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Hypertensive Crisis in the Optometry Office Kuniyoshi Kanai O.D., F.A.A.O.
________________________________________________________________________________________________
Hypertension in the United States
A 59 year‐old patient presented to your clinic for an eye examination. During pretesting, your office staff measured the patient’s blood pressure. The automated blood pressure device produced these numbers: Systolic blood pressure of 202mmHg Diastolic blood pressure of 125mmHg Is this a scene familiar to you? How would you manage a case like this? The Centers for Medicare & Medicaid Services (CMS) incentivized routine measurement of blood pressure through the Meaningful Use program. Over the last decade, blood pressure and the understanding of its role in pathogenesis of ocular diseases have evolved, such as the role of ocular perfusion pressure in glaucoma. As blood pressure measurement has become a routine part of the optometrists’ examination, a scenario like this has become a more common clinical encounter in the office. Hypertensive crises It is estimated that 32.5% of the adult population in the US is diagnosed with hypertension1. Of those, approximately 1% experience severely elevated blood pressure in one’s lifetime2. “Severely elevated blood pressure” is generally defined as systolic blood pressure (SBP) higher than 180mmHg or diastolic blood pressure (DBP) higher than 1103 or 120mmHg4. Severely elevated blood pressure is associated with two crises: emergency and urgency. In the 7th report of the Joint National Committee, hypertensive emergency is defined as a “severe elevation in BP complicated by evidence of impending or progressive target organ dysfunction”4. Target‐organ‐dysfunctions or target‐organ‐damages (TODs) involve the brain, heart, kidney, and large vessels: stroke, encephalopathy, acute heart failure with pulmonary edema, acute renal failure, and aortic dissection. Patients with hypertensive emergency need to be admitted immediately for antihypertensive treatment. In contrast to the consensus over a hypersensitive emergency, “hypertensive urgency” is less defined. Patients with hypertensive urgency have severely elevated blood pressure; however, they do not have the signs and symptoms of pending TODs. Clinical dilemma often exists in the management of these individuals because a
Author’s Bio
Dr. Kuniyoshi Kanai is an assistant clinical professor at University of California, Berkeley School of Optometry. He completed his degree of Doctor of Optometry and a residency in primary care at UC Berkeley. His current clinical duty involves community service at the clinic in the Alameda Health System where many patients present with cardiovascular diseases.
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One of the common sources for error is an inappropriate‐sized cuff. The diaphragm of the cuff should encircle 80% of the arm circumference6. Despite careful measurement technique, the measured blood pressure could still be inaccurate compared to its true value. A number of physiological factors may influence in‐office values: such as the white coat effect, diurnal fluctuation, bladder distension, caffeine intake, emotion, and noise exposure. True BP value can be investigated by using certain techniques, such as 24‐hour ambulatory blood pressure monitoring and invasive intra‐arterial measurement. However, those methods are unrealistic in the optometry office. With an effort to increase the accuracy of in‐office measurement, one can utilize the “time” patients spend in the office. It has been identified that blood pressure may significantly drop while the patients sit quietly in the office7, and the value may mimic that of ambulatory blood pressure measurement8. Grass, et al. applied this concept to 549 patients in the Emergency Department (ED) who presented with severely elevated blood pressure9. Patients in this study were all asymptomatic for acute organ damage, and they were instructed to rest and wait in the exam room for 30 minutes. 32% of them showed a spontaneous drop in blood pressure well below SBP of 180mmHg and DBP of 110mHg. Those patients with reduced BP were sent home without antihypertensive treatment. No adverse events occurred. Key:
● Proper selection of BP device ● Proper technique ● Confirm BP value over 30 minutes
#2: Symptomatology Symptomatology often dictates the urgency of management. Zampaglione and his colleagues2 tabulated the signs and symptoms of patients with hypertensive emergency and urgency (Table 1). The listed signs and symptoms are consistent with involved end organs. For example, a patient with pulmonary edema from acute heart failure may experience chest pain and difficulty in breathing. If a patient has any of the signs and symptoms below, optometrists should consider that individual as having a possible hypertensive emergency. The patient should be transported to ED immediately for investigation of target organ damage.
Signs and Symptoms Emergencies (%) Urgencies (%)
Headache 3.0 22.0%
Epistaxis 0.0 17.0%
Chest pain 27.0 9.0
Dyspnea 22.0 9.0
Faintness 10.0 10.0
Psychomotor agitation 0.0 10.0
Neurological deficit 21.0 3.0
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Vertigo 3.0 7.0
Paresthesia 8.0 6.0
Vomitus 3.0 2.0
Arrhythmia 0.0 6.0
Other 3.0 2.0
Table 1: Signs and symptoms of hypertensive crises* *Adapted from Zampaglione B, Pascale C, Marchisio M, Cavallo‐Perin P. “Hypertensive Urgencies and Emergencies Prevalence and Clinical Presentation” Hypertension. 1996; 27: 144‐147 One exception can be made for a non‐specific mild headache. Mild headache in severely elevated blood pressure is relatively common. In the absence of other signs and symptoms of central nervous system involvement, routine neuroimaging is unlikely to reveal CNS involvement10. Key:
● Symptomatic patients should be considered hypertensive emergency until proven otherwise #3: Fundus examination The fundus provides a tremendous amount of information about the integrity of the microvasculature. Different stages of hypertensive retinopathy represent different pathological processes. The Keith‐Wagener‐Barker 4‐stage classification has historically been applied to clinical practice. More recently, Wong and Mitchell simplified this classification to 3 stages11. The advantage of this simplified scheme is a linear correlation of retinopathy to target‐organ‐damages (TODs) that were identified from community studies. Keith‐Wagener‐
Barker Classification
Wong‐Mitchell Classification
Clinical findings Pathogenesis Target‐Organ‐Damages Risks
1 Mild ▪ Focal or general arteriolar narrowing
▪ Copper/silver wiring
▪ AV nicking
▪ Normal autoregulation response
▪ Hyalinization ▪ Sclerosis
▪ Concurrent ventricular hypertrophy14
▪ Future coronary heart diseases16, 17
▪ Future stroke15
2
3 Moderate ▪ Retinal hemorrhage
▪ Soft exudate ▪ Hard exudate
▪ Loss of BRB integrity Concurrent damages in● Glomerular filtration
barrier ● Blood brain barrier
4 Severe ▪ Optic disc edema ▪ Loss of BRB integrity ▪ Autoregulation
breakthrough
▪ Death
Table 2: Clinical picture of hypertensive retinopathy
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study showed that patients with severe hypertension suffer from impaired autoregulation in the brain21 and thus, this stage of retinopathy likely represents an impaired autoregulation in both the retina and the brain. Considering the high mortality rate22, patients with severe retinopathy should be considered as a hypertensive emergency and admitted to the ED immediately. Key:
● Progressively increased risk of TODs with worsening hypertensive retinopathy. #4: Review of history If the patient is asymptomatic and the fundus shows no retinopathy or only mild retinopathy, is he/she a non‐urgent patient? To address this question, a careful review of their history is critical. Experts suggest that true hypertensive urgency should be distinguished from “severe uncontrolled hypertension” among asymptomatic patients based on the presence of risk factors for progressive organ damages3, 10. These risk factors include, but are not limited to, the established history of cardiovascular, cerebral and renal diseases such as congestive heart failure, unstable angina, coronary artery disease, renal insufficiency, transient ischemic attack, or stroke10. Patients with such histories should be given greater attention and should be considered “hypertensive urgency” even if they are asymptomatic and have no clear signs of damages in the BRB or autoregulation. Attention should also be paid to how rapidly the blood pressure rose to this severe level. Autoregulation has an amazing adaptability of adjusting itself to chronically elevated blood pressure to provide a steady perfusion pressure to protect organs (Figure 4). Its effect is prominent in certain organs and vessels, such as the brain, coronary artery, kidney, aorta, and retina. However, this shift takes months and years to occur. Therefore, patients who experience sudden pressure rise are more likely to fall outside the protective range of autoregulation. High‐risk profiles include younger individuals, pregnancy, use of recreational drugs, and no prior diagnosis of hypertension.
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an African American racial background. This recommendation is not based on a patient’s blood pressure value, rather on a patient’s profile. You may wonder why a more aggressive treatment approach was not recommended in this review. The key is in autoregulation. When the patient has no overt signs, including in the fundus, and symptoms of organ damage from severe hypertension, it is very likely that the patient’s autoregulation has shifted to a rightward direction maintaining a steady perfusion pressure to vital organs even at a higher mean arterial pressure (Figure 4). This “right” shift ironically makes patients more vulnerable for a risk of hypo‐perfusion by an abrupt drop in blood pressure in an attempt to normalize it. These patients may suffer ischemia in vital organs, such as myocardial ischemia and infarction, stroke, and death from treatment itself25. To minimize this risk while achieving a substantial anti‐hypertensive effect, long‐acting medications should be administered by a provider who can monitor their progress regularly. This allows a gradual shift in autoregulation to a leftward direction. Thus, patients with low risks are more likely to achieve long‐term success in the hands of their own primary care physicians. Summary Management of patients with severely elevated blood pressure brings a number of dilemmas to optometrists. Inappropriate management of this condition could result in significant disability and mortality. While some patients need immediate care at the ED, others do not necessarily benefit from ED referral. Studies have noted a disappointing follow‐up rate at the primary care physician’s office after an ED visit26, 27. Meanwhile, budgetary constraints have recently made the CMS focus on reducing the cost for non‐emergent ED visits. Optometrists need a strategy. Optometrists are unique health care providers who are capable of making accurate assessments on the integrity of the microvasculature. By carefully examining a patient’s symptoms, fundus, and medical histories (Table 3), optometrists can triage this challenging condition and guide the patients to long‐term success in their lives. Severe uncontrolled
HTN Hypertensive urgency Hypertensive emergency
Symptomatology Asymptomatic or non‐specific mild headache
Asymptomatic or non‐specific mild headache
Symptomatic of acute TODs
Fundus No or mild retinopathy Moderate retinopathy Severe retinopathy
Medical History No pertinent history History of preexisting organ injury
May or may not have pertinent history
Timing of referral Within 1 week to PCP Within 24~48 hours to PCP or ED
Immediate referral to ED
Table 3: Management strategy for patients with severely elevated blood pressure Acknowledgment: I would like to thank Sean Umamoto, Ph.D. for his insightful comments on this manuscript. For comments and questions, please contact Dr. Kanai at [email protected] Reference
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1. The Centers for Disease Control and Prevention. “Health, United States, 2014” http://www.cdc.gov/nchs/data/hus/hus14.pdf#059 retrieved at 10:36 2/2/2016.
2. Zampaglione B, Pascale C, Marchisio M, Cavallo‐Perin P. “Hypertensive Urgencies and Emergencies Prevalence and Clinical Presentation” Hypertension. 1996; 27:144‐147.
3. Kessler CS, and Jourdeh Y. “Evaluation and Treatment of Severe Asymptomatic Hypertension.” Am Fam Physician. 2010 Feb 15;81(4):470‐476.
4. National Heart, Lung, and Blood Institute. “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure”. August 2004.; NIH Publication No. 04‐5230.
5. Aronow WS, et al. “A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents Developed in Collaboration With the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension”. J Am Coll Cardiol. 2011;57(20):2037‐2114.
6. Pickering TG, Hall JE, and et al. “Recommendations for Blood Pressure Measurement in Humans and Experimental Animals.” Circulation 2005; 111:697‐716.
7. Scherpbier‐de Haan N, van der Wel M, Schoenmakers G, and et al. “Thirty‐minute compared to standardised office blood pressure measurement in general practice.” Br J Gen Pract. 2011 Sep;61(590):e590‐7.
8. van der Wel MC, Buunk IE, van Weel C, et al. “A novel approach to office blood pressure measurement: 30‐minute office blood pressure vs daytime ambulatory blood pressure.” Ann Fam Med. 2011 Mar‐Apr;9(2):128‐35.
9. Grassi D, O’Flaherty M, Pellizzari M, et al. “Hypertensive urgencies in the emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles.” J Clin Hypertens. 2008;10:662‐667.
10. Shayne PH, Pitts SR. Severely increased blood pressure in the emergency department. Ann Emerg Med. 2003;41(4):513–529.
11. Wong TY, Mitchell P. “The eye in hypertension.” Lancet, 2007 Feb 3;369(9559):425‐35. 12. Leung H, Wang JJ, Rochtchina E, Wong TY, Klein R, Mitchell P. “Impact of current and past blood pressure on retinal
arteriolar diameter in an older population.“ J Hypertens 2004; 22: 1543–49. 13. Klein R, Myers CE, Knudtson MD, et al. “Relationship of blood pressure and other factors to serial retinal arteriolar diameter
measurements over time: the Beaver Dam Eye Study. “ Arch Ophthalmol. 2012;130:1019‐1027. 14. Tikellis G, Arnett DK, Skelton TN, Taylor HW, Klein R, Couper DJ, Richey SA, Yin WT. Retinal arteriolar narrowing and left
ventricular hypertrophy in African Americans. the Atherosclerosis Risk in Communities (ARIC) study. Am J Hypertens. 2008;21:352‐359.
15. Wong TY, Klein R, Couper DJ, Cooper LS, Shahar E, Hubbard LD, Wofford MR, Sharrett AR. Retinal microvascular abnormalities and incident stroke: the Atherosclerosis Risk in Communities Study. Lancet. 2001;358:1134‐1140.
16. Wong TY, Klein R, Sharrett AR, Duncan BB, Couper DJ, Tielsch JM, Klein BE, Hubbard LD. Retinal arteriolar narrowing and risk of coronary heart disease in men and women. The Atherosclerosis Risk in Communities Study. JAMA. 2002;287:1153‐1159.
17. Duncan BB, Wong TY, Tyroler HA, Davis CE, Fuchs FD. Hypertensive retinopathy and incident coronary heart disease in high risk men. Br J Ophthalmol. 2002;86:1002‐1006.
18. Wong TY, Coresh J, Klein R, et al. “Retinal Microvascular Abnormalities and Renal Dysfunction: The Atherosclerosis Risk in Communities Study”. J Am Soc Nephrol 15: 2469–2476, 2004.
19. Wong TY, Hubbard LD, Klein R, et al. “Retinal microvascular abnormalities and blood pressure in older people: the Cardiovascular Health Study. “Br J Ophthalmol 2002; 86: 1007–13.
20. Hayreh SS, Servais GE, Virdi PS. “Fundus lesions in malignant hypertension. IV. Focal intraretinal periarteriolar transudates.” Ophthalmology 1986. Jan; 93(1): 60‐73.
21. Immink RV, van den Born VH, and et al. “Impaired cerebral autoregulation in patients with malignant hypertension”. Circulation 2004; 110: 2241‐45.
22. Lane DA. “Improving Survival of Malignant Hypertension Patients Over 40 Years.“ Am J Hypertens 2009; 22: 1199~1204. 23. Dinsdale H. “Hypertensive encephalopathy” in Bernett H, Stein B, Morh J, Yatsu F, (eds): Stroke. New York, Churchill
Livingstone, 1986, vol 2, 869‐74. 24. The American College of Emergency Physicians Clinical Policies Subcommittee. “Clinical Policy: Critical Issues in the
Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure.” Ann Emerg Med. 2013;62:59‐68.
25. Decker WW, Godwin SA, Hess EP, and et al. “Clinical policy: critical issues in the evaluation and management of adult patients with asymptomatic hypertension in the emergency department” Ann Emerg Med. 2006;47:237‐249.
26. Baumann BM, Cienki JJ, Cline DM, et al. Evaluation, management, and referral of elderly emergency department patients with elevated blood pressure. Blood Press Monit. 2009; 14:251‐256.
27. Collins K, Gough S, Clancy M. Screening for hypertension in the emergency department. Emerg Med J. 2008;25:196‐199.
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2016 March/April Article
Name _______________________________________ License____________________________
1. Approximately what percentage of the US population is affected with hypertension?
a. 2.5% b. 5% c. 16% d. 25%
2. How does the JNC VII defined high blood pressure?
a. Systolic over 120, Diastolic over 80
b. Systolic over 140, Diastolic over 80
c. Systolic over 120, Diastolic over 100
d. Systolic over 140, Diastolic over 100
3. Which is not a cause of secondary hypertension?
a. Cushing’s Syndrome b. Diabetes c. Adrenal Tumors d. Cocaine
4. Which is not a sign of hypertensive changes in the retina?
a. AV ratio changes b. CRVO c. Soft exudates d. Changes in the ALR
5. A patient with cotton wool spots would be in which classification of hypertensive retinopathy, according to Wong and Mitchel?
a. Mild b. Moderate c. Severe
6. Patient over which age should have their blood pressure checked regularly?
a. 18 b. 25 c. 40 d. 65
7. Which of these cuff sizes would you use for a patient with an arm circumference of 46cm?
a. Small Adult b. Adult c. Large Adult d. Adult Thigh
8. What percent of patients have a blood pressure reading of >10mmHg?
a. 10 b. 20 c. 30 d. 40
9. What ocular sign would make you send a patient to the emergency room?
a. Retinal Bleeding b. Hard Exudates c. Macular Star d. Bilateral Optic Nerve
Head Swelling 10. How much physical activity
should patients be performing every day to maintain a healthy lifestyle?
a. 15 min b. 30 min c. 45 min d. 60 min
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