htn crises (final)

8/9/2019 HTN Crises (Final)

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HYPERTENSIVE CRISESFaris Mahmud

Provisionally Registered Pharmacist


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DEFINITION

Hypertensive crisis is defined as a severe

elevation in blood pressure (BP>180/110 mmHg)

If these conditions are not treated promptly, a

high rate of morbidity and mortality will ensue

These conditions are divided into two general

categories:Hypertensive urgencies

Hypertensive emergencies


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CLASSIFICATION OF

HYPERTENSIVE CRISES

Hypertensive urgencySeverely elevated BP above 180/110 mmHg without

evidence of end organ damage

Not immediately life threatening

Reduction of BP to a safe level may be done more slowly(over 24 to 48 hours)

Hypertensive emergencySeverely elevated BP with evidence of end organ damage

Usually occur when BP>180/110 mmHg, but may occur

at even lower level

Immediately life threatening

BP needs to be lowered to a safe level within minutes to

hours


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Hypertensive Emergency Hypertensive Urgency

Severely elevated blood pressure

(BP >180/110 mmHg)

Severely elevated blood pressure

(BP>180/110 mmHg)

Overt symptoms of end organ

damage present:

• CNS (encephalopathy,

intracranial/subarachnoid

hemorrhage, stroke)

• Heart (left ventricular failure,

pulmonary edema, MI, aortic

dissection)

• Renal failure/insufficiency

• Eyes (ocular hemorrhage,funduscopic changes, blurred

vision, loss of sight)

No evidence of end-organ damage

Requires immediate pressure

reduction

May be treated over several

hours (or even days)

Requires IV therapy May use oral or IV therapy


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COMMON CAUSES OF

HYPERTENSIVE CRISES

Renal parenchymal

diseaseChronic pyelonephritis

Primary

glomerulonephritisTubulointerstitial

nephritis

Systemic disorders with

renal involvementSystemic lupus

erythematosus

Systemic sclerosis

Vasculitides

Renovascular

Atherosclerotic disease

Fibromuscular disease

Polyarteritis nodosa Endocrine

Phaeochromocytoma

Conn syndrome

Cushing syndrome Recreational drugs Coarctation of aorta

Pre-eclampsia/eclampsia


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HYPERTENSIVE URGENCY


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GOAL OF THERAPY

Initial goal is BP reduction of up to 25% over

several hours (generally, 24-48 hours)

If the patient is then stable, BP can be further

reduced toward 160/100 mmHgPrecipitous drop in BP may lead to end-organ

ischemia or infarction

If patients tolerate this reduction well, additional

gradual reductions toward target BP values can

be attempted


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APPROACH OF TREATMENT

If the patient is already on maintenance therapy,

hypertensive urgencies are best managed by

optimizing the therapy, byadding a new antihypertensive

increasing the dose(s) of the present medication(s)

restart the medications (if the therapy was defaulted

or interrupted)

If acute BP reduction is necessary, short-acting

oral antihypertensive may also be administeredfollowed by careful observation for several hours – to

assure a gradual reduction in BP


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ORAL SHORT-ACTING ANTI-HTN FOR

HYPERTENSIVE URGENCIES

Drug Dose Onset ofaction (hr)

Duration (hr) Frequency(prn)

Maximumdaily dose

Captopril 25 mg 0.5 6 1-2 hrs 450 mg

Nifedipine 10-20mg 0.5 3-5 1-2 hrs 120-180 mg

Labetalol 200-400 mg 2.0 6 4 hrs 2400 mg

Adapted from CPG for Management of Hypertension 3rd ed. 2008

Available at HKB:• T. Capropril 25 mg

• T. Nifedipine 10 mg• T. Labetalol 100 mg


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USE OF NIFEDIPINE IN


Oralnifedipine was commonly used as a rapid-acting

therapy in the acute management of hypertension

However, its use has been associated with life-

threatening adverse events such as ischemia, MI, and

stroke(Psaty BM et al. 1995; Schwartz M et al. 1990; Fami MJ et al. 1998)

Prompt absorption of rapidly acting CCB is followed by a

precipitous decrease in BP due to peripheral vasodilation

This reduces coronary perfusion, induces a reflex tachycardia,

and increases myocardial oxygen consumption(Grossman E et al. 1996)

Decreased cerebral blood flow has also been reported with

sublingualnifedipine (Gemici K et al. 2003)

Elderly patients with underlying coronary or

cerebrovascular disease, volume depletion, or concurrent

use of other anti-HTN drugs are at increased risk for

significant adverse events(Summers K et al. 2009)


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USE OFCAPTOPRILIN


Oralcaptopril is as effective asnifedipine in acutely

reducing BP in both urgent and emergent conditions(Misra A et al. 1993; Kosuoglu B et al. 1991)

Captoprilhas been reported to increase cerebral blood

flow to a greater extent in patients with BP >180/120mmHg compared tonifedipine (Gemici K et al. 2003)

First-dose hypotension is a common limiting factor with

captopril use(Summers K et al. 2009)

Most likely to occur in patients with high renin levels – such

as those who are volume depleted or those receiving diureticsUnder these circumstances, initial doses should not exceed

12.5 mg, with repeat doses an hour or more later if necessary

Caution:captopril can induce severe renal failure in

patients with bilateral renal artery stenosis


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USE OFLABETALOLIN


Use oflabetalol have been shown to be effective to

lower BP in acute settings(Gonzalez ER et al. 1991; Zell-KanterM, Leikin JB 1991; Atkin S et al 1992)

Labetalol can cause profound orthostatic

hypotensionPatients should remain in the supine position and

should be checked for orthostasis before ambulation.

Labetalol should be avoided in patients with

asthma, bradycardia, or advanced heart block.


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HYPERTENSIVE

EMERGENCY


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GOAL OF THERAPY

Immediate reduction of BP is requiredto limit progression of target organ damage

to prevent development of new target organ damage

Initial goal is BP reduction of up to 25% within minutes to

hours

If the patient is then stable, BP can be reduced toward

160/100 mm Hg within the next 2 to 6 hoursPrecipitous drop in BP may lead to end-organ ischemia or infarction

If patients tolerate this reduction well, additional gradual

reductions toward goal BP values can be attempted after 24 to

48 hours

The exception to this goal is for patients with an acute

ischemic strokemaintaining an elevated BP is needed for a much longer period of

time


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APPROACH TO TREATMENT

Antihypertensive drug therapy has been shown

to improve mortality and morbidity in patients

presenting with hypertensive emergencies(Vadera R.

2011)

Optimal pharmacotherapy depends on the

specific organ at risk


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Drugs Dose Onset of

action

Duration Remarks

Sodium

nitroprusside

0.25-10 mcg/kg/min seconds 1-5 min Caution in

renal failure

Labetalol IV bolus 50 mg (over atleast 1 min) may

repeat at 5 min

interval

IVI 2 mg/min

(max 200 mg)


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NEUROLOGIC EMERGENCIES

Hypertensive encephalopathy

Hypertensive encephalopathy was used to describe the

encephalopathic findings associated with the malignant

hypertensive phase

Results from hydrostatic exudation of fluid into the braindue loss of blood-brain barrier integrity

The clinical symptoms are usually reversible with prompt

initiation of therapy

The treatment target is to reduce the MAP 25% over 8

hours(Pancioli AM. 2007)

Labetalol,nicardipine, esmolol are the preferred

medications(Pancioli AM. 2007)

Nitroprusside andhydralazine should be avoided(Pancioli AM.2007)


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Acute ischemic stroke

Brain vascular occlusion results in depletion of

oxygen and ATP to the neurons

UNLESS the patient is receiving IV fibrinolysis,ntihypertensive medications should be withheld

unless the BP is >220/120 mmHg(Castillo J et al. 2004)

An elevated BP (up to 220/120 mmHg) is desirable to aid

cerebral perfusion

If the patient is receiving IV fibrinolysis - then, the goalBP is < 185/110 mmHg to minimize risk for hemorrhage(Adams HP et al. 2007; Khaja AM, Grotta JC. 2007)

Preferred medications arelabetalol and

nicardipine (Adams HP et al. 2007)


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Intracerebral hemorrhage / hemorrhagic

stroke

Bleeding that occurs directly into the brain

parenchyma

The usual mechanism is thought to be leakage

from small intracerebral arteries damaged by

chronic hypertension

The treatment is based on evidence of increased

intracranial pressure (ICP)(Anderson CS et al. 2008)

For the 1st 24 hours after onset: With increased ICP, maintain the MAP < 130 mmHg or

SBP < 180 mmHg

Without increased ICP, maintain the MAP < 110 mmHg orSBP < 160 mmH


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Intracerebral hemorrhage / hemorrhagic

stroke

Preferred medications arelabetalol,nicardipine,

and esmolol (Anderson CS et al. 2008)

Avoidnitroprusside andhydralazine (Anderson CS et al.2008)


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Subarachnoid hemorrhage (SAH)

Extravasation of blood into the subarachnoid

space

~80% of non-traumatic SAH are due to aruptured berry aneurysm related to

hemodynamic stress on the arterial walls

Preferred medications arelabetalol,nicardipine,

and esmolol (Anderson CS et al. 2008)

Avoidnitroprusside andhydralazine (Anderson CS et al.2008)


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CARDIOVASCULAR EMERGENCIES

Aortic Dissection

Separation of the layers within the aortic wall

Occurs when blood pushes into the intima-media

space through a tear in the intimal layerCan be rapidly fatal, even with immediate

medical attention

Treatment goal is to maintain maintain the SBP

at < 110 mm Hg, unless signs of end-organhypoperfusion are present(Cheung AT, Hobson RW. 2008)


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Aortic Dissection

Preferred treatment includes a combination of

narcotic analgesic (morphine), B-blockers

(labetalol, esmolol), and vasodilators

(nicardipine,nitroprusside)(Cheung AT, Hobson RW. 2008)

Non-DHP CCB (verapamil,diltiazem) are an

alternative to beta blockers

AVOID B-blockers if there is aortic valvular

regurgitation or cardiac tamponade(Cheung AT, HobsonRW. 2008)


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Acute Coronary Syndrome & Heart Failure

Treatment is indicated if the BP rises >160/100

mm Hg(Diercks EB, Ohman EM. 2008)

Reduce the BP by 25% of baseline

For ACS, B-blockers andnitrates are the

preferred drugs(Diercks EB, Ohman EM. 2008)

Thrombolytics are contraindicated if the BP is

>185/100 mm Hg

In LVF with APO,nitroprusside ornicardipine,

plusnitrates and a loop diuretic ( frusemide) are

recommended


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PREECLAMPSIA/ECLAMPSIA

Treatment is indicated when BP >160/110 mm

Hg in the antepartum and intrapartum periods(Barton JR. 2008)

If the platelet count is less than 100,000 cells mm3,

target BP < 150/100 mm HgThe preferred medications arehydralazine,

labetalol, andnifedipine (Barton JR. 2008)

Should also be treated with IVmagnesium

sulfate to avoid seizures Avoidnitroprusside, ACE inhibitors, esmolol (BartonJR. 2008)


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CONCLUSION

Hypertensive urgencies and emergencies both are characterized

by the presence of very elevated BP, typically greater than

180/120 mm Hg

Hypertensive urgencies are ideally managed by adjusting

maintenance therapy, by adding a new antihypertensive, and/or

by increasing the dose of a present medicationHypertensive urgency requires BP reductions with oral

antihypertensive agents to stage 1 values over a period of hours

to days

Hypertensive emergencies are situations that require immediate

BP reduction to limit new or progressing target-organ damageHypertensive emergencies require parenteral therapy, at least

initially, with one of the specific agents listed

In most of the hypertensive emergencies, IVlabetalol are

preferred unless contraindicated


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REFERENCES

Abdul Rashid AR et al. Clinical Practice Guideline: Management of Hypertension. 3rd Ed. MOH.

2008

Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with

ischemic stroke: A guideline from the American Heart Association. Stroke 2007;38:1655–1711.

Anderson CS, Huang Y, Wang JG, et al. Intensive blood pressure reduction in acute cerebral

haemorrhage trial (INTERACT): a randomised pilot trial. Lancet Neurol. May 2008;7(5):391-9.

Angeli P et al. Comparison of sublingual captopril and nifedipine in immediate treatment of

hypertensive emergencies. Arch Intern Med 1991;151:678. Atkin S et al. Oral labetalol versus oral clonidine in the emergency treatment of severe

hypertension. Am J Med Sci 1992;303:9.

Barton JR. Hypertension in pregnancy. Ann Emerg Med. Mar 2008;51(3 Suppl):S16-7.

Castillo J, Leira R, García MM, Serena J, Blanco M, Dávalos A. Blood pressure decrease during

the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome.

Stroke. Feb 2004;35(2):520-6.

Cheung AT, Hobson RW 2nd. Hypertension in vascular surgery: aortic dissection and carotid

revascularization. Ann Emerg Med. Mar 2008;51(3 Suppl):S28-33.Diercks DB, Ohman EM. Hypertension with acute coronary syndrome and heart failure. Ann

Emerg Med. Mar 2008;51(3 Suppl):S34-6.

Fami MJ et al. Another report of adverse reactions to immediate-release nifedipine.

Pharmacotherapy 1998;18:1133.

Gemici K et al. Evaluation of the effect of sublingually administered nifedipine and captopril via

transcranial Doppler ultrasonography during hypertensive crisis. Blood Press 2003;12:46.


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REFERENCES

Gonzalez ER et al. Dose response evaluation of oral labetalol in patients presenting to the

emergency department with accelerated hypertension. Ann Emerg Med 1991;20:333.

Grossman E et al. Should a moratorium be placed on sublingual nifedipine capsules given for

hypertensive emergencies and pseudoemergencies? JAMA 1996;276:1328.

Khaja AM, Grotta JC. Established treatments for acute ischemic stroke. Lancet 2007;369:319–

330.

Komsuoglu B et al. Treatment of hypertensive urgencies with oral nifedipine, nicardipine, and

captopril. Angiology 1991;42:447.

Leavitt AD, Zweifler AJ. Nifedipine, hypotension, and myocardial injury. Ann Intern Med

1988;108:305.

Misra A et al. Sublingual captopril in hypertensive urgencies. Postgrad Med J 1993;69:498.

O'Mailia JJ et al. Nifedipine-associated myocardial ischemia or infarction in the treatment of

hypertensive urgencies. Ann Intern Med 1987;107:185.

Pancioli AM. Hypertension management in neurologic emergencies. Ann Emerg Med. Mar

2008;51(3 Suppl):S24-7.

Psaty BM et al. The risk of myocardial infarction associated with antihypertensive drug therapies.JAMA 1995;274:620.

Schwartz M et al. Oral nifedipine in the treatment of hypertensive urgency: cerebrovascular

accident following a single dose. Arch Intern Med 1990;150:686.

Summers K et al. Hypertensive Crises. Applied Therapeutics. 2009.

Vadera R. Does antihypertensive drug therapy decrease morbidity or mortality in patients with a

hypertensive emergency?. Ann Emerg Med. Jan 2011;57(1):64-5.

Zell-Kanter M, Leikin JB. Oral labetalol in hypertensive urgencies. Am J Emerg Med 1991;9:136.


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