Download Hypertensive Emergencies by Leben Tefera and Andrew Harris

HYPERTENSIVE
EMERGENCIES
Leben Tefera, MD
Andrew Harris, MD
PGY2
August 3, 2016
Objectives
• Define emergency vs urgency
• Overview of HTN urgency
• Brief review of classes of anti-hypertensives
• Review common scenarios and identify appropriate
treatments
• Common issues with diuretics
Take-home: sneak preview
 Hypertensive Urgency  ORAL MEDS!!
◦ Rapid overcorrection can be very harmful
◦ Start low, go slow
 IV Hydralazine  BAD
◦ Severe, unpredictable hypotension + reflex tachycardia
 Labetalol  GOOD
◦ Except in acute decompensated HF
 Dilt gtt  NEVER in acute HFrEF
 Always ask: “What is the EF?”
Hypertensive Medications
• Fast Acting PO Formulations
• Hydralazine (25 mg)
• Nifedipine (30 mg)
• Isosorbide dinitrate (10 mg)
• Clonidine (0.1 mg)
• Labetolol (200-400 mg)
• IV Options on the Floor
• Hydralazine 5 mg
• Labetolol 10-20 mg
Problems with inpatient HTN
 Difficult to determine true hypertensive emergency
 Nurses keep paging me!!! It’s not an emergency!!!
AAAARGH!
 No accepted guidelines for management
Cochrane Review 2008:
Insufficient evidence to
support a single drug as
being more effective in
HTN emergency
Emergency vs Urgency
• What differentiates emergency from urgency?
Hypertensive Urgency
• Best accepted definition
• Systolic BP > 180 OR
• Diastolic BP > 120
• No evidence of end organ damage (mild headache does not count!)
• Most commonly due to poorly controlled chronic
hypertension
• NOT an indication for hospital admission
• DO NOT use IV anti-hypertensives
Hypertensive Urgency
 If admitted for other reasons, slowly lower BP with oral
medications over days
◦ No good evidence to guide timeframe or choice of medication
◦ In general, lower systolic/MAP NMT 25% or to 160/100
 Rapid correction below auto-regulatory range can cause
ischemia
◦ Cerebral (stroke)
◦ Coronary (MI)
◦ Renal (AKI)
 Reasons to potentially lower over hours:
◦ Known aortic or cerebral aneurysm
◦ High risk of MI (known CAD, DMII)
Clinical Scenario #1
• 65 yo F with HTN admitted for PNA.
• You are on nightfloat. Nurse calls, BP is 180/110. Your
signout says “NTD”
• What should you do?
Next Steps:
• Stall:
• What are the full vitals?
• Is she symptomatic?
• Can you recheck a manual BP?
• What size cuff did you use?
• Is she in pain?
• Did she get her regularly scheduled meds?
• I’m at a code, can I call you back?
• OK, it’s still elevated, now what?
Hypertensive Urgency
• Remember: start low, go slow
• Fully titrate before adding a second med
• Titrate to effect (or side effect)
Hypertensive Urgency
 Good medications
◦ Patient’s previous meds (nonadherence)
◦ Amlodipine
◦ ACE/ARB (check renal panel as outpt)
◦ Labetalol (expensive outpatient med)
◦ Diuretics
 Bad Medications
◦ Anything IV
◦ Hydralazine, nifedipine (most of the time)
 Clonidine
◦ It works, but watch out…..
◦ Severe rebound HTN, must be tapered
Hypertensive Emergency
 This is an indication for ICU admission!
 Types of end organ damage
◦ Encephalopathy:
 Headache, altered mental status, visual disturbance
 Fundoscopic exam: look for papilledema
◦ Aortic or carotid dissection
◦ MI/ACS/chest pain
◦ Pulmonary edema with respiratory failure
◦ Renal Failure
◦ Pregnancy – ECLAMPSIA/HELLP
◦ Microangiopathic Hemolytic Anemia
Hypertensive Emergency
• BP Control
• Mean arterial pressure should be reduced
gradually by about 10 to 20 percent in the
first hour
• Further 5 to 15 percent over the next 23
hours
Classes of Anti-Hypertensives
• Beta Blockers
• Alpha Blockers
• ACE-I/ARBs
• Calcium Channel Blockers
• Vasodilators
• Diuretics
Beta Blockers
• Labetalol: Alpha 1 + non-selective Beta
• Onset (IV): 2.5mins
• Peak Effect: 15mins
• Decrease HR w/o decreasing CO
• Good in most settings (except HFrEF)
• Esmolol: short acting Beta 1 antagonist
• Very quick onset, primarily rate control  better with a vasodilator
• Comes with lots of fluid
• IV Metoprolol:
• Rate control, not anti-hypertensive
Calcium Channel Blockers
 Dihydropyridine
◦ Nicardipine
 SE: reflex tachycardia
◦ Clevidipine (mostly used in ED)
 Ultra-short onset (1 minute)
◦ Nifedipine
 AVOID – increased mortality
 Non-dihydropyridine – negative inotropes
◦ Diltiazem – bad news in HFrEF
Vasodilators
 Nitroglycerin
◦ Primarily venodilator, reduces preload
◦ Arterial vasodilator at high doses, modest afterload reduction
 Nitroprusside
◦ Arterial and venous dilator
◦ Cyanide toxicity (photodegradation) –
 Inhibits oxidative phosph
 Hydralazine - BAD
◦ Prolonged, unpredictable drops in blood pressure
◦ Effect lasts up to 10 hours, best avoided
Other
• ACE-Inhibitors
• Enalaprilat (only IV form)
• Diuretics (more to come shortly)
• Furosemide
• Torsemide
• Bumetanide
Clinical Scenario #2
• 65 yo M, PMH of ischemic cardiomyopathy (EF 35%),
HTN, DMII presents with acute SOB.
• T 98.8, BP 190/120, RR 25, PO2 sat 88%
Pulmonary Edema
 Goals of therapy:
◦ Reduce afterload and preload
◦ Increase or maintain contractility
◦ Maintain stroke volume (permissive tachy)
 Low EF  avoid beta blockers/negative inotropes
 Nitroglycerin (reduces preload)
 IV Diuretic (reduces preload and afterload)
 NIPPV – reduces preload and afterload
Clinical Scenario #3
• 65 yo F, PMH of HTN, DMII, PAD presents with chest pain
at rest
• T 98.8, BP 190/120, RR 25, PO2 sat 94%
• ECG:
• new TwI in I, II, aVL, V3-V6
• What do you want to use?
Acute Coronary Syndrome
• Goals of therapy:
• Reduce Myocardial Oxygen Demand
• Reduce Heart Rate
• Reduce Afterload
• Labetalol (or Esmolol)
• Nitroglycerin
• Primarily anti-anginal
• ACE-Inhibitor if no contraindication
• Captopril short acting, easily titrated
Clinical Scenario #4
• 65 yo M, Marfan’s syndrome, HTN, presents with severe
•
•
•
•
CP radiating to back
T 98.8, BP 190/120, RR 25, PO2 sat 94%
CXR: widened mediastinum
CT scan: descending aortic dissection
What do you want to use?
Aortic Dissection
• Goals of therapy:
• Reduce shear stress
• Reduce Heart Rate
• Reduce Velocity of Blood Flow
• Vasodilator alone will increase HR
• Vasodilator + beta blocker
• Labetalol OR
• Nicardipine + Esmolol
• OK to aggressively reduce (<120/80)
Other Scenarios
 Encephalopathy (goal: reduce ICP)
◦ Labetalol or Nicardipine
 Sympathetic Crisis
◦ Cocaine, Amphetamines, PCP (Urine Tox!!)
◦ Others: MAO inhibitor + tyramine, clonidine withdrawal
◦ Avoid beta blockers – theoretical risk of sympathetic crisis,
unopposed alpha agonism
◦ Good options: Nicardipine or Verapamil + benzo; Labetalol likely
safe
A Word on Diuresis
 Threshold Dose
◦ Minimum effective dose
◦ 0.5-1mg/kg (or 40mg) IV over 1-2 mins
◦ Often 40 IV Lasix
◦ No response w/ in 1 hour double the dose
 Tolerance – hypertrophy of nephrons
◦ Add thiazide such as metolazone
 Conversions
◦ 40 IV Lasix = 20 IV Torsemide = 1 IV Bumex
◦ 40 Lasix PO = 20 Lasix IV
◦ Rule of thumb = give PO dose as IV
Diuretic Drips
• Equivalent to bolus (DOSE trial)
• Good for quick titration in ICU
• Always bolus prior to starting drip or adjusting the rate
• Furosemide: 40 IV then 10/hr
• Torsemide: 20 IV then 5/hr
• Bumetanide: 1 IV, then 0.5/hr
• Remember: higher doses in renal failure!
Take-home Points
 Hypertensive Urgency  ORAL MEDS!!
◦ Rapid overcorrection can be very harmful
◦ Start low, go slow
 IV Hydralazine  BAD
◦ Severe, unpredictable hypotension + reflex tachycardia
 Labetalol  GOOD
◦ Except in acute decompensated HF
 Dilt gtt  NEVER in acute HFrEF
 Always ask: “What is the EF?”