Hypertensive Emergencies:
Diagnosis and Treatment
Jamie Johnston, MD
University of Pittsburgh
School of Medicine
Today’s Road Map
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Case Presentations
Definitions
Evaluation
Management
Will not cover pre-eclampsia or pediatric
hypertensive emergencies
Case 1
• 51 year old man admitted to an outside
hospital
• CC: Sudden onset of left-sided weakness,
severe headache, slurred speech and left
facial droop
– BP 260/172
– Head CT Scan showed Right basal ganglia
hemorrhage with shift
• HPI: Transported by air ambulance to PUH.
– Intubated en route due to declining mental status
Case 1
• PMH - Hypertension - according to wife,
patient was non-adherent with prescribed
medications
– Out patient medications and allergies - not
available
– Family History +for HTN/CVA
• Exam PUH - BP 196/130
– Positive for Left dense hemiparesis
Case 1
• Hospital day 2
– Dilated right pupil
– Emergent right frontotemporal craniotomy
and evacuation of clot
• Subsequent Hospital Course
– Difficult to control BP
– Pneumonia
Case 1
• Renal MRI
– Right kidney 8.1 cm with three renal
arteries
– Left kidney 12.2 cm with two renal arteries
• Patient transferred to rehab at South
Side Hospital on 7/19/07
Question 1
•
What is the primary reason for
hypertensive emergencies in the USA
today?
1. Renovascular Disease
2. Pheochromocytoma
3. Non-adherence to anti-hypertensive
medication
4. Hyperaldosteronism
5. Erythropoeitin
What is the primary reason for
hypertensive emergencies in the
USA today?
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1. Renovascular
Disease
2. Pheochromocytoma
3. Non-adherence to
anti-hypertensive
medication
4. Hyperaldosteronism
5. Erythropoeitin
When you hear hoof beats…
Hypertensive Emergency
• According to the Joint National
Committee on Hypertension Report
• Severely elevated blood pressure with
signs and symptoms of acute end organ
damage
• Requires hospitalization
• Requires parenteral medication
Hypertensive Urgency
• Severely elevated blood pressure
without signs and symptoms of acute
end organ damage
• Can be managed as an outpatient
• Can be managed with oral medications
Hypertensive Emergency
CNS - encephalopathy,
• Damage
intracranial hemorrhage,
Grade 3-4 retinopathy
Kidneys - acute kidney
injury, microscopic
hematuria
Vasculature Vasculatur
e aortic dissection,
eclampsia
Heart - CHF, MI, angina
Epidemiology
• Hypertensive emergencies are common
– Occur in 1-2% of the hypertensive population
– But, 50 million hypertensive Americans
– 500,000 hypertensive emergencies/year
• Parallels the distribution of primary
hypertension
• Higher in the elderly and African Americans
• Incidence in men 2 times higher than in
women
Epidemiology
• Common associations
– Previous history of hypertension
– Lack of a primary care physician
– Non adherence to antihypertensive
regimen
– Elicit drug use (cocaine)
Pathophysiology
Sudden increase in
Systemic Vascular
Resistance
Mechanical Stress with
endothelial injury, increased
permeability, Coag/Plt
activation, fibrin deposition
BP
1) Fibrinoid necrosis
2) Ischemia
3) Activation of RAA
4) Proinflammatory
cytokines
Vaughan and Delanty Lancet 2000; 356:411
Underlying Etiology?
• Unclear, but some candidates
– ACE DD genotype
– Absence of the b and g subunit of ENaC
– Elevated adrenomedullin levels*
– Elevated natriuretic peptide level*
– Abnormalities in oxidative stress markers and
endothelial dysfunction*
– *Correct after effective BP treatment
Question 2
•
What is the most common complaint in
hypertensive emergency?
1.
2.
3.
4.
5.
Neurologic defect
Gross Hematuria
Chest pain
Headache
Epistaxis
What is the most common complaint
in hypertensive emergency?
Neurologic defect
Gross Hematuria
Chest pain
Headache
Epistaxis
0%
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2.
3.
4.
5.
Clinical Presentation
• Variable
• Zampaglione et al (Hypertension 27:144, 1996)
– 14, 209 ER visits in one year period
– 108 met definition of hypertensive
emergency (0.8%)
– Mean Systolic BP 210 + 32
– Mean Diastolic BP 130 + 15
Clinical Presentation
• Frequency of signs and symptoms
– Chest Pain
– Dyspnea
– Neuro defect
– Interestingly….
27%
22%
21%
• Headache was only 3% and epistaxis was 0%
in this study
Question 3
•
Hypertensive emergency is associated
with a threshold BP of
1.
2.
3.
4.
5.
Systolic > 225 mm Hg
Diastolic > 110 mm Hg
Systolic > 250 mm Hg
Diastolic > 120 mm Hg
All of the above
Hypertensive emergency is
associated with a threshold BP of
Systolic > 225 mm Hg
Diastolic > 110 mm Hg
Systolic > 250 mm Hg
Diastolic > 120 mm Hg
All of the above
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Sy
1.
2.
3.
4.
5.
Threshold BP
• There is no specific BP where
hypertensive emergencies occur
• But, organ dysfunction is rare with
diastolic BPs < 130 mm Hg
– Rate of increase may be more important
– Hence, encephalopathy will occur at lower
BPs in pregnancy and in children
Initial Evaluation
• Focused history
– History of hypertension?
– How well is hypertension controlled?
– What antihypertensives?
– Adherence to antihypertensive regimen?
– Last dose of antihypertensive?
Initial Evaluation
• Social History
– Recreational Drugs
• Amphetamines
• Cocaine
• Phencyclidine
Initial Evaluation
• Confirm BP in both arms
• Use appropriate sized BP cuff
• Cuff that is too small
– BP cuffs that are too small falsely elevate
BP measurements in obese patients
Initial Evaluation
• Assess for end-organ damage
• Vascular Disease
– Assess pulses in all extremities
– Auscultate over renal arteries for bruits
• Cardiopulmonary
– Listen for rales (CHF)
– Murmurs or gallops
Initial Evaluation
• Neurologic Exam
– Hypertensive Encephalopathy - mental
status changes, nausea, vomiting, seizures
– Lateralizing signs uncommon and suggest
cerebrovascular accident
• Retinal Exam
– Lost art
– Keith-Wagener-Barker Classification
Keith-Wagener-Barker Classification
• Grade 1
– Mild narrowing of the arterioles
– “Copper Wire”
• Grade 2
– Moderate narrowing Copper wire and AV nicking
• Changes associated with long standing
essential hypertension
Normal
Grade 1
Keith-Wagener-Barker Classification
• Grade 3
– Severe Narrowing Silver wire changes, hemorrhage, cotton
wool spots, hard exudates
• Grade 4
– Grade 3 + Papilledema
• Grade 3 and 4 highly correlated with
progression to end organ damage and
decreased survival
Grade 3 KWB Retinopathy
Lab Testing
• ECG
– LVH, look for signs of ischemia, injury, infarct
• Renal Function Tests (urine included)
– Elevated BUN, Creatinine, proteinuria, hematuria
• CBC
• CXR - pulmonary edema, aortic arch, cardiac
enlargement
Lab Testing
• Aortic Dissection?
– Suspect with severe tearing chest pain,
unequal pulses, widened mediastinum
– Contrast Chest CT Scan or MRI
• Pulmonary Edema/CHF
– Transthoracic Echocardiogram
– Differentiate between systolic dysfunction,
diastolic dysfunction, mitral regurgitation
Management
• Elevated BP without target organ
damage
• Hypertensive urgency
• Oral meds
• Goal - gradual reduction of BP over 24 48 hours
Management
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Elevated BP with target organ damage
Hypertensive emergency
Parenteral meds
Goal - Reduce diastolic BP by 10-15%
or to 110 mm Hg over a period of 30 60 minutes
How Quickly?
• Cerebral Blood Flow Autoregulation
– Cerebral Blood constant in normotensive
individuals over range of MAPs of 60 -120
mm Hg.
– In chronically hypertensive patients
autoregulatory range is higher
– MAP Range 100-120 to 150-160 mm Hg
• Autoregulation also impaired in the
elderly and those with cerebrovascular
disease
How Quickly?
• General rule is to lower MAP by 20% in
first hour
• Should always be done with close
clinical observation
Management
• Where?
– ICU with close monitoring
– Severe requires intra-arterial BP
monitoring
• Which Parenteral meds?
• Depends on the situation
Question 4
•
Which of the following drugs should not
be used to treat hypertensive emergency?
1.
2.
3.
4.
5.
Sublingual Nifedipine
Labetolol
ACE Inhibitors
Nicardipine
1 and 3
Which of the following drugs should
not be used to treat hypertensive
emergency?
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1. Sublingual
Nifedipine
2. Labetolol
3. ACE Inhibitors
4. Nicardipine
5. 1 and 3
Preferred Agents
• Beta blockers
– Labetolol
– Esmolol
• Calcium Entry blocker
– Nicardipine
• Dopamine-1 receptor agonist
– Fenoldapam
• Vasodilators - nitroprusside/nitroglucerin
Scenarios
• Our Case - Acute ischemic
stroke/cerebrovascular bleed
• Agents
– Fenoldopam
– Labetolol
– Nicardipine
CVA or Ischemic Stroke
• BP elevation after CVA or ischemic stroke
can be protective to preserve cerebral
perfusion
• Hold on aggressive lowering unless
– Thrombolytic therapy anticipated or
– BP excessively high ( SBP > 220 mm Hg or DBP
>120)
• BP Goal for thrombolytic therapy is to lower
SBP if > 185 or DBP >110
Cardiac Conditions
• Acute Pulmonary Edema with systolic
dysfunction
– Nicardipine
– Fenoldopam
– Sodium nitroprusside
– Nitroglycerin
– Loop diuretic
Cardiac Conditions
• Acute Pulmonary Edema with diastolic
dysfunction
– Esmolol, metoprolol, labetolol
– verapamil
– Nitroglycerin
– Loop diuretic
Cardiac Conditions
• Acute myocardial ischemia
– Esmolol, labetolol
– Nitroglycerin
Sympathetic Crisis
• Generally in association with
recreational drugs such as cocaine,
amphetamine or phencyclidine
• Sudden cessation of clonidine or Betaadrenergic antagonist
• Pheochromocytoma - rare
Question 5
•
Which of the following drugs should be
avoided in sympathetic crises with
hypertensive emergency?
1.
2.
3.
4.
5.
Phentolamine
Benzodiazepine
Labetolol
Nicardipine
Fenoldopam
Which of the following drugs should
be avoided in sympathetic crises with
hypertensive emergency?
Phentolamine
Benzodiazepine
Labetolol
Nicardipine
Fenoldopam
B
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1.
2.
3.
4.
5.
Sympathetic Crisis
• Beta-adrenergic antagonists will result
in unopposed alpha-adrenergic
stimulation
• In cocaine use, Beta blockers can
– Increase blood pressure
– Worsen coronary artery vasoconstriction
– Decrease survival
• Avoid beta blockade (including non
selective agents such as labetolol)
Sympathetic Crisis
• Recommended Drugs
– Nicardipine
– Fenoldopam
– Verapamil
– Benzodiazepine
– If pheo suspected use phentolamine
Aortic Dissection
• Treatment is paramount
– 75% of patients with ascending aortic
dissection die in 2 weeks of the acute
episode without successful therapy
– 5 year survival is 75% with successful
intervention
• Khan et al. Chest 2002, 122:311
• Kouchoukos New Engl J Med 1997; 336:1876
Aortic Dissection
• Vasodilator alone?
– Causes reflex tachycardia
– Increases cardiac ejection velocity
– Increases aortic shear forces
– Extends the dissection
Aortic Dissection
• Standard therapy
– Beta-adrenergic blocker plus vasodilator
– Esmolol + Nicardipine or fenoldopam
• Nitroprusside can be used as well
Acute Post Operative Hypertension
• Frequent in post-operative state (2075%)
• Hyper-responsiveness to surgical
trauma
– Increased stress hormones?
– Activation of RAA?
• Also hypothermia, hypoxia, carbon
dioxide retention, bladder distention
Acute Post Operative Hypertension
• Prevention
– Safe to give antihypertensives pre-op
– Hold diuretics
• Treatment - BP thresholds vary
– Control pain and anxiety
– While NPO use nicardipine, esmolol or
labetolol
– Resume oral medications when possible
What happened to sodium nitroprusside?
• Mansoor and Friedman. Heart Disease
2002; 4:358
– Sodium nitroprusside recommended for all
hypertensive emergencies except
eclampsia
• Marik and Varon. Chest 2007; 131:1949
– Sodium nitroprusside recommended for
• acute aortic dissection
• acute pulmonary edema with systolic
dysfunction
“riding the pride”
• Disadvantages of sodium nitroprusside
– Decrease cerebral blood flow and increases
intracranial pressure
– Can reduce regional blood flow in coronary artery
disease
– Risk of cyanide toxicity
• Use when other agents not effective
– Monitor thiocyanate levels
– Avoid in renal or hepatic dysfunction
Have we made progress?
• First described by Volhard and Fahr
– Die Brightsche Nierenkrankenheit: Klinik
Patholgie und Atlas. Berlin, Germany,
Springer 1914:247
• Keith, Wagener, Barker Am J Med Sci,
1939;197:332
– Mean survival of patients with htn and
grade 4 retinopathy was 10.5 mo with none
living beyond 5 years
We have made progress
•
•
•
•
Development of antihypertensive drugs
Increased diagnosis of hypertension
Increased ICU settings
Survival of patients with hypertensive
urgency and emergency is 18 years
compared to 21 years in those with
uncomplicated hypertension
Thank you!
Questions?
Messerli N Engl J Med 1995;3321038.
Messerli N Engl J Med 1995;3321038.