Hypertensive Crises

Introduction• Blood pressure is the force exerted by the blood against the walls of blood vessels, and the

magnitude of this force depends on the cardiac output and the resistance of the blood vessels.

• Normal blood pressure is below 120 systolic and below 80 diastolic

• Hypertensive crisis (a medical emergency) is when blood pressure is above 180 systolic or above 110 diastolic.

▪ Prehypertension is 120-139 systolic or 80-89 diastolic.

▪ Stage 1 high blood pressure (hypertension) is 140-159 systolic or 90-99 diastolic

▪ Stage 2 high blood pressure (hypertension) is 160 or higher systolic or 100 or higher diastolic above 180

Introduction▪ Primary hypertension has no

identifiable cause.

▪ Secondary hypertension has identifiable cause.

Source : American Heart Association.

Classification Systolic Pressure(mmHg)

Diastolic Pressure(mmHg)

Normal 90 - 119 60 - 79Prehypertension

120 - 139 81 - 89

Stage1 140 -159 90 - 99Stage2 ≥160 ≥100Secondary Hypertension

≥140 <90

Causes Of Hypertension

• The disease burden of high blood pressure is a growing

problem worldwide . The increases are blamed on lifestyle

factors, includes,

• Physical inactivity

• A salt-rich diet through processed and fatty foods.

• Alcohol and tobacco use.

Risk Factors

•Age - everyone is at greater risk of high blood pressure as they get older. Prevalence of

hypertension is higher in people over 60 years of age.

•Race - African-American adults are at higher risk than white or Hispanic American adults

•Size - being overweight or obese is a key risk factor

•Sex - men and women have different risk profiles. While they have the same lifetime

risks, men are more prone at younger ages while women are more prone at older ages

•Lifestyle - as mentioned above, this is to blame for growing rates of hypertension, from

greater uptakes of dietary salt, excessive alcohol, low dietary potassium, and physical

inactivity.

Specific Causes

• Primary hypertension is unlikely to have a specific cause but multiple factors, including blood plasma volume and activity of the renin-angiotensin system, the hormonal regulator of blood volume and pressure - and primary hypertension is affected by environmental factors, including the lifestyle-related ones above.

• Secondary hypertension has specific causes - that is, it is secondary to another problem. One example, thought to be the most common, is primary aldosteronism, a hormone disorder causing an imbalance between potassium and sodium levels and so high blood pressure.

• Other secondary hypertensions are caused by:• Kidney diseases.• Pheochromocytoma (a cancer)• Cushing syndrome (which can be caused by use of corticosteroid drugs)• Congenital adrenal hyperplasia (disorder of the adrenal glands, which secrete the hormone cortisol)• Hyperthyroidism (overactive thyroid gland).

Types of Hypertension

Malignant HypertensionThis, the most severe form of hypertension.•It rapidly leads to organ damage. Unless properly treated.•it is fatal within five years for the majority of patients.•Death usually comes from heart failure, kidney damage or brain haemorrhage.•Malignant hypertension is becoming relatively rare, and is not caused by cancer or malignancy.

Isolated Systolic Hypertension•systolic blood pressure above 160 mm Hg, and the diastolic below 90 mm Hg.•This may occur in older people, and results from the age-related stiffening of the arteries.•The loss of easticity in arteries, like the aorta, is mostly due to arteriosclerosis.•The Western lifestyle and diet is believed to be the root cause.

Types of hypertension

White coat hypertension•Also called anxiety-induced hypertension, it means blood pressure is only high when tested by a health professional.•If confirmed, with repeat readings outside of the clinical setting, or a 24-hour monitoring device, it does not need to be treated.

Resistant Hypertension•If blood pressure cannot be reduced to below 140/90 mmHg, despite a triple-drug regime, resistant hypertension is considered.

Renal Hypertension•Condition which consists of high blood pressure caused by the kidneys' hormonal response to narrowing of the arteries supplying the kidneys.

Melignant Hypertension

Renal Hypertension

White-Coat Hypertension

Symptoms

• An enlarged or weakened heart, to a point where it may fail to pump enough blood (

heart failure)

• Aneurysm - an abnormal bulge in the wall of an artery

• Blood vessel narrowing - in the kidneys, leading to possible kidney failure; also in

the heart, brain and legs, leading to potential heart attack, stroke or amputation,

respectively

• Blood vessels in the eyes my rupture or bleed, leading to vision problems or

blindness (hypertensive retinopathies, which can be classified by worsening grades

one through four).

Blood PressureDiagnosis

Blood Pressure Is measured by sphygmomanometer.

Complications

High Blood Pressure and AtherosclerosisOne of the most serious health problems related to untreated high blood pressure, atherosclerosis contributes to coronary artery disease. Stroke and HypertensionA stroke occurs when blood flow to an area in the brain is cut off and people who have hypertension are four to six times more likely to have a stroke. Hypertension and Heart DiseaseHeart disease is the No. 1 cause of death associated with hypertension. Kidney Disease and HypertensionHypertension is a major cause of kidney disease and kidney failure

Complications

High Blood Pressure and Eye DiseaseUntreated hypertension can affect your eyesight, causing damage to the blood vessels in the retina. Known as hypertensive retinopathy, learn more about this condition and its prevention.High Blood Pressure and DiabetesHypertension is a risk factor for the development and worsening of many diabetes complications, and likewise having diabetes increases your risk of developing high blood pressure.Preeclampsia: High Blood Pressure and PregnancyHigh blood pressure can be a sign of preeclampsia, a pregnancy-related problem that can become life-threatening.

Complications

Metabolic Syndrome and High Blood PressureMetabolic syndrome is a group of health problems which include too much fat around the waist, elevated blood pressure, elevated blood sugar, and more -- all increasing your risk of heart attack, stroke, and diabetes. Find out more about metabolic syndrome here.

High Blood Pressure and Erectile DysfunctionHigh blood pressure by itself can lead to erectile dysfunction. But some drugs for treating high blood pressure can actually be the cause as well. Find out more about why high blood pressure is a major cause of erection problems.

Consequences

• Heart attack

• Heart failure

• Kidney damage/failure

• Transient ischemic attack

• Stroke – due to rupture of brain aneurysms.

• Progressive vision loss

• Pulmonary edema – fluid buildup on lungs

• Convulsions

• Loss of consciousness

First Aid Management

•Reassure the patient and call for medical help.

•Make him/her to lie on the bed and rest adequately.

•Try to comfort and reduce anxiety, as anxiety alone can increase blood pressure.

•Keep monitoring breathing, pulse rate, blood pressure, level of consciousness and for any

other dangerous signs ( e.g. paralysis of body in stroke, convulsions etc.)

•Do not allow them to walk about, accompany the patient if it is really needed. Watch out

for falls.

•If the patient is vomiting or having seizures, turn to lateral side to prevent aspiration.

First Aid Management

• If patient complains of difficulty in breathing, prop him/her up using pillows behind upper

back.

• Do not give anything by mouth to eat/drink if there is suspicion of stroke.

• Specially avoid caffeine or alcohol containing beverages.

• Meanwhile look for possible cause for hypertensive crisis. If the patient is a known

hypertensive and missed medication, consult doctor over the phone and give a dose of

medications if instructed.

• If breathing is unsatisfactory go for basic life support. Mouth to mouth breathing and CPR

if needed.

Management In Emergency

PharmacotherapyOptimal pharmacotherapy is dependent upon the specific organ. In patients presenting with hypertensive emergencies, antihypertensive drug therapy has been shown to be effective in acutely decreasing blood pressure.•Sodium nitroprusside is a commonly used medication. It is a short-acting agent, and the BP response can be titrated from minute to minute.•The potential exists for thiocynate and cyanide toxicity with prolonged use or if the patient has renal or hepatic failure.•Labetalol, an alpha- and beta-blocking agent is particularly preferred in patients with acute dissection and patients with end-stage renal disease. Boluses of 10-20 mg may be administered, or the drug may be infused at 1 mg/min until the desired BP is obtained.

Management In Emergency

• Fenoldopam, a peripheral dopamine-1-receptor agonist is given as initial IV dose of 0.1 µg/kg/min titrated every 15 minutes.

• Clevidipine, a dihydropyridine calcium channel blocker, is administered intravenously for rapid and precise BP reduction.[10] It is rapidly metabolized in the blood and tissues and does not accumulate in the body.

As the BP approaches its goal, increase the clevidipine dose by less than double, and lengthen the time between dose adjustments to every 5-10 minutes. An approximately 1-2 mg/h increase produces an additional 2-4 mm Hg decrease in SBP.

Management In Emergency

Neurologic Emergencies

•Rapid BP reduction is indicated in neurologic emergencies, such as hypertensive encephalopathy, acute ischemic stroke, acute intracerebral hemorrhage, and subarachnoid hemorrhage.•In hypertensive,Labetalol, nicardipine, esmolol are the preferred medications; nitroprusside and hydralazine should be avoided.•For acute ischemic stroke, the preferred medications are labetalol and nicardipine. Withhold antihypertensive medications unless the SBP is >220 mm Hg or the DBP is >120 mm Hg.•For acute intracerebral hemorrhage, the preferred medications are labetalol, nicardipine, and esmolol; avoid nitroprusside and hydralazine

Cardiovascular emergenciesRapid BP reduction is also indicated in cardiovascular emergencies, such as aortic dissection, acute coronary syndrome, and acute heart failure.•In aortic dissection, the preferred medications are labetalol, nicardipine, nitroprusside (with beta-blocker), esmolol, and morphine sulfate. Maintain the SBP at < 110 mm Hg, unless signs of end-organ hypoperfusion are present.•For acute coronary syndrome, beta blockers and nitroglycerin are the preferred drugs. Treatment is indicated if the SBP is >160 mm Hg and/or the DBP is >100 mm Hg. Reduce the BP by 20-30% of baseline. Note that thrombolytics are contraindicated if the BP is >185/100 mm Hg.•In acute heart failure, the preferred medications are IV nitroglycerin or sublingual nitroglycerin and IV enalaprilat.

Management In Emergency

Management In Emergency

Cocaine toxicity/pheochromocytomaDiazepam, phentolamine, and nitroglycerin/nitroprusside are the preferred drugs. However, avoid beta-adrenergic antagonists before administering phentolamine.Alpha-adrenergic antagonists (phentolamine) are the preferred agents for cocaine-associated acute coronary syndromes.

Preeclampsia/eclampsiaHydralazine, labetalol, and nifedipine are preferred medication. Avoid - Nitroprusside, angiotensin-converting enzyme inhibitors, esmolol. In women with eclampsia or preeclampsia, the SBP should be < 160 mm Hg and the DBP should be < 110 mm Hg. If the platelet count is less than 100,000 cells mm3, the BP should be maintained below 150/100 mm Hg. Patients with eclampsia or preeclampsia should also be treated with IV magnesium sulfate to avoid seizures.

Management In Emergency

Perioperative hypertensionNitroprusside, nitroglycerin, and esmolol are preferred. Target the perioperative BP to within 20% of the patient's baseline pressure, except if there is the potential for life-threatening arterial bleeding. Perioperative beta blockers are the first choice in patients undergoing vascular procedures or in patients with an intermediate or high risk of cardiac complications.

Management Of Hypertensive Emergencies

Agent Mechanism of Action

Doses Onset Duration of Action

Adverse Effects/Precautions

Sodiumnitroprusside

Nitric oxide compound,direct arterialand venous vasodilator

0.25–10 μg/kg/min IVinfusion

Immediate 2–3 min afterinfusion

Nausea, vomiting,Thiocyanate and cyanide intoxicationIncreased intracranial pressureMethemoglobinemiaDelivery sets must be light resistant

Fenoldopammesylate

Dopamine-1 receptoragonist

0.1–0.3 μg/kg/min IVinfusion

< 5 min 30 min Headache, flushing, tachycardiaLocal phlebitisMild tolerance after prolonged infusionMay reduce serum potassiumECG changes: nonspecific T-wavechanges/ventricular extra systoles

Management Of Hypertensive Emergencies

Agent Mechanism of Action

Doses Onset Duration of Action

Adverse Effects/Precautions

Nitroglycerin Nitric oxide compound;direct arterialand venodilator(mainly venous)

5–100 μg/min IVinfusion

2–5 min 5–10 min Headache, tachycardia, flushingMethemoglobinemiaRequires special delivery system due todrug binding to tubing

Enalaprilat ACE inhibitor 0.625–2.5 mg every6 hr IV

Within 30min

12–24 hr Acute renal failure in patients withbilateral renal artery stenosisProlonged half-life

Management Of Hypertensive Emergencies

Agent Mechanism of Action

Doses Onset Duration of Action

Adverse Effects/Precautions

Hydralazine Direct vasodilation ofarterioles with littleeffect on veins

5–20 mg IV bolus or10–40 mg IM; repeatevery 4–6 hr

10 min IV20–30 min IM

1–4 hr IV Tachycardia, flushing, headacheSodium and water retentionIncreased intracranial pressureAggravation of angina

Nicardipine Calcium channelblocker

5–15 mg/hr IV infusion

1–5 min 15–30 min, but mayexceed 4 hr afterprolonged infusion

Tachycardia, headache, flushingLocal phlebitisAggravation of angina

Management Of Hypertensive Emergencies

Agent Mechanism Of Action

Doses Onset Duration of Action

Adverse Effects/Precautions

Esmolol β-Adrenergic blocker

500 μg/kg bolus injectionIV or 50–100 μg/kg/min byinfusion. May repeatbolus after 5 min orincrease infusion rateto 300 μg/kg/min

1–2 min 10–30 min Hypotension, nauseaAsthmaFirst-degree atrioventricular blockHeart failure

Labetalol α-, β-Adrenergicblocker

20–80 mg IV bolusevery 10 min; 0.5–2.0 mg/min IV infusion

5–10 min 3–6 hr BronchoconstrictionHeart blockVomiting, scalp tinglingHeart failure exacerbation

Management Of Hypertensive Emergencies

Agent Mechanism Of Action

Doses Onset Duration of Action

Adverse Effects/Precautions

Phentolamine α-Adrenergic receptorblocker

5–15 mg IV bolus 1–2 min 10–30 min Tachycardia, flushing, headache

ReferencesR1: http://www.medicalnewstoday.com/articles/150109.phpR2: http://www.webmd.com/hypertension-high-blood- pressure/guide/hypertension-symptoms-types

R3: http://www.health24.com/Medical/Hypertension/Types-of-blood- R4; http://firstaidsaskatoon.ca/first-aid-management-of-hypertensive-crisis/

R5: http://emedicine.medscape.com/article/1952052- overview#a2

R5: http://www.turner-white.com/pdf/hp_mar07_hypertensive.pdf