Hypertensive Urgency & Hypertensive Emergency 15 th Annual Rocky mountain Hospital Medicine Symposium November 6-7 th, 2017 Renaissance Hotel Denver DISCLOSURES NONE Objectives Define Hypertensive Urgency vs Emergency Describe pathophysiology, epidemiology & prognosis Understand the fundamentals of evaluation and management Understand the fundamentals of the treatments and goals
Case: H.L. 57 y/o AAM with history DM and HTN. One week of headache, squinting and mild dyspnea on exertion. PMH: DM All: NDKA Meds: FH: DM SH: 20 pk history HTN Lisinopril Metformin HTN CAD CVA Postman Case: H.L. Physical Exam Vitals: T 97.9F HR 93 RR 20 BP 230/120 SpO2 94% on RA Gen: Awake and alert, mild distress HEENT: PERRL, EOMI, anicteric, MMM, normal posterior oropharynx, neck supple Resp: Clear to auscultation bilaterally, no w/r/r CV: Normal S1/S2, no m/g/r; Abd: Protuberant, soft, non-tender, BS+ Ext: warm to the touch, no cyanosis, 1+ pretibial edema Skin: no jaundice, lesions or rashes noted Neuro: alert and oriented, no meningismus, CN II-XII grossly intact Case: H.L. Initial Work-Up 7.2 135 3.8 11.9 161 94 8 20 1.6 128 Total protein 4.5 Albumin 3.9 Total bili 1.4 AST 77 ALT 49 AlkP 55 Lactate 2.1
Case: H.L. Diagnosis Headache SOB HTN, severe Anemia Scr Transaminitis 135 3.8 AST 77 ALT 49 7.2 94 20 1.6 11.9 8 161 128 Unifying diagnosis? Definition Hypertensive Urgency Elevated Blood Pressure WITHOUT evidence of acute end-organ damage Hypertensive Emergency Elevated Blood Pressure WITH evidence acute end-organ damage Malignant Hypertension has been removed from guidelines Case: H.L.Diagnosis Hypertensive Emergency Scr Headache SOB Anemia NAFLD 135 3.8 AST 77 ALT 49 7.2 94 8 128 20 1.6 (0.8) (AST 65) (ALT 41) (14.4) 11.9 161
Hypertensive Emergency Epidemiology Systemic hypertension is common 65 million Americans 1% of all patients with HTN will experience Hypertensive emergency at any point in their lives Elderly African-American Men > female Urgency vs Emergency Urgency Emergency BP SBP >180 mmhg or DBP > 110mmHG SBP >180 mmhg or DBP > 110mmHG EndOrgan Damage ABSENT PRESENT Time to Target BP 24 48 hours Immediately Level of Care Inpatient ICU Medications Oral IV, titratable Marik PE, Rivera R.. Curr Opin Crit Care. 2011;17(6):569 80. Padilla Ramos A, Varon J. Curr Hypertens Rep. 2014;16(7):450. Hypertensive Emergency Prognosis Mortality 5 year survival 32% prior to 1977 The Studying the Treatment of Acute hypertensive (STAT) 25-institution U.S. 1588 patients with severe acute hypertension Hospital mortality was 6.9% with an aggregate 90-day mortality of 11% and a 90-day readmission rate of 37%. Median Survival of 144 months 5 year 74% Katz JN et al. Am Heart J. 2009;158(4):599 606. e1. Deal. Et. al Arch Dis Child 1992
Clinical Presentation Shortness of breath (29%) Chest pain (26%) Headache (23%) Acute Encephalopathy (20%) Focal Deficit (11%) Katz JN et al. Am Heart J. 2009;158(4):599 606. e1. Van den Born BJ, Honnebier UP, Koopmans RP, et al.hypertension 2005; 45:246 251 Patterns of End-Organ Damage Reversible renal dysfunction (22%) Acute heart failure (14%) Encephalopathy (8.3%) Acute MI/ACS (11%) Intracerebral hemorrhage (11%) Subarachnoid hemorrhage (12%) Retinal hemorrhage and/or papilledema (0.9%)* Katz JN et al. Am Heart J. 2009;158(4):599 606. e1. *Funduscopic exam documented 13% Van den Born BJ, Honnebier UP, Koopmans RP, et al.hypertension 2005; 45:246 251 Pathophysiology HTN Emergency Circulating Vasoconstrictors End Organ Ischemia Loss of Autoregulatory function Abrupt SVR Abrupt BP Endothelial Damage Pressure Naturesis Vasoconstriction Renin Angiotensin System Volume Depletion
Pathophysiology Autoregulation BP = PVR x CO (SV x HR) Increase in BP Increase in BP Vasoconstriction Ineffective Vasoconstriction Normal flow of circulating blood Shear Stress (endothelial damage) Wallach R, Karp RB, Reves JG, et al.. Am J Cardiol 1980; 46:559 565. Vascular Autoregulation Flynn JT. Severe hypertension. Ped Nephrol 2009; 241101-1112 Pathophysiology Rate of increase in BP more important the absolute number Organ dysfunction is uncommon with DBP <130 Children and pregnant women are notable exceptions
Case: H.L. Given IVP labetalol 20mg 190/105 Medically adherent to outpatient treatment plan. Drinks 2 beers after work, 6-8 during Bronco games. No recreational drugs but Doc, marijuana isn t illegal anymore Old and new Initial Evaluation CBC w/smear LDH (>220U/l) Plts (<150x10 9 /l) CMP Cardiac enzymes UA Proteinuria Microscopic hematuria Urine Pregnancy Test Initial Evaluation
Initial Testing Initial Evaluation -Neuro Acute Encephalopathy Headache SAH Nausea/Vomitting - ICP Focal findings rare (11) Initial Evaluation Cardiac Check BP in both arms
Initial Evaluation Renal Worsening Scr, hematuria, proteinuria or RBC cast formation Case: H.L. MICU Right radial arterial line placed Foley placed LVH, Repolarization Pulmonary Edema No acute abnormality Vascular Autoregulation
Hypertensive Encephalopathy Rapid increase in BP (DBP >140) Uncontrolled Cerebral Blood Flow Cerebral vasospam, punctate hemorrhage, ischemia, increased vascular permeability Cerebral Edema Reversible Posterior Leukoencephalopathy Syndrome formerly Posterior Reversible Encephalopathy Syndrome (PRES) T1 normal T2 occipital hyperintensity Visual disturbances Seizures B.E. Hamilton, and G.M. Nesbit AJNR Am J Neuroradio2008;29:456-457 Associated Conditions Pulmonary Edema Systolic Diastolic Acute Myocardial Infarction Hypertensive Encephalopathy Acute Aortic Dissection Acute Renal failure Microangiopathic Hemolytic Anemia (MAHA) Preeclampsia, eclampsia Cocaine use/overdose Acute postoperative HTN Ischemic Stroke (SBP >180-200) Hemorrhagic Stroke (SBP >140-160)
Treatment Goals Preserve organ function Reduce BP in controlled fashion Minimize complications Management HTN Urgency Inpt vs outpatient Telemetry Unit Intermediate if comorbid HTN Emergency ICU Cardiopulmonary Monitoring Pulse Ox Telemetry BP monitoring Cycling BP cuff Cardiopulmonary Monitoring Pulse Ox Telemetry BP monitoring Arterial Line Case: H.L. No evidence of RPLS 190/105 (MAP 133) Continued headache What are the treatment goals? Which medication should be initiated?
Treatment Goals Dysfunctional autoregulation of BP prevents normal response to hypotension MAP lowered by 10 20% in first hour MAP lowered to 25% of initial MAP in 1 st 8-12 hours Then decrease by another 25% in the next 8-12 hrs Final 50% by 48 hrs Treatment Goals 2 Main Classes of Medications Vasodilators Adrenergic inhibitors Case: H.L. Repeat BP 190/105 Nicardipine infusion started 1L NS Goal 173/90 (MAP 117) in 24 hours Neuro checks Q2hrs
Vasodilators MEDICATION DOSAGE ONSET OF ACTION Nitroprusside 0.25 10 mcg/kg/min DURATION OF ACTION ADVERSE REACTION Immediate 1-2 min Thiocyanate toxicity Nitroglycerine 5-100 mcg/min 1-5 min 3-5 min Flushing, h/a, methgb Nicardipine 5-15 mg/hr 5-10 min 1-4 hr HR, flushing Fenoldopam 0.1-0.3 mcg/kg/min 5 min `10-15 min Flushing, h/a, HR Clevidipine 1-2 mg/hr Immediate 5-15 min HR, Afib, h/a, nausea Hydralazine 10-20 mg 5-15 min 3-8 hrs Flushing, HR Enalapril 10-40 mg IM 1.25-5 mg IV 20-30 min 6 hrs BP, SCr, hyperkalemia Adrenergic Inhibitors MEDICATION DOSAGE ONSET OF ACTION Labetalol 20-80mg IV x 10min, 2 mg/min gtt DURATION OF ACTION ADVERSE REACTION 5-10 min 3-6 hrs CV block, BP Esmolol 200 mcg/kg/min 1-2 min 10-20 min BP Phetolamine 5-15 mg 1-2 min 3-10 min HR, flushing, h/a Condition Consideration Medication Pulmonary Edema -- Systolic Pulmonary Edema -- Diastolic Hypertensive Encephalopathy Acute Aortic Dissection Ischemic Stroke (SBP >180-200) Hemorrhagic Stroke (SBP >140-160) Concomitant CHF Nicardipine or clevidipine + nitro + loop diuretic Goal MAP < 25% or DBP <100mmHg 1 st hour Decrease vessel wall sheer stress (dp/dt) Hemorrhagic conversion with SBP CPP=MAP-ICP Esmolol or labetalol or metoprolol or verapamil + nitro + loop diuretic Nicardipine, labetolol, fenoldopam, clevidipine Avoid nitroprusside Labetalol or nicardipine + beta-blocker or nitroprusside + beta-blocker Nicardipine, labetolol, fenoldopam, clevidipine Labetalol, nicardipine or esmolol Cocaine use/overdose Avoid beta-blocker Nitroprusside Pregnancy Fetal effects of medications Hydralazine, labetalol, **nitroprusside (4hrs)
Case: H.L. Over the course of 2 days, BP titrated to 150/80 Scr 1.0 Lisinopril restarted HCTZ PO Discharge to PCP follow-up in 1 week Thank you