Hypertensive Emergencies
Phillip D. Levy, MD, MPH, FACEP
Associate Professor
Associate Director of Clinical Research
Wayne State University Department of Emergency Medicine
Relevant Disclosures
• Grant/Research Support
– The Robert Wood Johnson Foundation Physician
Faculty Scholars Program, the NIH Loan Repayment
Program (Health Disparities Division), and the
NIH/NIHMD (1R01 MD005849-01A1)
• Consultant
– The Medicines Company, EKR Therapeutics
Purpose of This Lecture
• To provide an overview of the “what”
and “why” of contemporary ED
management of acute HTN
– Utilize an evidence-based discussion
format
– Focus on differentiation between simple
BP elevation and true hypertensive
emergency
Why This Topic?
Nawar et al. Adv Data 2007; 386:1-32.
Why This Topic?
Pitts et al. Natl Health Stat Report 2008;7:1-38.
Based on JNC VII Class
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm
Reflects the General
Population Prevalence
Lloyd-Jones et al. Circulation 2010;121;e1-e170.
As Well As Racial and Ethnic
Demographics
Lloyd-Jones et al. Circulation 2010;121;e1-e170.
And Low Levels of Awareness,
Treatment and Control
Lloyd-Jones et al. Circulation 2010;121;e1-e170.
So The BP is High - Now What ?
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm
So The BP is High - Now What ?
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm
So The BP is High - Now What ?
http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm
Shayne and Pitts. Ann Emerg Med. 2003;41:513-29.
Are All of These Patients
the Same?
Kessler and Joudeh. Am Fam Physician. 2010;81:470-76.
Clearly Not!
Kessler and Joudeh. Am Fam Physician. 2010;81:470-76.
What Constitutes a
Hypertensive Emergency? 1,2
1
2
Varon and Marik. Chest 2000;118:214-27.
Rynn et al. J Pharm Prac 2005;18:363-76.
Pathophysiology of a
Hypertensive Emergency1,2
1 Ault
2
and Ellrodt. Am J Emerg Med 1985; (suppl 6):10-15.
Varon and Marik. Chest. 2000;118:214-27.
Chirinos and Segers. Hypertension 2010;56:563-70.
Macrocirculatory:
Arterial Impedance
Kawaguchi et al. Circulation 2003;107:714-20.
What End-Organs Are
Typically Involved?
Zampaglione et al. Hypertension 1996;27:144–7.
Katz et al. Am Heart J 2009;158:599-606.
Patient Outcomes
Katz et al. Am Heart J 2009;158:599-606.
Szczech et al. Circulation 2010;121:2183-91.
Deshmukh et al. Am Heart J. 2011 [epub ahead of print].
Stead et al. Neurology 2005;65:1179-83.
Gheorghiade et al. JAMA 2006;296:2217-26.
Perez et al. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD003653.
Perez et al. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD003653.
Treatment Typically Parenteral
• Adrenergic receptor
blockers
–
–
–
–
Esmolol (β1)
Labetalol (α1 and β)
Phentolamine (α1)
Urapidil (α1)
• Ca2+ channel blockers
– Nicardipine
– Clevidipine
• ACE inhibitors
– Enalaprilat
• NO donors
– Nitroprusside
– Nitroglycerin
– Isosorbide dinitrate
• NP analogue
– Nesiritide
• Dopamine agonist
– Fenoldopam
• Direct vasodilator
– Hydralazine
What Is Used Most Commonly?
Katz et al. Am Heart J 2009;158:599-606.
How Well Does That Work?
One
First IV Antihypertensive
Labetolol (n=501)
32%
40%
Nitroglycerin (n=241)
41%
Hydralazine (n=235)
41%
Nicardapine (n=121)
25%
37%
27%
23%
32%
45%
51%
22%
Three or more
42%
Metoprolol (n=277)
Sodium nitroprusside (n=82)
Two
14%
28%
32%
21%
46%
Percent of Patients
Katz et al. Am Heart J 2009;158:599-606.
Differential Antihypertensive
Response
Katz et al. Am Heart J 2009;158:599-606.
Blood Pressure Dynamics
• MAP = DBP + ([SBP - DBP]/3)
• MAP = (CO x SVR) + CVP
– CO = HR x SV
Reference: Peacock et al.
Peacock et al. Critical Care 2011 [epub ahead of print].
CLUE Study
Evaluation of Intravenous niCardipine and Labetalol Use in the Emergency
Department
Reference: Peacock et al.
Peacock et al. Critical Care 2011 [epub ahead of print].
CLUE Study
Evaluation of Intravenous niCardipine and Labetalol Use in the Emergency
Department
Final multivariable logistic regression model†* for
“met target SBP within first 30 minutes”
Reference: Peacock et al.
Peacock et al. Critical Care 2011 [epub ahead of print].
Specific Indications
Rhoney and Peacock. Am J Health-Syst Pharm. 2009; 66:1343-52.
How Low Should You Go?
• Simple answer
– 25% reduction in MAP within 1st hour
– Target ~ 160/100 mm Hg by 2-6 hours
Marik and Varon. Critical Care 2003, 7:374-84.
How Low Should You Go?
• Better answer
– It really depends on clinical condition
• Less aggressive with ischemic stroke
• More aggressive with hemorrhagic stroke,
acute HF and aortic dissection
AHA/ASA Recommendations for
BP Management in AIS
Aiyagari and Gorelick. Stroke 2009;40:2251-56.
AHA/ASA Recommendations for
BP Management in AIS
Aiyagari and Gorelick. Stroke 2009;40:2251-56.
AHA/ASA Recommendations for
BP Management in AIS
Aiyagari and Gorelick. Stroke 2009;40:2251-56.
AHA/ASA Recommendations for
BP Management in ICH
Aiyagari and Gorelick. Stroke 2009;40:2251-56.
AHA/ASA Recommendations for
BP Management in ICH
Aiyagari and Gorelick. Stroke 2009;40:2251-56.
Sandset et al. Lancet 2011 [epub ahead of print].
Sandset et al. Lancet 2011 [epub ahead of print].
Sandset et al. Lancet 2011 [epub ahead of print].
Impact of Early Reduction
Rhoney et al. Presented at the 2011 Neuro-Critical Care Society Meeting.
Impact of Early Reduction
Rhoney et al. Presented at the 2011 Neuro-Critical Care Society Meeting.
Guideline: SBP < 180 mm Hg
Intensive: SBP < 140 mm Hg
Anderson et al. Stroke 2010;41:307-12.
But No Direct Clinical Benefit
at 90 Days…
Anderson et al. Lancet Neurol 2008;7:391–9.
Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) investigators Crit Care Med 2010;38:637-48.
Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) investigators Crit Care Med 2010;38:637-48.
Hematoma Expansion
Modified Rankin Scale Score
Qureshi et al. Arch Neurol. 2010;67:570-6.
Qureshi et al. Arch Neurol. 2010;67:570-6.
BP Goal by 1 hr: 11% vs. 56% (p=0.02)
Liu-DeRyke et al. Neurocrit Care 2008;9:167-76.
n=51
n=20
n=51
n=20
Stead et al. Neurology 2006;66:1878–81.
AHA/ACC Recommendations for
BP Management in Acute HF
Hunt et al. Circulation. 2009;119(14):e391-479.
What About the Rest?
Kessler and Joudeh. Am Fam Physician. 2010;81:470-76.
Pitts and Adams. Ann Emerg Med 1998;31:214-8.
Grassi et al. J Clin Hypertens 2008;10:662–7.
BP Response to Rest
Grassi et al. J Clin Hypertens 2008;10:662–7.
Retrospective Cohort Study
Untreated Treated
n = 435
19 (4.4)
12 (2.8)
3 (0.7)
1 (0.2)
p-value
ED Visit 24 Hrs, n (%)
ED Visit 24 Hrs Due to HTN, n (%)
Hospital Admission within 24 Hrs, n (%)
Complication at 24 Hrs Due to HTN, n (%)
n = 581
14 (2.4)
7 (1.2)
0 (0.0)
0 (0.0)
ED Visit within 30 d, n (%)
ED Visit within 30 d Due to HTN, n (%)
ED visit within 30 d for antihypertensive refill, n (%)
Hospital Admission within 30 d, n (%)
Complication within 30 d Due to HTN, n (%)
88 (15.2)
30 (5.2)
10 (1.7)
15 (2.6)
6 (1.0)
82 (18.9)
36 (8.3)
11 (2.5)
13 (3.0)
11 (2.5)
0.118
0.046
0.371
0.695
0.066
ED Visit within 90 d, n (%)
ED Visit within 90 d Due to HTN, n (%)
ED visit within 90 d for antihypertensive refill, n (%)
Hospital Admission within 90 d, n (%)
Complication within 90 d Due to HTN, n (%)
95 (16.4)
41 (7.1)
10 (1.7)
17 (2.9)
13 (2.2)
89 (20.5)
44 (10.1)
12 (2.8)
23 (5.3)
14 (3.2)
0.092
0.082
0.261
0.056
0.336
1 (0.2)
9 (1.6)
1 (0.2)
9 (2.1)
0.837
0.534
Death within 30 d, n (%)
Death within 1 year, n (%)
0.082
0.070
0.450
0.248
Levy et al. Accepted for poster presentation at ACEP Scientific Assembly 2011 (San Francisco, CA).
Wrap Up
• Critical first step is to differentiate
true emergencies from poorly
controlled chronic hypertension
• Intervention for emergencies should
be driven by condition-specific goals
– Involve more than just a number!
– Equate with problems caused by acute
HTN
– Best achieved using co-morbidity
congruous agents