"with sudden onset SOB, pink sputum & chest pressure VS: hr 100, BP 209/105, RR 20, temp 36.9 o C CINETVDATE / VINDICATE P.E.? Infectious? Cancer? Boerhaave s? HF secondary to BP

15 Patient B Treatment Treat the BP (which will address the HF) Nitroglycerin Sprays, drip 1. Start: mcg/min 2. Titrate: Increase 5-10 mcg/min q 5-10 minutes 3. Usual dosage: mcg/min (max 500 mcg/min) +/- BiPAP/CPAP +/- Furosemide If total body fluid overloaded +/- Nitroprusside

16 Patient C Patient C: 56 y o!with sharp chest & back pain VS: hr 100, BP 209/105, RR 20, temp 36.9 o C CINETVDATE / VINDICATE P.E.? ACS? Infectious? Pneumomediastinum? Boerhaave s? Pneumothorax? Aortic dissection

17 Patient C Aortic Dissection Symptoms: Sharp c.p. May migrate Neck (often anterior) or jaw pain Aortic arch involvement / extension into great vessels Intrascapular pain Descending aorta Abdominal pain Descending aorta, below diaphragm

18 Patient C Aortic Dissection Symptoms: End organ manifestation RV AMI Tamponade Ischemic stroke (carotids, vertebrals) Mesenteric ischemia RF Ischemic Limb (5 Ps)

19 Patient C Aortic Dissection Signs: BP difference in arms, Pulse deficit AR diastolic murmur bounding pulses, wide pulse pressure +/- HF Tamponade muffled heart sounds, hypotension, pulsus paradoxus, jugular venous distention, Kussmaul sign Horner s syndrome ptosis, miosis, anhidrosis

20 Patient C Aortic Dissection Diagnostic tests Lab Leukocytosis D-dimer + (Cr, trop ) ECG If proximal propagation, RV AMI (inf leads, V4R) CT angiogram TEE MRI Aortography

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22 Patient C Treatment: shearing forces to decrease the intimal tear & propagation of dissection Exception to 25% Rule Goal SBP mm Hg 1) Labetalol 20 / 40 / 80 / 160 (slow push / 2 min, q10min) Æ Hr 60 bpm 2) Add Nitroprusside 0.5 mcg/kg/min, up to 2.0 mcg/kg/min Good iv site Mixed properly, aluminum cover

23 Patient C Asthmatic? Esmolol for mild/mod RAD Load mcg/kg IVP/1-3 min, then initiate infusion mcg/kg/min May repeat loading dose or increase infusion up to 300 mcg/kg/min Diltiazam Severe AR? Use BB cautiously (blocks compensatory tachycardia) Pain control / analgesia Art line (arm with higher BP)

24 Patient D Patient D: 64 y o"with a 6-hr of right-sided weakness VS: hr 100, BP 209/105, RR 20, temp 36.9 o C CINETVDATE / VINDICATE SAH ICH Intracranial mass Hypoglycemia Ischemic CVA

25 Patient D Treatment Treat at all? Even v brief episodes hypotension " worse outcomes AHA/ASA 2007: Antihypertensive(s) should be withheld unless the SBP is >220 mm Hg or DBP is >120 mm Hg 1) Labetalol» Goal: 15% / over the first 24 hours Æ If use, choose agent that is easily titrated, with minimal vasodilatory effects on cerebral blood vessels» mg / 1-2 min, repeat q10min, max 300mg 2) Nicardipine» 5 mg/h, 2.5 mg/h q5-15min, max 15 mg/h Stroke. 2007;38:

26 Patient D Treatment If thrombolysis eligible, goal SBP 185 mm Hg OR 1) Labetalol mg / 1-2 min, may repeat q10min x 1 2) Nitro paste 1-2 OR 3) Nicardipine 5 mg/hr, titrate up by 2.5 mg/hr at 5-15 minute intervals, maximum dose 15 mg/hr Æ If BP not reduced & maintained at SBP 185 & DBP 110 mm Hg, do not administer tpa

27 Patient D ICH? Treatment AHA/ASA 2007: If SBP>180 mm Hg (or MAP>130) & no evidence of elevated ICP, consider lowering the BP to target 160 mm Hg INTERACT 1 trial, ATACH trial: rapid (6 hrs) SBP reduction to 140 mmhg associated with hematoma expansion INTERACT 2: No difference ATACH II: in progress Labetalol Nicardipine

28 Patient D SAH? Treatment Damned if you do, damned if you don t 1) Schmidt et al, Stroke, 2011 n = 134 Reduce DBP <100 mm Hg vs standard care» 15% re-bleeds in intervention grp, 33% in control (18% better)» 43% had ischemic events in intervention grp, 22% in control (21% worse) 2) 2012 American Stroke Association: in SBP to < 160 mm Hg is reasonable Not nitroprusside

29 Patient D SAH? Treatment Nimodipine Vasospasm 3+ days afterward Not your concern unless looking after patient in the ED 3 days later

30 Patient E Patient E: 51 y o" with a mild headache, concerned about her BP level VS: hr 100, BP 209/105, RR 20, temp 36.9 o C History Hx HTN? Taking meds / compliance? EtOH? NSAIDS? Med change? N/v, h/a, restlessness/confusion Visual changes HF sx C.P. (AMI / Dissection sx)

31 Patient E Patient E: 51 y o" with a mild headache, concerned about her BP level Physical exam Retina Neuro Chest CVS Asymptomatic v high BP: 1) Hypertensive urgency 2) Severe hypertension 3) Grade III hypertension 4) Asymptomatic markedly elevated blood pressure Æ The patient you see most shifts

32 Patient E Diagnostic tests? ECG CXR Bloodwork (Cr)? Urine dip ED treatment IV meds? PO meds? Rx?

33 Patient E Diagnostic tests? ACEP HTN Guidelines: Level C recommendations 1) In ED patients with asymptomatic markedly elevated BP, routine screening for acute target organ injury (serum Cr, u/a, ECG) is not required. 2) In select patient populations (eg, poor follow-up), screening for an elevated serum Cr level may identify kidney injury that affects disposition (eg, hospital admission).

34 Patient E ACEP HTN Guidelines: Karras, 2008 n=109, 3 EDs, BP 180/110 Clinically meaningful unanticipated test results 7 patients (6%) Nishijima, 2010 n=167, 2 EDs, DBP patients (7.2%) " Hess 2010, CXR in c.p.: 2.1% Δ, 6% abnormal " Brown 2011, Spec Exam in PV bleed: 6% Δ

35 Patient E ED treatment? ACEP HTN Guidelines: Level C recommendations 1) In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. 2) In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control.

36 Patient E ED treatment? ACEP HTN Guidelines: Grassi, 2008 n=549, rest then tx if >180/110 No AE within 72 hrs Freis, 1967, JAMA n=143!, DBP % (controls) vs 0% (Rx) complications within 4 mo sudden death, ruptured aortic aneurysm/death, BUN, & HF 39% vs 3% at 20 months, respectively

37 Patient E ED treatment My practice IV meds? O PO meds? O Rx? P No comorbidities: HCTZ, CCB (amlodipine), ACE-I or ARB Comorbidities: LVH, diabetes, RF, afib " ACE-I or ARB Exceptions:» Black persons: CCB or HCTZ» BB only for post AMI or angina

38 Patient E ED treatment Long term goal: JNC 8: age > 65 = 150/90 mm Hg, else 140/90 mm Hg CHEP: 140/90 mm Hg, DM 130/90 mm Hg ESC: mm Hg for elderly

39 Patient F Patient F: 31 y o", 23 weeks pregnant, concerned about her BP level VS: hr 90, BP 162/100, RR 20, temp 36.9 o C Pre-eclampsia GA > 20 weeks >140/90 mm Hg or 30 / 15 mm Hg OLD: NEW: 1. Hypertension 2. Proteinuria (5g/24h) 3. Edema 1. Hypertension 2. Proteinuria 0.3g/24 hr OR Dipstick 1+ No proteinuria: Platelets < 100,000 Cr double LFTs twice normal Pulmonary edema Cerebral or visual sx

40 Patient F Patient F: 31 y o", 23 weeks pregnant, concerned about her BP level Pre-eclampsia presentation Photophobia, scotomas, cortical blindness Headache ALOC Severe RUQ pain Pulmonary edema Lab Tests U/A, Cr, Glc, lytes, platelets, LFTs U/A + Æ 24 hr protein

41 Patient F All normal in Patient F (gestational HTN) HTN Classification in Pregnancy Mild / mm Hg Moderate / mm Hg Severe 160+ / 110+ mm Hg

42 Patient F Treatment When to initiate anti-hypertensives? SOGC New onset SBP > 160 or DBP > 110 ACOG SBP 160 or DBP 105 ESC SBP 150 mm or DBP 95 Æ Target / mm Hg

43 Patient F Treatment IV PO Labetalol 20/40/80/160 (q10min) Hydralazine 5 mg/1-2 min, q20min repeat 5-10 mg (depending on response) Max 20 mg bolus Nitroglycerin (pulmonary edema) 5 mcg/min, q3-5min Methyl-dopa (250 mg bid-tid, q2day) Very mild Labetalol (100 mg bid, q2-3 day) Long acting nifedipine (30-90 mg od)

44 Patient F Treatment Not in pregnancy Nitroprusside ACE-I, ARB, direct renin inhibitors Short-acting nifedipine Esmolol, metoprolol, atenolol

45 Overview Medications - IV 1. Beta-blockers 1. Labetalol 2. Esmolol 2. Vasodilators 1. Nitroprusside 2. Nitroglycerin 3. Hydralazine 4. Phentolamine 3. Non-dihydropyridines Diltiazam, Verapamil

46 Medications (IV) - Unavailable in Canada 1. Nicardipine CCB (2 nd gen dihydropyridine) Hypertensive encephalopathy Dose: 5 mg/hr, increase up to 15 mg/hr 2. Clevidipine CCB (3 rd gen dihydropyridine) Ultra-short acting Dose: 1 mg/hr, increase up to 21 mg/hr 3. Fenoldopam Peripheral dopamine-1-receptor agonist Maintains or increases renal perfusion Dose: 0.1 mcg/kg/min,! q15 min

47 IV Anti-hypertensives Medication Dosage Pathophysiology Labetalol Bolus: 20 mg IV; may administer mg IV q10 min to a max of 300 mg total Infusion: After 20 mg IV bolus, mg/min to total dose of 300 mg/24hr Selective α1-adrenergic and nonselective β-adrenergic receptor blocker Esmolol Load: mcg/kg over 1-3 min, then initiate infusion at mcg/kg/min. Titrate up to max 300 mcg/kg/min. Cardioselective β-adrenergic receptor blocker. Onset 60 seconds, duration minutes Nitroprusside Infusion: mcg/kg/min Increase at rate of 0.5 mcg/kg/min to desired effect (after 2 mcg/kg/min risk cyanide poisoning ) Nitroglycerin Infusion: 5-10 mcg/min, increase by 5-10 mcg/min q3-5 min Phentolamine Bolus: 5-20 mg IV q5-15min Infusion: mg/min Hydralazine Load 5 mg iv over 1-2 min, repeat after 20 min prn, max 30 mg Arterial & venous vasodilator. Onset in seconds, duration 1-2 minutes Potent, nonselective venodilator. Affects arterial tone at high doses. Onset 2 min, duration 5-10 min α1- & α2-adrenergic blocker Direct arteriol vasodilator

48 Questions?