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Acute Complication
Chronic complication
- Abruptly
- Gradually
elevation of BP
- BP must be decreased
aggressively
of hypertension
- BP managed smartly
COMPLICATIONS OF HYPERTENSION
Acute Complication
Chronic complication
- Abruptly
- Gradually
elevation of BP
- BP must be decreased
aggressively
Hypertensive Crisis
of hypertension
- BP managed smartly
Hypertensive Emergency
- A relative increase in blood pressure from baseline
combined with Target Organ Dysfunction (TOD)
- No Defined Pressure Measurement
- Target Organ Damage is evident
- Also known as Hypertensive Crisis or Malignant
Hypertension
- The MOST Serious form of hypertension
Hypertensive Crises
Hypertensive Urgency
Markedly elevated BP
Without severe symptoms or
progressive target organ damage
BP should be reduced within hours
Oral agents
Hypertensive Emergency
Markedly elevated BP
With acute or progressing
target organ damage
BP should be reduced immediate
Parenteral agents
Definition :
Not determined by BP level, but rather the imminent
compromise vital organ function
Formerly when :
systolic
180 mm Hg
diastolic
110 mm Hg
(stage III ESH)
HYPERTENSIVE EMERGENCY
Accelerated-malignant hypertension with papilledema
Cerebrovascular conditions
Hypertensive brain infarction with severe hypertension
Intracerebral hemorrhage
Subarachnoid hemorrhage
Head trauma
Cardiac conditions
Acute aortic dissection
Acute left ventricular failure
Acute or impending myocardial infarction
After coronary bypass surgery
Renal conditions
Acute glomerulonephritis
Renovascular hypertension
Renal crises from collagen-vascular diseases
Severe hypertension after kidney transplantation
Typical symptoms
Typical signs
Comment
Weakness, altered
motor skill(s)
Focal neruological
deficit(s)
Hypertension not
usually treated
Suibarachnoid hemorrhage
Headache,
delerium
Altered mental
status, meningeal
signs
Lumbar puncture
typically shows
xanthochromia or red
blood cells
Headache, altered
sensorium or
motor skills
Lacerations,
ecchymoses,
altered mental
status
Computed
tomographic (CT)
scan is helpful to
determine extent of
intracranial injury
Hypertensive
encephalopathy
Headache, altered
mental status
papilledema
Usually a diagnosis of
exclusion
Cardiac ischemia/infraction
Chest discomfort,
nausea, vomiting
Abnormal EKG
(esp. T-wave
elevations)
Typical symptoms
Typical signs
Comment
Shortness of
breath
Rales auscultated
in chest
Aortic dissection
Chest discomfort
Widened aortic
knob on chest xray
Echocardiogram,
chest CT, or
angiogram usually
needed to confirm
Bleeding,
tenderness at
suture lines
Bleeding at suture
lines
Pheochromocytoma
Headache,
sweating,
palpitations
Pallor, flushing,
rare skin signs
(phakomatoses)
Phentolamine is very
useful
Drug related
catecholamine excess
state
Headache,
palpilations
tachycardia
History regarding
drug exposure is key
Preeclampsia / eclampsia
Headache, uterine
irritability
Edema,
hyperreflexia
New treatment
guidelines exist
Management of
Hypertensive Emergency (general)
Management of
Hypertensive Emergency (general)
1.
2.
3.
Dose
Onset
Duration of
Action
Sodium
nitroprusside
0.25-10 ugr/kg/min
Immediate
Nitroglycerin
5-500 ug/min
1-3 minutes
5-10 minutes
Labetolol HCl
5-10 minutes
3-6 minutes
Fenoldopan HCl
0.1-0.3 ug/kg/min
<5 minutes
30-60 minutes
Nicardipine HCl
5-15 mg/h
5-10 minutes
15-90 minutes
Esmolol HCl
250-500 ug/kg/min IV
bolus, then 50-100
ug/kg/min by infusion;
may repeat bolus after 5
minutes or increase
infusion to 300 ug/min
1-2 minutes
10-30 minutes
Continous Infus
Rate
Labetalol
Nicardipine
Esmolol
Enalapril
Hydralazine
Nipride
NTG
5 20 mg every 15
NA
250 ug/kg IVP loading dose
1,25-5 mg IVP every 6 h
5 20 mg IVP every 30
NA
NA
Hypertensive encephalopaty
Preeclampsia, eclampsia
Labetalol or nicardipine
Nicardipine or fenoldopam
Acute postoperative
hypertension
Nitroglycerin
Nitroglycerin is a potent venodilator and only at high doses affect
arterial tone. It reduces BP by reducing cardiac
ouput and preload which are undesirable effects in patient with
compromised cerebral and renal perfusion
Nifedipine
Nifedipine has been widely used via oral or sublingual
administration in the management of hypertensive
emergencies. This mode of administration has not been
approved by FDA and since JNC VI because it may cause
sudden uncontrolled and severe reductions in blood pressure
may precipitate cerebral, renal, and myocardial ischemia that
have been associated with fatal outcomes
Clonidine
Central alfa blocker, sedative effect
CI : in patient with Cerebrovascular
accident
Rebound effect
USE OF NICARDIPINE
Nicardipine :
. Dihydropiridine class of CCB
Reduce peripheral resistance --- blood pressure
water soluble, light insensitive, -- can be
parenteraly used (deference with nifedipine /
sodium nitroprusid)
Blocking
effect of CCB
Ca++
Myosin Kinase
Myosin Kinase
Actin-Myosin Interaction
Contraction
Ca++
Ca++
PRIMARY HEMODYNAMIC OF
NICARDIPINE EFFECT
peripheral vasodilatation
preserve or enhanced cardiac pump activity
------ improve tissue perfusion
fall in systemic blood pressure, maintain at desired
level
in comparison with sodium nitropruside equally
effective, but no cyanide toxic effect in long term use
not associated adverse effect on cardiovascular and
renal function
NICARDIPINE
CHARACTERISTIC
1.VASOSELECTIVITY
Nicardipine selectivity 30.000 x in smooth muscle cells
blood vessels compared with myocardium
2. Myocardial depression (-)
3. Negative inotropic (-)
4. Rapid and stable antihypertensive effects, reduce blood
pressure gradually < 25% in 2 hours, minimal effects to
heart rate
5. Increase blood flow in major organ : Renal, coroner,
cerebral
60
40
20
0
-10
Mean blood
pressure
Vertebral
artery
blood flow
Renal
blood flow
Coronary
blood flow
(Hypertensive patients, n = 9)
Baseline value
Mean blood pressure
103 11 mmHg
Vertebral artery
blood flow
183 65 mL/min
Renal artery
blood flow
563 29mL/min
Coronary artery
blood flow
121 42 mL/min
-20
(%)
(Shoji Suzuki, et al., The 20th Annual Scientific Meeting of the Japanese Society of Hypertension: 1997)
Coronary
Vasodilation
Suppression
of Cardiac
Contractility
Suppression
of SA Node
Suppression
of AV Node
Verapamil
(phenylalkylamine)
++++
++++
+++++
+++++
Diltiazem
(benzothiazepin)
+++
++
+++++
++++
Nicardipine
(dihydropyridine )
+++++
Stability of antihypertensive
effect better than Diltiazem
Nicardipine vs Nitrovasodilators
Drug
Nicardipine
(Perdipine IV)
Nitroprusside
Nitroglycerin
++++
++++
+++
Afterload Reduction
++++
++++
Preload Reduction
++
++++
+++
++++
+++
+/-
+/-
Tachycardia
++
++
++
+++
++++
++
+++
++++
Ease of Administration
Cyanide Toxicity
Pepine CJ. Intravenous nicardipine: cardiovascular effects and clinical relevance. Clin Ther.
1988;10:316-25.
SUMMARY