HypertensionDr. Stella YiuStaff Emergency Physician

LMCC objectives: Hypertension

Diagnose and determine severity

Investigate target organ damage and 2nd causes

List medical management (po and iv)

1. Diagnosis

Cdn 2012 guidelines

> 160 or > 100 x 3 Or> 140 or > 90 x 5

Most HTN = Essential HTN

5-10% 2nd – curable

More demand on pump or

Stiff pipes

2. 2nd causes

2nd Causes: Cardiac output (pump demand)

Renal failure + fluid overload++ aldosteroneAortic coarctation

2nd Causes: Vascular resistance (stiff pipes)

Renal artery stenosisPheochromocytomaDrugs Brain (CVA, ICH, SAH)

MCQ 8: What is the most common treatable 2nd cause for HTN?A. HyperaldosteronismB. Renal artery stenosisC. PheochromocytomaD. Aortic coarctationE. Sympathomimetic use

CDMQ: What are the clinical clues and investigations for 2nd causes?

Cardiac output (pump stress)Renal failure + fluid overload++ AldosteroneAortic coarctation

Vascular resistance (stiff pipes)Renal artery stenosisPheochromocytomaDrugs Brain (CVA, ICH, SAH)

Investigations

Renal failure + fluid overload

Creatinine, CXR

Investigations

++ aldosterone

High Na, Low K

Cushingoid on exam

Investigations

Aortic coarctation

HTN in Upper extremitySystolic murmur over backDelayed Femoral Pulse

Echo, Angio

Vascular resistance (stiff pipes)Renal artery stenosis

Young female + fibromuscular dysplasiaResistant to HTN medsMost common treatable cause

Abdo bruits, low K, Abdo US

Vascular resistance (stiff pipes)Pheochro-mocytoma

Episodes of HTN + HA + palp +diaphoresis

Urine catecholamines, metanephrines

Vascular resistance (stiff pipes)Drugs

Amphetamines, sympathomimeticsMAOI

Clinical exam: toxidromeUrine toxECG

Vascular resistance (stiff pipes)Brain (CVA, ICH, SAH)

CT head

3. Manage HTN emergency

What are the target organs?

What are the target organs?

MCQ 9: Which is not an HTN emergency?

A. 35 M 220/140, dizzy, normal neuro exam

B. 50 M 200/120, chest pain, CXR wide mediastinum

C. 25 F 28 wks pregnant, 150/80, seizure

D. 80 F 220/120, left arm weaknessE. 45 F 200/120, crackles to apex,

JVP 6cm

ACS

Pulmonary

edema

Aortic Dissectio

n

Bleeds, seizures Encephalopathy (not just headache,

dizzy)

Acute renal failure

CDMQ: List Investigations for HTN emergency

Investigations for HTN emergency

ACS

Pulmonary edema

Aortic Dissection

Bleeds, seizure,

encephalopathy

ARF

Treat HTN emergency: GeneralBP: Reduce MAP by 25%

Iv medications:LabetololNitroprussideHydralazine

CDMQ: 45 F 220/120, bilateral crackles, JVP 6cm, Sat 80%, treatment?

Specific Treatment: Pulmonary EdemaBiPAPNitrates ivFurosemide iv

Specific Treatment: ACS

ASANTGBeta-blockers

Specific Treatment: DissectionIv Nitroprusside + beta-blocker

Iv labetolol

Surgery if ascending aorta

Specific Treatment: Seizure+ preg (Eclampsia)

MgSO4

Iv Hydralazine

Delivery

3. Manage HTN in Ambulatory setting

Diagnosis

> 160 or > 100 x 3 or> 140 or > 90 x 5

MCQ 10: What test is not needed in ambulatory testing for HTN?

A. Urine, urine albumin (DM)B. Lytes + creatinineC. Fasting glucose +

cholesterolD. CBC + diff E. ECG

Treatment HTN ambulatoryNon-pharmacological management

First line med, dosage and side effects?

No other comorbidities?CAD?Diabetes?Asthma?Renal failure?

No co-morbid – 1st line

Thiazide (HCTZ 251)Beta-blocker (Metoprolol 252)CCB (Amlodipine 51)ARB (Losartan 25mg )

DM

+ Renal: ACEI/ARBCCBThiazide

Asthma

Avoid beta-blocker

CRF (non-DM)

ACEI/ARBThiazide

CAD

ACEI /ARB Angina/recent MI: Beta-blocker

Improving compliance

Fit daily routine

Once daily dosing

Single pill combination

Dosette

LMCC objectives: Hypertension

Diagnose and determine severity

Investigate target organ damage and 2nd causes

List medical management (po and iv)