Recent Hype in Hypertension

1
How to Define and Treat Hypertensive Emergencies
Ronald Victor, M.D.
Chief, Hypertension Division
SO HWESTERN Medical Center
2
Franklin Roosevelt(1882-1945)
Messerli, F. H. N Engl J Med. 1995.
3
Hypertensive Emergency Improved survival with
early Dx and Rx
100
Japan
Chicago

Melbourne
France
75
France
France
Cleveland
U.K.
50
London
Sydney
Melbourne
S.F.
25
Mayo
S.F.
Chicago
London
0
1925
1937
1950
1962
1975
1987
WJ Elliott, 1992
4
How to Define Hypertensive Emergencies
5
Severe Hypertension
BP gt 180/110 mm Hg
Progressive Target Organ Damage?
6
Hypertensive Emergencies
Stroke Encephalopathy
Aortic Dissection
Decompensated Heart Failure
Acute Coronary Syndrome
Acute Renal Failure
From D Sicca, MD
7
How to Treat Hypertensive Emergencies
The evidence base.
8
(No Transcript)
9
Some great teaching cases
10
Case 1-Hx/PE
Seizure episode in a 40 y/o African American man
with progressive headache, nausea, vomiting,
ataxia, and blurred vision

• Hypertension detected one year earlier
• but Rx self-discontinued
• BP 240/148mmHg HR 78
• Postictal, moving all 4 extremeties
• Bronchial breath sounds

11
Case 1-Labs

• Na 132 K 3.2 CO2 35
• Serum Cr 2.3 BUN 49
• HCT 31 Platelets 66K, schistocytes
• Urinalysis proteinuria, hematuria,
• urobilinogen
• EKG NSR, possible LVH
• CXR mild failure

12
Eye Grounds
Grade 3 K-W Retinopathy
13
Case 1- Clinical Dx
hypertensive encephalopathy
an acute organic brain syndrome (delirium)
resulting from autoregulation breakthrough
dilation of the cerebral vessels causing
hyperperfusion and cerebral edema
14
Cerebral Autoregulation Failure
15


MRI Confirmation
posterior leukoencephalopathy
Posterior fossa
Occipital lobes
Edema predominately of the white matter of the
parieto-occipal regions and post. fossa

                                                                                                                                                                 
Privacy Policy 2004 Nature Publishing Group
16
Vasculopathy of Hypertensive Emergencies
Vaugh and Delanty, Lancet, 2000
17
Case 1-Treatment
ICU Day 1 Parenteral Rx

• Dilantin, i.v. fluids
• Nitroprusside 0.25-10 mg/kg/min
• Diastolic BP Goal 110mmHg
• Discontinued after 24h avoid toxicity

18
Nitroprusside vs. Fenoldopam
Devlin et al., Ann Pharmacotherap, 2004
19
Sodium Nitroprusside
Dont
Do

• Use for most hypertensive emergencies
• Admit to ICU for arterial monitoring
• Protect from light with aluminum foil

• Use for gt24h
• Use as monotherapy in acute coronary syndromes
  (ACS)
• (add NTP after i.v. metoprolol NTG)

20


Reversible Posterior Leukoencephalopathy Syndrome
Before Rx
After Rx
Occipital lobes
Posterior fossa

                                                                                                                                                                 
Privacy Policy 2004 Nature Publishing Group
21
Suspect secondary HTN in ALL cases of
hypertensive emergency.
22
Atherosclerotic Renal Artery Stenosis
suspect with hypertensive emergency and
flash pulmonary edema
23
Hypertensive Encephalopathy
Major Causes

• Primary hypertension 70
• Secondary hypertension 30
• Renal disease (vasculitis, epogen, CsA)
• Renovascular hypertension
• Eclampsia
• Sympathomimetics
• (cocaine, meth, herbals and other MAOIs)
• Clonidine withdrawal
• Pheo

24
Case 2
Severe hypertension in a 70 y/o woman admitted
to the Parkland stroke unit

• Admitted 24 hours after onset of confusion
• and left arm weakness
• Long history of hypertension
• BP 220/111mmHg
• Left hemiparesis, confusion
• Baseline serum Cr 2.7

25
CT Scan
right middle cerebral artery CVA
26
Case 2-Hospital Course
Renal consultation for refractory
hypertension and deteriorating renal function

• BP 220/118mmHg
• Serum Cr 4.0, K 5.1
• Initial Rx furosemide, metoprolol, captopril
• Added Minoxidil BP 100/70mmHg, coma,
• infarct extension

27
The biggest mistake in treating hypertensive
emergencies is over-correction of BP.
28
Cerebral Autoregulation
100
Brain Blood Flow maximal
Normotensive
50
Hypertensive
Cerebral hypoperfusion
0
50
100
150
200
250
Systolic BP mm Hg
29
Approach to BP in Acute
Ischemic Stroke
Eligible for thrombolytic therapy?
No
Yes
Initial BP
Labetalol or Nicardipine for BP gt 185/110
lt 220/120
gt 220/120
Labetalol or Nicardipine
No Rx
Adams et al., Stroke, 2005
30
Case 3
Sudden onset of severe back pain in a 67 y/o man
with long-standing hypertension

• BP 186/123mmHg (both arms)
• Bibasilar rales
• Grade 2/6 systolic ejection murmur
• no diastolic murmur
• EKG- ST 102 LVH with strain/ischemia

31
CT Angiogram
distal (type B) aortic dissection
32
Emergency Rx of Aortic Dissection
Goal systolic BP 100-110mmHg in 20 min
Rx i.v. b-blockade (?dP/dT) plus
Nitroprusside
metoprolol 5 mg i.v. x 3 doses OR
labetalol 20-80mg bolus Q 10 min
33
Case 4 an anesthesiologists nightmare
Hypertensive crisis (300/150mmHg) during
induction of anesthesia for removal of an
adrenal mass in a 62 y/o man with stable
2-vessel CAD borderline hypertension
Preop cardiology consult add metoprolol
to isordil, enalapril, amlodipine
34
Approach to Pheo Crisis
Emergency Rx
Preop. Prevention
Phenoxybenzamine Inderal Fluids
Phentolamine Labetalol
80 mortality
3 perioperative mortality
35
Case 5
Severe hypertension with crushing chest pain,
agitation, and low-grade fever in a 38 y/o
man (Dallas August, 2001)

• BP 179/125mmHg HR 98 T 383
• Rx in ED
• metoprolol
• 15mg i.v.
• cTi pending

36
Treatment of Cocaine Overdose
Benzodiazepines Nitrates CCBs ( HR, pulse
pressure) Labetalol (paradoxical HTN)
Avoid pure b-blockers
37
Acute Effects of Cocaine Traditional Teaching
Peripheral sites of action
RA Kloner SJ Rezkalla NEJM, 2003
38
Hot Weather and Cocaine Deaths
5
Cumulative Mean No. of Cocaine Deaths
4
NYC 1990-1992
3
2
1
0
1000
800
600
300
880
Daily Maximum Temperature 0F.
PM Marzuk et al., JAMA, 1998
39
Cocaine
NE
Coronary Vasoconstriction
Hypertensive Crisis Tachycardia
40
Hypertensive Emergencies
EncephalopathyStroke
Aortic Dissection
Decompensated Heart Failure
Acute Coronary Syndrome
Acute Renal Failure