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Jay Patel, MD CR FIRM C Slide 2 Initial Evaluation What are the vitals? EKG Is this new or old? What has the rate of increase been? Is the patient mentating well? Are there signs of acute end-organ damage? Slide 3 Acute Hypertension Is it urgent or emergent? Urgent SBP >180 or DBP >120 Emergent Urgent + End-organ damage End-organ damage Cardiac: pulmonary edema, ACS, aortic dissection Renal: ARF, proteinuria, hematuria ATN Neuro: cerebral edema, CVA, TIA, ICH Many patients will have headache from hypertensive urgency but no other end organ damage. Ophtho: retinal hemorrhage/exudate, papilledema Slide 4 Acute Hypertension Presentations c/w hypertensive emergency: BP >180/100 AND Encephalopathy Dyspnea Chest pain Slide 5 Things Not to miss Aortic Dissection Intracranial Bleeding Acute Coronary Syndromes Slide 6 Treatment: Hypertensive urgency Titrate up current medications, Q2H BP checks untilSlide 7 Physiology: Hypertensive Emergency As blood pressure rises, arterial/arteriolar vasoconstriction occurs (autoregulation) to protect distal arterioles and maintain perfusion. With increasing blood pressure, autoregulation fails. The vascular endothelium loses integrity, and plasma contents enter the vessel wall. The vascular lumen is narrowed or obliterated, leading to ischemia. Slide 8 Slide 9 Treatment: Hypertensive Emergency Use IV bolus/drips to rapidly correct blood pressure Labetalol: 20mg initially, with repeat boluses (20-80mg) Q10min to total 300mg. Then gtt 0.5-2mg/min. Nitroprusside: 0.25-0.5mcg/min, titrate to goal BP with max rate 10mcg/min. Nitroglycerin: 5-100+mcg/min. Nicardipine: 5-15mg/hr. DO NOT USE HYDRALAZINE The goal is to decrease diastolic BP to 100-105mmHg with initial MAP decrease no greater than 25% in MINUTES to HOURS Slide 10 Nitrates Nitroglycerin Good for pulmonary edema and angina Preload/afterload reduction Tachyphylaxis occurs quickly Need high doses to reduce BP Will cause headache Nitroprusside Do not use in renal failure, due to cyanide metabolite Slide 11 Beta-blockers Labetolol Good for rapid onset of action ( Slide 12 Calcium channel blockers Nicardipine Effective, use if contraindications to other agents Do not use in acute CHF, ACS Slide 13 Case 1 J.B. is a 55 y.o. AAM with hx of HTN, GERD, in the ER with chest pain and dyspnea The patient looks extremely uncomfortable but is able to answer questions appropriately pain is 10/10 and going right through his chest 195/120 105 24 96% RA What is your initial DDx? Slide 14 Case 1 Get BP in BOTH arms R 190/100, L 165/95 What therapy do you start empirically? What imaging/labs do you want? Slide 15 Case 1 Slide 16 Slide 17 Therapy: IV labetalol and IV nitrate Goal SBP CVA/Hemorrhage Ischemic CVA: Do not treat HTN unless BP >220/120 OR the patient has concomitant ACS, CHF, aortic dissection, eclampsia IV labetolol is drug of choice If lytics are being used, BP has to beSlide 32 Case 4 D.Y. is a 52 y.o male with history of HTN, DM2, admitted for community acquired pneumonia You are on night float and get a call that the patients BP is 175/95. How do you approach this? Slide 33 Case 4 A) Review the patients medication list B) Review the patients BP trends C) A and B D) Give 5mg IV hydralazine Slide 34 Case 4 Inpatient hypertension that is not urgent or emergent should be treated like outpatient hypertension. Add appropriate anti-hypertensives as you would in clinic and dont aggressively add multiple agents. Remember, amlodipine, lisinopril, etc. often take several days to reach their effect. Slide 35 Summary Any patient with hypertension and chest pain or dyspnea needs blood pressure measured BY YOU in both arms. Evaluate the hypertensive patient for signs of end- organ damage with EKG, troponin, and neurologic exam. Hypertensive urgency: Oral medications. Hypertensive emergency: IV medications and consider ICU transfer. Inpatient hypertension: Treat like you would in clinic. Slide 36 Why Hydralazine is Terrible Reflex tachycardia can increase myocardial oxygen demand and cause ischemia in patients with CAD. Unpredictable hypotension can ensue, especially in patient with pulmonary hypertension. Patient with low GFR may have several dips in blood pressure, resulting in drug stackinghydralazine is renally cleared. Drug-induced lupus and neuropathy are long-term risks, but those with HLA-DR4 genotype may be at risk with IV dosing.