Jay Patel, MD
CR FIRM C
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?
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
Acute Hypertension
 Presentations c/w hypertensive emergency:
 BP >180/100

AND
 Encephalopathy
 Dyspnea
 Chest pain
Things Not to miss…
 Aortic Dissection
 Intracranial Bleeding
 Acute Coronary Syndromes
Treatment: Hypertensive urgency
 Titrate up current medications, Q2H BP checks until
<160/100
 Add rapid onset/rapid offset oral medications to assess
response
 Captopril: ~6.25-12.5mg
 Clonidine: ~0.2mg
 In this situation, try to avoid starting IV drips
 DO NOT USE HYDRALAZINE
 The goal is BP <160/100 in HOURS to DAYS
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.
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
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
Beta-blockers
 Labetolol
 Good for rapid onset of action (<5 minutes)
 Limited by bradycardia, can cause heart block
 Do not use in acute CHF
 Caution with underlying COPD/Asthma
Calcium channel blockers
 Nicardipine
 Effective, use if contraindications to other agents
 Do not use in acute CHF, ACS
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?
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?
Case 1
Case 1
Case 1
 Therapy: IV labetalol and IV nitrate
 Goal SBP <100, goal HR 60s
 DO NOT USE HYDRALAZINE
 Imaging:
 Dissection protocol CT
 TEE
 Labs:
 BMP, CBC, troponin, CK-MB, type/cross, PT, PTT
 Consult vascular surgery
CT
Aortic Dissection
 Types:
 Type A/Proximal  ascending aorta
 Type B/Distal  descending aorta only
 Complications:





Valvular insufficiency
CVA/TIA
Tamponade
Renal/bowel ischemia
MI
Case 2
 F.M. is a 84 y.o AAF with hx of HTN, DM2, CHF, and
CKD in the ER with chest pain and dyspnea
 She missed several doses of medication (BB, ACE-I,
CCB, ASA) while out of town at a Ham Eating Festival
 205/115 105 24 87% RA
 What is your initial DDx?
Case 2
 Get BP in BOTH arms
 R 205/110 L 210/105
 What therapy do you start empirically?
 What imaging/labs do you want?
Case 2
Case 2
Case 2
 Therapy: IV furosemide, IV nitroglycerin, O2
 Goal: improvement in dyspnea, O2 requirement
 Avoid beta-blocker in this patient
 DO NOT USE HYDRALAZINE
 Imaging:
 CXR
 Labs:
 BMP, CBC, troponin, CK-MB, BNP
Case 3
 A.C. is a 76 y.o WF with history of HTN, DM2, CAD
admitted for hypertension and headache
 Initial workup including EKG, Trop, BMP, and CXR are
unremarkable… The patient’s HTN remains difficult
to control with oral agents.
 On HD#1, you are called to see patient for “garbled
speech”
 What is your initial DDx?
Case 3
 BP 220/135 in both arms, HR 90, SaO2/RR stable
 Exam notable for inability to follow commands and
agitation, no cranial nerve deficits, moving all four
extremities
 What imaging/labs do you want?
Case 3
Case 3
Case 3
 Therapy: IV labetalol or nicardipine
 Goal: improvement in mental status, airway protection,
seizure precautions
 DO NOT USE HYDRALAZINE
 Imaging:
 Brain MRI to follow up
 Labs:
 BMP, CBC, troponin, CK-MB
RPLE/RPLS/PRES
 Results from disordered cerebral autoregulation,
endothelial dysfunction, and ischemia
 Hypertensive encephalopathy, eclampsia, and
immunosuppressive drugs (esp. cyclosporine) are
associated conditions
 Therapy involves control of blood pressure, removal of
offending agents (delivery, cyclosporine), and
management of seizures if they occur
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 be <180/105 and
maintained there for 24 hours post lytics
 Intracranial/subarachnoid hemorrhage
 Goal is SBP <200 or MAP <150, use IV labetalol
 Call neurosurgery for ICP monitoring
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 patient’s
BP is 175/95.
 How do you approach this?
Case 4
 A) Review the patient’s medication list
 B) Review the patient’s BP trends
 C) A and B
 D) Give 5mg IV hydralazine
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 don’t aggressively add multiple agents.
 Remember, amlodipine, lisinopril, etc. often take
several days to reach their effect.
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 endorgan 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.
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 stacking—hydralazine 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.