Hypertensive Urgencies & Emergencies

Ray Townsend MD

University of Pennsylvania

August 6, 2014

Disclaimer

• Grants – yesSpeaker Bureau – no

• Stocks – Bucket list item

• Travel support – ASN, ASH, NKF

• Royalties – UpToDate

• Consultant – Janssen, Medtronic

ARS 1• A 57 year old man arrives ED holding his

nose with a bloody handkerchief. His blood pressure at home was 184/100 mm Hg. He is alert, neurologically intact, lungs clear, no chest pain, no CV history. He initiated therapy with an ACE/CCB three days ago. Is This a Hypertensive Emergency?– A) Yes

– B) No

– C) I don’t know

Agenda

• Definitions

• Pathogenesis

• History that matters

• Exam that matters

• Selected testing

• Meds

• Stroke

What is a Hypertensive EMERGENCY?

• >180/120 mm Hg (from JNC 7)

• “complicated by evidence of impending or progressive target organ dysfunction.”– Encephalopathy, unstable angina, heart

failure, aortic dissection, acute MI, eclampsia

– (The JAMA 2014 did not specifically cover this topic; long story over a beer, and you’re buying!)

Urgencies

“A hypertensive urgency can be diagnosed in this setting if the treating physician feels that it would be unsafe to leave such a patient without lowering the BP. There is very limited evidence in the medical literature that this feeling is, in fact, true, and even less evidence to support BP lowering in this setting. All authorities agree, however, that in a hypertensive urgency, BP lowering should be performed at a more leisurely pace than with a true hypertensive emergency”.

Elliott Progr. Cardiovasc. Dis. 2006; 48:316

Specific in-hospital causes Managing Urgencies

• 24-48 hour time frame (not minutes to an hour as with an emergency)

• Oral medication (often simply restarting a prior regimen)

• For those needing something now there is no preferred regimen but oral– Captopril, nicardipine and labetalol have

reasonably quick oral onset and little likelihood of too much BP reduction

The processes of emergent htnInciting Factor(s)

BP Increases

Endothelial InjuryMechanical Stress

Clotting activation │ Increased vessel permeability │ Fibrin deposition

Vessel Necrosis & Ischemia

Katakam & Townsend Ch 37 Antmann’s “Cardiovascular Therapeutics”Derhaschnig Journal of Human Hypertension (2013) 27, 368–373

Inflammation Coagulation

Which of these are signs/images of hypertensive

emergency?

Marik Chest 2007;131:1949-1962 Neth J Med 2011;69:248-255

Who is at risk for hypertensive emergency?

• Poorly controlled blood pressure (systolic)– Tisdale Fam Pract 2004;21:420-424

• AA, Male, poorly adherent– Shea NEJM 1992;327:776-781

• Pre-existing target organ damage– Tisdale

BenderJ Clin Htn2006;8:12-18

Antmann Cardiovascular Therapeutics 3rd Edition Chapter 37

ARS : Which symptoms is not typical of hypertension emergency

• A) Chest pain

• B) Shortness of breath

• C) Epistaxis

• D) Neurologic defect

Zampaglione Hypertension 1996;27:144-147

Katakam & Townsend 2006 Antmann Cardiovascular Therapeutics 3rd Edition Chapter 37

Essential History

Katakam & Townsend 2006 Antmann Cardiovascular Therapeutics 3rd Edition Chapter 37

Katakam & Townsend 2006 Antmann Cardiovascular Therapeutics 3rd Edition Chapter 37

Basic tests

• Creatinine and electrolytes

• CBC (smear helps)

• Urinalysis (blood)

• EKG

• Imaging per presentation

– Chest X-Ray / CT / MR / Echo

ARS

• A 22 yo man is brought by ambulance to the ED and directly admitted to the MICU.  He collapsed on the basketball court (pick up game).  He said he was feeling “winded” just before collapsing.  Known health was good previously as far as is known.  He was intubated in the ED, tube placement verified and made the road trip to the MICU immediately after the Chest X Ray was done.

ARS ‐

• His BP is 244/160 mmHg.  What do you want to know next?

• A.  His heart rate

• B.  His Hb level

• C.  His favorite color

• D.  A serum potassium value

ARS

• His heart rate is 138 beats/minute (sinus tachycardia).  He is in pulmonary edema.  What do you do next?

• A.  25 mg of metoprolol IV

• B. 25 mg of hydralazine IV

• C.  2.5 mg/min of nicardipine IV

• D.  1 mg of phentolamine IV 

ARS

• What would cinch the diagnosis in this case?

• A.  Plasma metanephrines

• B. Plasma angiotensin‐II

• C. Serum aldosterone

• D.  Serum brain natriuretic peptide (BNP) level

Going Forward: Think about…

• Emergency?

• “Type” of presentation (main organ at risk)

• What would you reach for?

Neurologic Insult

► Hypertensive encephalopathy Waxing and waning symptoms

H/A, nausea, vomiting

Retinal findings

CBF is constant from MAP 60 to 125 mmHg• Overwhelmed in HTN encephalopathy• CBF can be dangerously decreased if BP lowered

too much

Isolated H/A IS NOT a focal finding

► Hypertensive encephalopathy Waxing and waning symptoms

H/A, nausea, vomiting

Retinal findings

CBF is constant from MAP 60 to 125 mmHg• Overwhelmed in HTN encephalopathy• CBF can be dangerously decreased if BP lowered

too much

Isolated H/A IS NOT a focal finding

ARS ‐ <no response needed>

• A 25 year old hispanic woman presents to the ER with a history of shortness of breath, leg swelling and headache.  Evaluation shows AKI and a kidney Bx showed class IV lupus with vasculitis.  She is treated with steroinds, Cytoxan and Rituxan.  ON the 9th hospital day she has a seizure.

• Her BP is 154/97 mmHg with a heart rate of 81 beats/minute.

ARS case – <no response> 

• Neuro exam shows cognitive slowing a dnpoor coordination; normal cranial nerves, equal tendon reflexes and 5/5 strength bilaterally.

• Ca++, glucose normal.

• Creatinine = 3.7 mg/dL.  Hb 9.2 gm/dL

ARS

• What does this likely represent?

– A – PUSH

– B – PULL

– C – PRES

– D ‐ LEGGO

► headaches, vomiting, confusion

► seizures, cortical blindness

► other visual abnormalities

► motor signs

Hinchey NEJM 1996;334:494-500 Hamilton and Nesbit Am J Neuroradiology 2008 29: 456-457

29 Year Old AA male

► Presents with dyspnea, lower extremity edema and history of “bad high blood pressure”

► Creatinine is 6.8 mg/dl

► His urine has gross hematuria

► His blood pressure is 200/144 mm Hg

ARS

► A) Intramuscular

► B) Orally if the patient can take p.o.

► C) Topically

► D) Intravenously

What is the preferred route to administer BP medications during an emergency?

Basic principles of emergent hypertension treatment

• Use I.V. route

– Oral/IM less predictable absorption

• Decide volume status (most are dry)

• Use short acting agent

• Think ahead (goal BP = ???) and be ready to back off

Medications

• Quick on/Quick off desirable

• Try and associate agents with scenarios; for example:

– aortic dissection = esmolol + nipride

Specific Associations

• Neurologic

• Cardiac

• Autonomic

• Vascular

• Renal

• Obstetrical

• Post-Op

• Nitroprus (NTP); Labetalol

• NTG; NIC; NTP; ENALAPRIL

• Phentolamine (Pheo)

• Esmolol + NTP; NIC

• Fenoldepam

• Hydralazine; MgSO4

• NIC, Labeta, Esmo, Clevid

Marik Chest 2007;131:1949-1962

Clevidipine 1-2 mg/hour (up to 16 mg/hr [32 mg/hr rarely done])

Marik Chest 2007;131:1949-1962

Practice points

• Nipride – usually no increase in heart rate; needs a art-line; protect from light

• Nicardipine – can be given without an art-line; little slower to wear off; some report headaches and inc. in heart rate; rotate peripheral IV site

Case

• 78 year old woman with aortic transection post trauma managed medically with esmolol and nitroprusside in SICU

• Dose of nipride is 3-4.4 ug/kg/min

• Lactate was 2.4 mol/L at first and rose to 4.3 mol/L in the next 8 hours

Case: 78 y.o. woman with aortic transection

• She received about 1300 mg of nipride over five days when her mental status worsened & ativan stopped

• A cyanide level on the fourth day was 2.0 mg/dL (80 umol/L; mild cyanide toxicity is 20-95, fatal is > 114 umol/L)

Cyanide Toxicity

► Tachyphylaxis — Important sign of impending toxicity

► Neurological manifestations Hyperpnea

Headache, Vertigo

Altered mental status

Coma, Seizures

► Laboratory manifestations Lactic acidosis

Increased base deficit

Sipe EK, et al. Am Surg. 2001;67:685-686.

Caveats

• Thiocyanate toxicity more likely when Nipride infusion is prolonged or patient has CKD/ESRD

• LOOK for the cause, if not evident at first then remain vigilant (it will usually show up!)

• Don’t give a diuretic without a volume reason

• Good follow-up may prevent the next one for this patient …

ARS

• A 64 year old man admitted through ER with ACS has an eGFR of 56 mL/min/1.73. Does he have “CKD”?– A – Yep

– B – Probably

– C – Naw, its expected in HTN emergencies

– D – could you repeat the question?

Kidney Function in non-Renal Hypertensive Emergencies

N=

20

N=

20

N=

19

N=

20

N=

20

N=

19

Recap: Emergencies

• Admit to monitored bed

• Use parenteral meds

• Goal BP reduction up to 25% of presenting value within 1-60 minutes

• If stable after that then aim for 160/100 mm Hg over the next 2-6 hours

• Watch for CNS or Cardiac decompensation – be prepared to back off

STROKE

Stroke in the ED: presentation BP

Qureshi Am J Em Med 2007;25:32-38

Acute Stroke: BP management 2009

• ICH

– Rx if SBP>200 or MAP > 150 mm Hg

– If ICP possibly or definitely high try to keep SBP-ICP > 70* mm Hg

– If SBP >180 or MAP > 130 mm Hg MAY Rx (to 160 SBP or 110 MAP) with care

– Condition like AHF, MI (troponin), and encephalopathy warrant lower goals

• Acute Ischemic Stroke

– Not a lysis candidate:

• Consider Rx for >220/120 mm Hg

– 15-25% reduction

– Lysis candidate:

– Rx if SBP>180

• >185/110 mm Hg contra-indicates thrombolytic approach

Broderick .. Stroke 2007;38:2001Adams .. Stroke 2007;38:1655

BP management Acute Ischemic Stroke

Adams .. Stroke 2007;38:1655

PRE-tPA

Gorelick Disease A Month 2010;56:39-100

Acute Ischemic Stroke: during/after tPA

Adams .. Stroke 2007;38:1655

Stroke/ICH: Study Update

INTERACT II – Anticipated in December 2011

Original Article

Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage

Craig S. Anderson, M.D., Ph.D., Emma Heeley, Ph.D., Yining Huang, M.D., Jiguang Wang, M.D., Christian Stapf, M.D., Candice Delcourt, M.D., Richard

Lindley, M.D., Thompson Robinson, M.D., Pablo Lavados, M.D., M.P.H., Bruce Neal, M.D., Ph.D., Jun Hata, M.D., Ph.D., Hisatomi Arima, M.D.,

Ph.D., Mark Parsons, M.D., Ph.D., Yuechun Li, M.D., Jinchao Wang, M.D., Stephane Heritier, Ph.D., Qiang Li, B.Sc., Mark Woodward, Ph.D., R. John Simes, M.D., Ph.D., Stephen M. Davis, M.D., John Chalmers, M.D., Ph.D.,

for the INTERACT2 Investigators

N Engl J MedVolume 368(25):2355-2365

June 20, 2013

Effect of Early Intensive Blood-Pressure–Lowering Treatment on the Primary Outcome, According to Prespecified Subgroups.

Anderson CS et al. N Engl J Med 2013;368:2355-2365

Conclusions

• In patients with intracerebral hemorrhage, intensive lowering of blood pressure did not result in a significant reduction in the rate of the primary outcome of death or severe disability.

• An ordinal analysis of modified Rankin scores indicated improved functional outcomes with intensive lowering of blood pressure.

Latest words on stroke ---

The skinny on Stroke

• “The management of hypertension in the setting of an acute stroke is a vexing clinical problem. Recent data suggest that lowering BP in acute ICH is probably safe; however, it remains to be seen if this decreases hematoma expansion or improves outcome. BP management in acute ischemic stroke remains problematic and questions such as when to start anti-

• -hypertensives and by how much to reduce BP are yet to be resolved. Although BP lowering is effective for recurrent stroke prevention, the degree of BP reduction may be more important than the class of agent used.”

Aiyagari Stroke June 2009; 40:2251-2256

Hypertensive Emergencies

• Dyspnea, Chest pain, Neurologic ∆

• Keep cocaine and other illicit drugs in your DDx

• Use IV meds that are short acting

• Usually a 15-20% reduction is tolerated OK

• Don’t diurese unless dry, and watch the creatinine

• If the cause isn’t apparent; look again Johnson Cardiol Clin 30;(2012):533–543.

Johnson Cardiol Clin 30;(2012):533–543.

Johnson Cardiol Clin 30;(2012):533–543.

Agenda

• Definitions

• Pathogenesis

• History that matters

• Exam that matters

• Selected testing

• Meds

• Stroke

• Mini-review….