HYPERTENSIVE

CRISIS

Candra Wibowo
 DEFINITION

Abbreviations: ACCF/AHA, American College of Cardiology Foundation/American Heart Association; ACEP,

American College of Emergency Physicians;
ACOG, American College of Obstetrics and Gynecology; AHA/ASA, American Heart Association/American Stroke
Association; BP, blood
pressure; ESC/ESH, European Society of Cardiology/European Society of Hypertension; HR, heart rate; HTN,
hypertension; JNC 7, Seventh Joint
National Committee; JNC 8, Eighth Joint National Committee; MAP, mean arterial pressure; SBP, systolic blood
pressure; STEMI, ST-segment
elevation myocardial infarction; tPA, tissue plasminogen activator.
 DEFINITION
 Acute HTN with BP >180/120 mmHg :
 HTN Urgency : w/o TOD
 HTN Emergency : w/ TOD
 Brain : PRES, stroke, TIA, infarct, seizure
 Eye : retinopathy,hemorrhagie,choroidopathy, blind

 Heart : AMI, acute HF, acute pulmonary edema

 Aorta : acute aorta dissection

 Kidney : AKI

 Pregnancy : pre/eclamptia, HELLPs

 Hematology : microangiopathy hemolitic anemia

 EPIDEMIOLOGY

 Shorr et.al, 2006 – 2011 in 114 US hospital

 Prevalence 23.7%
 1.2 million admissions in hospital
 13,8% is acute HTN in the ED
 Acute HTN in the ED increased 25%

 Ina :
 Prevalenceof HTN 26,5% (Riskerdas 2013)
 Acute HTN : ?
 SIGNS SYMPTOMS
 Hypertensive Urgency:
 Canbe completely asymptomatic
 Some symptoms include:
 Severe headache
 Shortness of breath

 Nose bleeds

 Severe anxiety
 SIGNS SYMPTOMS
 Hypertensive Emergencies:
 Malignant Hypertension: End-organ damage :
eyes, kidneys, brain (hemorrhage/infarct)
affected
 Hypertensive encephalopathy: Cerebral
edema leading to neurological symptoms
 SIGNS SYMPTOMS
 Hypertensive Emergencies
 Symptoms:
 nausea, vomiting (cerebral edema)
 Chest Pain

 SOB

 Blurry vision

 Confusion

 Loss of consciousness
 SIGNS SYMPTOMS
 Signs:
 Retinal hemorrhages, exudates, or papilledema
 Renal involvement (malignant nephrosclerosis) with
AKI, proteinuria, hematuria
 Cerebral edema  seizures and coma
 Pulmonary Edema
 Myocardial Infarction
 Hemorrhagic Stroke, lacunar infarcts
"There is some truth in the saying that the
greatest danger to a man with a high blood
pressure lies in its discovery, because ‘then
some fool is certain to try and reduce it,’”
 MANAGEMENT
 Hypertensive Urgency:
 Goal: Reduce BP to <160/100 over several
hours to day
 Elderly at high risk of ischemia from rapid
reduction of BP, therefore slower reduction in BP in
this patient population
 Previously treated hypertension:
 Increase dose of existing med or add another med
 Reinstitution of med in non-compliant patients
 MANAGEMENT
 Hypertensive Urgency:
 Previously untreated hypertension:
 Slow reduction of BP (one to two days):
Amlodipine, Metoprolol XL, lisinopril (po anti-
hypertensives usually enough), Nifedipine OROS
 Experts recommend: Initiate two agents or a

combination agent (one being a thiazide diuretic)

 Rationale: Most patients with BP >20/10 above goal will
require two agents to control their BP
 MANAGEMENT
 Hypertensive Emergency:
 Goal: Lower DBP to approximately 100-110 mmHg over 2-6
hours; max initial fall not to exceed 25%
 More aggressive decrease can lead to ischemic stroke and myocardial
ischemia
 1st h : not to exceed 25%  2-6 h later 160/100-110  gradual
normalization in 24-48 h
 Iffocal neurological sx presentobtain MRI to r/o acute
stroke (rapid BP correction contraindicated)
 Parenteral antihypertensives (IV Drip) recommended over
oral agents in hypertensive emergency
MANAGEMENT
 MANAGEMENT
 RECOMMENDED parenteral AHA(IV drip) for
HTN Emergencies and admission to
 HCU/ED/HD-hospitalized
 Pts with resp.failure have to admission in ICU
 Pts with cardial disorder have to admission in ICCU
 Nitroprusside (cautious about cyanide toxicity),
Nicardipine, and Labetalol, Isosorbid.
 Once BP controlled, switch to OR overlap with
oral AHA and follow-up closely
MANAGEMENT
MANAGEMENT
 GOAL OF MANAGEMENT
 Manage CVD risk factors, cause of HTN and TOD

 Reduce CVD-Renal morbidity and mortality

 Treat to BP <140/90 mmHg for pts < 60 yo and

<150/90 mmHg for pts ≥60 yo

 Treat to BP <140/90 mmHg in patients >18 yo with

DM or CKD
 HOW DO I DO?
Evaluation pts with documented HTN has 3 objectives:

1.Assess lifestyle and identify other CV risk factors or

concomitant disorders that affects prognosis and guides
treatment.

2.Reveal identifiable causes of high BP.

3.Assess
the presence or absence of target organ damage
and CVD.
 CVD RISK FACTORS
 Hypertension
 Cigarette smoking
 Obesity* (BMI >30 kg/m2)
 Physical inactivity
 Dyslipidemia*
 Diabetes mellitus*
 Microalbuminuria or eGFR <60 ml/min
 Age (older than 55 for men, 65 for women)
 Family history of premature CVD
(men age <55 or women age <65)
IDENTIFIABLE CAUSES OF HTN
 Sleep apnea
 Drug-induced or related causes
 Chronic kidney disease
 Primary aldosteronism
 Renovascular disease
 Chronic steroid therapy and Cushing’s syndrome
 Pheochromocytoma
 Coarctation of the aorta
 Thyroid or parathyroid disease
LABORATORY TESTS
• Hematology routine, urinalysis
• Ureum, creatinine, uric acid serum
• Na, K, Cl, Ca, Mg, P anorganic
• Blood glucose (fasting, pp, A1c)
• Lipid profiles
• CXR
• ECG, Echocardiogram
• ACR
• USG, CT scan abdomen
• Funduscopy
• Brain CT Scan/MRI
 VIGNETTE
 65 y/o M with past medical history of Type II DM (on oral
hypoglycemics), presenting with headache, chest pain
and shortness of breath that developed after lunch the
day of admission; non-exertional; no alleviating factors.
 Physical Exam:
 Vitals: 37.3, 195/125, 92, 24, 93% on RA
 HEENT: Decreased A:V on retinal exam (<25%)
 Heart: S4 heard on exam, no m/r/g
 Lungs: mild resp distress, otherwise clear to auscultation

What’s the diagnosis and next best step in management?

 SUMMARY
 Hypertensive Crisis are common
 Differentiate Hypertensive Urgency from
Emergency on the basis of end-organ damage
 Treat HTN urgency with oral AHA &
PARENTERAL AHA for HTN emergencies
 25% reduction in diastolic BP over 2-6 hours for
hypertensive emergencies
 Start Oral AHA and follow-up closely.