Download Primary hypertension

Management of severe
asymptomatic hypertension
(hypertensive urgencies)
Shiva Seyrafian
IKRC- IUMS
16-10-2014 __ 24-7-93
 Definition:
systolic blood pressure ≥180 mmHg
and/or diastolic blood pressure ≥120 mmHg)
 Can produce a variety of acute, lifethreatening complications( hypertensive
emergencies).
 Relatively asymptomatic (other than perhaps
headache) and have no acute signs of endorgan damage (hypertensive urgency).
Accelerated-malignant
hypertension with papilloedema
Cerebrovascular
Renal
Acute glomerulonephritis
Hypertensive encephalopathy
Renal crises from collagen
vascular diseases
Atherothrombotic brain infarction with
severe hypertension
Severe hypertension after
kidney transplantation
Intracerebral hemorrhage
Subarachnoid hemorrhage
Cardiac
Acute aortic dissection
Acute left ventricular failure
Acute or impending myocardial infarction
After coronary bypass surgery
Excessive circulating
catecholamines
Pheochromocytoma crisis
Eclampsia
Surgical
Food or drug interactions with
monoamine-oxidase inhibitors
Severe hypertension in
patients requiring immediate
surgery
Sympathomimetic drug use
(cocaine)
Postoperative hypertension
Rebound hypertension after
sudden cessation of
antihypertensive drugs
Postoperative bleeding from
vascular suture lines
Severe body burns
Severe epistaxis
Most commonly in patients who are:
1. Nonadherent with their chronic
antihypertensive regimen or those who are
nonadherent with a low sodium diet.
2. Medication-adherent patients following
ingestion of large quantities of salt.
 Quickly
confirmed with a repeat measurement
Blood pressure reduction goals:
 In the absence of symptoms, a more gradual
reduction in pressure.
 Sublingual nifedipine is now contraindicated
 Blood pressure may decline spontaneously
simply with rest in a quiet room.
 Cerebral or myocardial ischemia or infarction
can be induced by aggressive antihypertensive
therapy.
 In
the absence of signs of acute end-organ
damage, the goal of management is to reduce
the blood pressure to ≤160/100 mmHg over
several hours to days.
 An elderly patient may be at particularly high
risk for cerebral or myocardial ischemia from
excessively rapid reduction of blood pressure.
 This patient who often have a high pulse
pressure (eg, diastolic blood pressure <90
mmHg with systolic blood pressure ≥180
mmHg), the initial goal blood pressure
of ≤160/100 mHg, achieved even slower.
 All
patients should be provided a quiet room
to rest, fall in BP of 10 to 20 mmHg or more.
If treated previously:
 Increase the dose of existing antihypertensive
medications, or add another agent.
 Reinstitution of medications in non-adherent
patients.
 Addition of a diuretic, and reinforcement of
dietary sodium restriction, in patients who
have worsening hypertension due to high
sodium intake.
If Untreated hypertension:
 Relatively rapid initial blood pressure
reduction (over several hours):
oral furosemide (if the patient is not volume
depleted) at a dose of 20 mg (or higher if the
renal function is not normal), a small dose of
oral clonidine (0.2 mg); or a small dose of
oral captopril (6.25 or 12.5 mg).
 A low dose of a calcium channel blocker, beta
blocker or ACE inhibitor, but not a diuretic
alone. Oral nifedipine XL 30 mg once daily (of
the long-acting preparation),
oral metoprolol XL 50 mg daily, or ramipril 10
mg once daily.
Monitoring and follow-up:
 managed in the emergency room, since
exclusion of acute end-organ damage
 laboratory testing,
 may require administration of medications
 several hours of observation.
 in the physician's office if the evaluation and
management can be carried out.
 observed for a few hours,
 sent home with close follow-up over the
subsequent days
 evaluation
for
symptoms
related
to
hypertension or hypotension.
 Monitoring
and close phone follow-up.
 does not have a physician, follow-up may need
to be in the emergency room.
 Over the course of weeks to months, the dose
and selection of medications is modified to
achieve desired goals usually with longer acting
agents.
 Hypertension
accounts for an estimated 54
percent of all strokes and 47 percent of all
ischemic heart disease events globally.
 Hypertension: the most important risk factor
for premature cardiovascular disease,
 More common than cigarette smoking,
dyslipidemia, and diabetes.
Major risk factors
Target organ damage
Hypertension
Heart disease
Cigarette smoking
Left ventricular hypertrophy
Obesity (BMI ≥30 kg/m2)
Angina or prior myocardial
infarction
Physical inactivity
Prior coronary revascularization
Dyslipidemia
Heart failure
Diabetes mellitus
Stroke or transient ischemic
attack
Microalbuminuria or estimated GFR
<60 mL/min
Chronic kidney disease
Age >55 years for men, >65 years in
women
Peripheral arterial disease
Family history of premature coronary
disease
Retinopathy
Men - <55 years
Women - <65 years
The JNC 7 report. JAMA 2003; 289:2560.
Shiva Seyrafian
IKRC- IUMS
16-10-2014 __ 24-7-93
 Reduction
of sodium intake,
 Moderation of alcohol,
 weight loss in the overweight or obese,
 Diet rich in fruits, vegetables, legumes,
 Low-fat dairy products and low in snacks,
sweets, meat, and saturated fat.
Individual dietary factors:
 Increased intakes of potassium, calcium, fish
oil, fiber.
 Milk-based and vegetable-based protein,
folate, flavonoids (cocoa, tea).
 Cessation
of smoking
 Institution
of an aerobic exercise regimen.
 In
prehypertension or stage 1 hypertension,
lifestyle changes may control the blood
pressure adequately.
 In higher BP or additional risk (eg, diabetes
or chronic kidney disease), drug therapies
should first be used to more quickly and
effectively control the blood pressure.
 Once blood pressure is well controlled,
lifestyle changes should be strongly advised.
If these are successfully achieved, reduction
of medications may be possible.
DASH trial (Dietary Approaches to Stop
Hypertension ):
 A combination diet rich in fruits, vegetables,
legumes, and low-fat dairy products and low in
snacks, sweets, meats, and saturated and total
fat (this combination diet is called the “DASH
diet”).
 The DASH diet is comprised of four-five servings
of fruit, four-five servings of vegetables, twothree servings of low-fat dairy per day, and <25
percent fat.
lower risk of developing hypertension (14 years
F/U):
 Body mass index of less than 25kg/m2,
 A daily mean of 30 minutes of vigorous
exercise,
 Adherence to the DASH diet,
 Modest alcohol intake,
 Infrequent use of nonnarcotic analgesics,
 Intake of 400microg/d or more of folate .
The presence of all six factors: a marked
decrease in the risk for hypertension.
Perioperative management
of hypertension
SHIVA SEYRAFIAN
IUMS, IKRC
PERIOPERATIVE MANAGEMENT OF
HYPERTENSION
 Of
76 patients who died of a cardiovascular
cause within 30 days of elective surgery, a
preoperative history of hypertension was
four times more likely than among 76
matched controls.
 Induction
of anesthesia: systolic blood
pressure can increase by 90 mmHg and heart
rate by 40 beats per minute.
 period of anesthesia: The mean arterial
pressure tends to fall, intraoperative
hypotension.
 Immediate postoperative: Blood pressure
and heart rate slowly increase.
 Diastolic
dysfunction from left ventricular
hypertrophy, systolic dysfunction leading to
congestive heart failure, renal impairment,
and cerebrovascular and coronary occlusive
disease.
 Mild to moderate hypertension: (diastolic
pressure less than 110 mmHg) do not appear
to be at increased operative risk
Six independent predictors of major cardiac complications
High-risk type of surgery (examples include vascular
surgery and any open intraperitoneal or intrathoracic
procedures)
History of ischemic heart disease (history of MI or a
positive exercise test, current complaint of chest pain
considered to be secondary to myocardial ischemia, use of
nitrate therapy, or ECG with pathological Q waves; do not
count prior coronary revascularization procedure unless one
of the other criteria for ischemic heart disease is present)
History of HF
History of cerebrovascular disease
Diabetes mellitus requiring treatment with insulin
Preoperative serum creatinine >2.0 mg/dL (177 µmol/L)
Abruptly discontinuing some medications (eg,
beta blockers, clonidine ) may be associated
with significant rebound hypertension.
 Most antihypertensive agents can be continued
until the time of surgery, taken with small sips of
water on the morning of surgery.
 ACEI,ARB: withhold them on the morning of
surgery in patients who are taking them for
congestive heart failure in whom the baseline
blood pressure is low, OR in renal failure
patients to avoid significant hypotension during
the induction of anesthesia.

 Calcium
channel blockers : increased
incidence of postoperative bleeding,
probably due to inhibition of platelet
aggregation,
 Withdrawal syndromes:
clonidine, methyldopa, guanfacine and the
beta blockers are associated with acute
withdrawal syndromes that can lead to
adverse perioperative events.
These drugs should not be abruptly stopped
perioperatively.
 Centrally
acting sympatholytic drugs:
Rebound hypertension usually occurs after
abrupt cessation of fairly large oral doses (eg,
greater than 0.8 mg/day), but has also been
noted with transdermal clonidine.
 Beta blockers: reduce intraoperative
myocardial ischemia, recommended that
patients with one or more risk factor for CHD
be given beta blockers perioperatively.
Hypertension usually begins within 30 minutes
of the completion of surgery and lasts
approximately two hours.
 History of hypertension preoperatively
 Pain
 Excitement on emergence from anesthesia
 Hypercarbia
 Type of surgery
A
marked rise in blood pressure following
surgery should be treated immediately.
 Remedial causes: pain, agitation,
hypercarbia, hypoxia, hypervolemia, and
bladder distention
 Chronic antihypertensive therapy should
resume with their usual medications.
 Therapy should be considered for patients
with a sustained systolic blood pressure
above 180 mmHg or diastolic blood pressure
greater than 110 mmHg, once remedial
causes have been excluded or treated.
 Patients
taking diuretics may be given
parenteralfurosemide or bumetanide .
 Patients taking beta blockers may be given
parenteral propranolol , labetalol ,
or esmolol .
 Patients taking an ACE inhibitor may be given
parenteral enalaprilat .
 Patients taking centrally acting agents can be
given a clonidine patch.
 Patients taking calcium channel blockers can
be given intravenous nicardipine .
Uptodate® Oct 2013
 The
ideal circumstance is to normalize blood
pressure (eg, to less than 140/90 mmHg) for
several months prior to elective surgery.
 It is not necessary to postpone elective
procedures in patients with a blood pressure
below 170/110 mmHg.
 Elective surgery should be postponed in
patients with blood pressures
above 170/110 mmHg.
 Such patients who require urgent surgery
should be treated with a parenteral drug
acutely.
 Patients
who
are
taking
chronic
antihypertensive
medications
should
continue taking their medication until the
time of surgery.
 The drug can be administered with a sip of
water on the morning of surgery and
resumed postoperatively as needed.
 Alternative
parenteral agents can be
prescribed for patients who are unable to
resume oral medications.
 In
particular, beta blockers and centrally
acting agents such as clonidine should not be
stopped acutely.
If necessary,
 Intravenous propranolol or labetalol can be
administered to patients taking beta blockers
 Or transdermal clonidine can be administered
to patients taking clonidine.
 Remedial
causes
of
postoperative
hypertension such as pain, agitation,
hypercarbia, hypoxia, hypervolemia, and
bladder distention should be excluded or
treated.
 Once this has been done, therapy should
be considered for patients with a
persistent systolic blood pressure above
180 mmHg or a diastolic blood pressure
above 110 mmHg.
 Before
age 50, women have a lower
prevalence of hypertension than men, but
after age 55, they have a higher prevalence.
 The prevalence rises with age, approaching
80 to 90 percent in women over the age of
70.
1. Incidence of coronary heart disease(1/2).
2. Left ventricular hypertrophy is less
common.
3. At equal degrees of hypertension, women
were at lower risk than men in all age
groups from 40 to 70.
 Body
mass index of less than 25 kg/m 2
 A daily mean of 30 minutes of vigorous
exercise
 Adherence to the DASH diet, modest alcohol
intake
 Infrequent use of nonnarcotic analgesics
 Folate intake of 400 microg/day or more
Women and men respond similarly to
antihypertensive therapy.
 All women should follow a health lifestyle and
periodically monitored for rises in blood pressure
and end-organ damage.
 Other cardiovascular risk factors (smoking,
hypercholesterolemia, and diabetes mellitus): an
important determinant of the need for
antihypertensive medications.
 The presence of left ventricular hypertrophy
(LVH) by echocardiography carries an increased
risk of cardiac events in women that is
equivalent to that in men.
