??????S??? ???S?: ??t?

1
??????S??? ???S? ??t?µet?p??eta? e??a?a?

• ?.???????S
• t.???ed??? ?µ?da? ?pe?tas?? ???
• ?pe?tas??? ?at?e?? ????e?? ??s???µe??
• ?pe?tas??? ?at?e?? ?pe?????a?d????af???
  e??ast???? ???? ???

2
??????S??? ???S?

• ???a?? Se?????
• ?s?e??? µet?? ?? 180/100mmHg
• ????t?p??e?ta? ? ?????e?e?a??? µ??a??sµ??
• ?a????? ?a? sp??d? ?a ?e????s??? ???? µa?? ??a t?
  ef?µe?e??? ??s???µe??
• ?? 210/110mmHg

3
??????S??? ???S? (?????OS?-S???S??) ?

• ??? ?a? spa???te?? µet? t? d?aded?µ??? ???s?
  fa?µ???? (1-2).
• S?????? se ?????a ???, a??? ?a? se p??sfata
  d?a???s?e?sa ? µ????? d????e?a?
• ?a????st??? t? ep?ped? t?? BP pa?? ? a?t??????a
  t?? ???
• S?µa?t??? t? ap?t?µ? t?? a???s?? (pa?d?? µe ??e?a
  spe??aµat??ef??t?da, t????a?µ?a ???s??,
  fa?µa?e?t???)

4
??????S??? ???S? (?????OS?-S???S??) ??

• Se µe????? s???p?????se? ?atast?se?? s?µa?t??? ?
  ta??tat? µe??s? t?? BP (d?a????st??? a?e???sµa,
  ??e?a CHF)
• as?eta ap? t? ???? t?? BP

5
??????S???S ???S??S (????)

• EMERGENCIES ?a?? p?????s?, µe??s? BP se ???e?
  ??e? (??? apa?a?t?ta se f?s???????? ep?peda), ??a
  p?????? ? pe?????sµ? ß??ß?? se ???a?a st?????.
• URGENCIES ?????te??? ?µes?? ???d???? a???
  p??a?? ep?de???s?
  ?e??s? BP se a??et?? ??e? ? ?a? ?µ??e?
• ?e? ?p???e? ?e???a?? ep?ped? ?? ?a t??
  ?e?????e? µeta?? t???.

6
??????S??? ???S? 25 ?? epe????t??
EMERGENCIES 25-30

• ???gt120mmHg
• ?pe?tas??? e??efa??p??e?a 16
• ???efa???? a?µ???a??a 4.5
• ??? e??efa???? ?µf?a?t? 24
• ??e?a ?? ??e?µ????? ??d?µa 36.8
• ???, asta??? st?????? 12
• ??a????st??? a?e???sµa 2
• ???aµ??a
  4.5

Zampaglione et al Hypertension 1996 27144-47
7
??????S??? ???S? (EMERGENCIES) ?

• 1. ?pe?tas??? e??efa??p??e?a
• 2. ?a?????? ?p??tas? (µe????? pe??pt?se??)
• 3. S?ßa?? ??? µe ??e?e? ep?p?????
• ?. ???e?a??? e??efa?????
• ??d?e??efa???? a?µ???a??a
• ?pa?a???e?d?? a?µ???a??a
• ??? e??efa???? ?µf?a?t? (???)
• ?. ?ef?????
• ?a???? ep?de????µe?? RF

8
??????S??? ???S? (EMERGENCIES) II

• G. ?a?d?a???
• ??a????st??? a?e???sµa a??t??
• ??e?a CHF p?e?µ????? ??d?µa
• ???
• ?sta??? st??????
• 4. ???aµ??a ? s?ßa?? ?p??tas? st?? e???µ?s???.

9
??????S??? ???S? (EMERGENCIES) III

• 5. ?atast?se?? ?pe??ate???aµ??a?µ?a?
• ???s? fa?????µ???t?µat??
• ?????ep?d?as? t??f??-fa?µ???? (Tyramine MAOI)
• Rebound HTN (d?a??p? ?????d????, ???a?e??d????,
  µe????t?pa)
• 6. Fa?µa?e?t???
• ?pe?d?s?????a s?µpa??µ?µ?t???? ??p (LSD, ???a???
  ??p)

10
??????S??? ???S? (EMERGENCIES) IV

• 7. ???efa???? t?a?µa
• 8. ?et? CABG
• 9. ?ete??e???t??? a?µ???a??a se a??e?a?? ??µµata.

11
??????S??? ???S? (URGENCIES) I

• 1. ?p?ta????µe?? ?a? ?a?????? ???
• 2. ??tetaµ??a e??a?µata
• 3. ??e?a spe??aµat??ef??t?? ()
• 4. ???s? s?????d??µat??
• 5. ??e?a s?st?µat??? a??e??t?? ()
• 6. ?e?????????? ?atast?se??
• ??? se as?e?e?? p?? ??e?????ta? ?µes? e??e???s?
  ()
• ?ete??e???t??? ??? ()
• ?et? ap? µetaµ?s?e?s? ?ef??? ()

12
??????S??? ???S? (URGENCIES) II

• 7. S?ßa?? ?????a??a
• 8. Rebound µet? ?af???? d?a??p? a?t??pe?tas????
  fa?µ????
• 9. F??µa?a ()
• ?pe?d?s?????a s?µpa??µ?µ?t????
• Metoclopramide
• a-advenergic agonist nonselective b-b
• 10. ?????? t?a?µa ??t?a??? µ?e??? ()
• (autonomic hyperreflexia).

13
??????S??? ???S?
14
??????S??? ???S?
15
??????? ?????????S???? ??????S???S ???S?S

• ??? gt 120-130 mmHg
• ????s??p?s? ??µ???a??e?, ???d??µata, ??d?µa
  ?????.
• ?e????????? ??????fa???, S????s?, ?p????a,
  Stupor, ??f??s?, Spasµ??, ??µa.
• ?ef??? ????????a, ????a?µ?a.
• Gast?e?te???? ?a?t?a, ?µet??.

16
??????S??? ???S?

• ??????? ?????????S????
• DBP gt 140 mmHg
• ????s??p?s? ??µ???a??e?, ???d??µata, ??d?µa
  ?????.
• ?e????????? ??????fa???, S????s?, ?p????a,
  Stupor, ??f??s?, Spasµ??, ??µa.
• ?ef??? ????????a, ????a?µ?a.
• Gast?e?te???? ?a?t?a, ?µet??.

17
?.?. ??????S???S ???S?S ?

• ??e?a a?ep???e?a a??ste??? ?????a?
• ???a?µ?a ?????? ap? ?pe?f??t?s? ?????
• ???e?a?? e??efa???? epe?s?d??
• ?pa?a???e?d?? a?µ???a??a
• ????? e??ef????
• ??a?µa ?efa???
• ?p?????a

18
?.?. ??????S???S ???S?S ??

• ??s?? ????a????? (S?? µe e??efa???? a??e??t?da)
• ???efa??t??
• ?pe?d?s?????a ?a? st???s? ?a???t????, aµfetaµ????
  ??p
• ?pe?asßest?a?µ?a
• ??? ????? µe ?pe?ae??sµ?

19
?? gt 220/120 mmHg
??????fa??? ?e????????? s?µe?a (-) ??µ?? se
???a?a st?????(-)
?e????????? s?µe?a () (e??efa??p??e?a ?
???) ?µf?ß??st??e?d?p??e?a ???-IV T??a????
????? (?s?a?µ?a ? d?a?/?? a?e???sµa) ??e?µ?????
??d?µa ???aµ??a ?pe??ate???aµ??a?µ?a ??e?a
?ef???? a?ep???e?a
Urgency
?a?t?p???s? a?t?a? Se ???se?? pa????? ? a?????
a?a???t???, a?????t??? ???s? fa?µ???? ap? t?
st?µa ?pa???e???? 6-24 h
Emergency
??d?f??ß?a Te?ape?a
20
S????? T???????S ??? ???S?S

• ?????? µe??s? ?? lt 25 (2min - 2h)
• 160/100 mmHg (2 - 6h)
• ?p?f??? ap?t?µ?? pt?s?? ?? ????
  ?ef?????,e??efa????? ? stefa??a?a? ?s?a?µ?a?.
• BP / 15-30 min

21
??????S??? ???S? F??????
????G???? PER OS
???????????

• ???? ?apt?p????
  Enalaprilat
• a-ap???e?st?? Terazosin
• Doxazosin
• Prazosin
• ??????t??? F????seµ?d?
  F????seµ?d?
• ?-ap???e?st?? ?et?p??????
  ?sµ?????
• 
  ?et?p??????
• aß-ap???e?st?? Labetalol
  Labetalol
• Carvedilol
• ?2-a????st?? Clonidine
  Clonidine (TTS)
• Guanfacine

22
??????S??? ???S? F?????? PER OS
F?????? ??S?
??????/???????? ???S?S

• Capropril 25 mg po 15-30
  min/6-8h
• ?p????s.
  15-30 min/2-6h
• Clonidine 0.1-0.2mgpo/h 30-60 min/8-16h
• max 0.6mg
• Labetalol 200-400mgpo/2-3h 30-2h/2-12h
• Prazosin 1-2 mg po/h 1-2h/8-12h
• Minoxidil 5-10 mg po 30-60 min/12-16h
• Furosemide 40-80 mg
• Nitroglycerin 1.25-2.5 mg

23
??????S??? ???S? ??????????? F??????
F?????? ??S?
??????/???????? ???S?S

• Nitroprusside 0.25-10 µg/Kg/min secs/1-2min
• Labetalol 20-80mg/10-15min 5-10min/3-6h
• 2-4mg/min
• Enalaprilat 0.625-1.25mg
  15min/4-12h
• Diazoxide 50-150mg5min 1-5min/4-12min
• Hydralazine 10-20mg
  5-30min/3-9min
• Furosemide 40-80 mg
• Nitroglycerin 3-100µg/min
  1-5min/3-5min

24
??????S??? ???S? ??????????? F??????
F?????? ??S?
??????/???????? ???S?S

• Esmolol 0.5mg/Kg50-300µg/kg/min 1-2/10-20
• Trimethaphan 1-15mg/min 1-10min/3-10min
• Fenoldopam 0.1-1.6µg/kg/min 3-40min/60min
• Phentolamine 5-10mg5min 1-2min/3-5min
• Urapidil 12.5-25mg5-40mg/h 3-5min/4-6h
• Methyldopa 250-500mg/6h 30-60min/4-6h
• Nicardipine 5-15mg/h
  5-15min/30-40min

25
??????????? F?????? (EMERGENCIES) I

• ?pe?tas??? e??efa??p??e?a
• () (-)
• Labetalol Methyldopa
• Nicardipine Diazoxide
• Nitroprusside Reserpine
• Trimethaphan

26
T????O???? ???

• ? ?? ? a???s? ??de?s?? pe?????? ß??ß?? ???d?µa
  ?p?es? ?????? ?st?? (??? µe p??s???).
• ??p??? a??e??s?spas?? a????? µe?a??te??? ??
  ??de?s??.
• ?aµp??? a?t?????µ?s?? ?????f???a? ? de??? (???
  ??a t?? ?d?a ???).
• S?????? ? ?? µe???eta? a?t?µata µesa st?? 4
  p??te? ?µ??e?.

27
(No Transcript)
28
???

• BPlt180/105 mmHg t?p?ta
• BPgt230/120 mmHg gt20min i.v
• S????? ???OS?S ??
• 160-170/95-100 mmHg ???µ?tas????
• 180-185/105-110 mmHg ?pe?tas????

29
?????G??F????? ???????G??

• lt 48h ? BP
• ?s????p?a a?µ?t?s?? a?µ???a??a?
• ?? ??? lt 20 ?? ??a????
• DBP gt 140mmHg ??a gt20 min ? i.v.
• Nitroprusside, Labetalol, Fenoldopam, Urapidil,
  Nimodipine

30
??????????? F?????? (EMERGENCIES) III

• ??? ? t?a?µa ?efa???
• ()
  (-)
• Labetalol
  Methyldopa
• Trimethaphan Reserpine
• Nitroprusside Hydralazine
• Esmolol Diazoxide

31
??????????? F?????? (EMERGENCIES) II

• 2) ?p?ta????µe?? ?a??????
• () (-)
• Labetalol
• Enalaprilat
• Nicardipine
• Nitroprusside

32
??????????? F?????? (EMERGENCIES) IV

• 4)CHF () (-)
• Enalaprilat Labetalol
• Nitroglycerin Esmolol
• Nitroprusside
• 5) Stefa??a?a ?s?a?µ?a
• Nitroglycerin Hydralazine
• Labetalol
  Diazoxide
• Enalaprilat
  Nitroprusside

33
??????????? F?????? (EMERGENCIES) V

• 6) ??a????st??? a?e???sµa
• ()
  (-)
• Trimethaphan Hydralazine (co)
• Nitroprusside Diazoxide (co)
• Esmolol
• 7) ?pe??ate???aµ??a?µ?a
• Phentolamine
• Labetalol

34
??????????? F?????? (EMERGENCIES) VI

• 8) ?ete??e???t???
• ()
  (-)
• Labetalol
  Trimethaphan
• Nitroglycerin
• Nicardipine
• Hydralazine

35
??F???? ??????????

• () Nitroprusside (pa?a???????s?
  ep?p?d?? ?e????a???????)
• Labetalol,
• CCB,
• Fenoldopam
• (-) b-blockers ? ? RPF, GFR

36
(???)-????????

• ? ?? ? ??µ?t?s? p?a????ta
• Hydralazine (DBP gt 115 mmHg)
• Labetalol, Urapidil
• ??ta????st?? Ca (? s?sp?se?? µ?t?a?, ap??e?a
  eµß????)
• (-) ??????t???, Trimethaphan, Nitroprusside, AMEA
• Spasµ?? Te???? µa???s??

37

• ?atast?se?? µe ????? ?e????
• ?a?????? ?p??tas?
• ?atast?se?? µe µ?s? p??? ????? ?e????
• ?te??p?e??? ?ef?a??e?a?? ?p??tas?
• ?ef???? a??e??t?? (s?????de?µa, S??,
  p???a?t????t??)
• ?ef???? t?a?µa
• ????? e???????te? ?e????
• ?d?e?e?????? ???se?? (fa??, ???a,?????d???-mDOPA(-
  ))
• ???a?a µ?s?-????? ?e???? (PRA?0.65 ng/ml/h)
• ?pe?tas??? e??efa??p??e?a
• ?pe?tas? µe e??efa???? a?µ???a??a ? ???
• ?pe?tas? µe p?e?µ????? ??d?µa, ???,? ast.
  st??????
• ??a????st??? a?e???sµa ?e??e??e???t??? ?p??tas?
  

R ?atast?se??
38

• ?atast?se?? µe ????? ?e????
• ?a?????? ?p??tas?
• ?atast?se?? µe µ?s? p??? ????? ?e????
• ?te??p?e??? ?ef?a??e?a?? ?p??tas?
• ?ef???? a??e??t?? (s?????de?µa, S??,
  p???a?t????t??)
• ?ef???? t?a?µa
• ????? e???????te? ?e????
• ?d?e?e?????? ???se?? (fa??, ???a,?????d???-mDOPA(-
  ))
• ???a?a µ?s?-????? ?e???? (PRA?0.65 ng/ml/h)
• ?pe?tas??? e??efa??p??e?a
• ?pe?tas? µe e??efa???? a?µ???a??a ? ???
• ?pe?tas? µe p?e?µ????? ??d?µa, ???,? ast.
  st??????
• ??a????st??? a?e???sµa ?e??e??e???t??? ?p??tas?
  

39

• ?pe?f??t?s? ??at??,?aµ???? ?e????? ?atast?se??
  (PRAlt 0.65 ng/ml/h)
• ??e?a s????a??a?? ?????s?
• ??e?a spe??aµat??ef??t??
• ?p?f?a?? ????f???? ?d??
• ???t?pa??? a?d?ste????sµ??
• ?aµ???? ?e????? ?d??pa??? ?p??tas?
• ???e??aµ??a-e??aµ??a (PRA1ng/ml/h, e?? se
  f?s???????? e???µ?s??? e??a? 6-10ng/ml/h)
  

V ?atast?se??
40
??????S??? ???S? ????-????

• K,Na,Ca,U,Cr.,PRA
• ??/f?a,??G,?ate?/?e?
• ???? ?ef??(a??e?a)??,Fa????/??t?µa
• a-Blocker
  Fa???/µa, ??e????
• ?aµpeta???? ??e????,Fa???/µa,?a?????
• F????seµ?d? ??e????,?ef???? ??s??,CHF
• ?????d???
  ??????d???,??????

??a????st??? ??e???sµa
B-?locker
(-)
?.?
F??????
???
41
???G?OSS?? ??F??????? ? ???????? ?O? ??
????G???O?

• ?e? d?af??e? ap? t?? PER OS ??????s? .
• ?e? ap???f?ta? aµ?s?? ?p????ss??? a???
  ??e?????ta? t??????st?? 10 min ??a ta a?????
  ap?te??sµata.
• ?? µ???st? ap?t??esµa 30-40 min
• ?pe?e?????s? ?ate???aµ????
• ? pt?s? t?? ?? ap??ß?ept?, p???????sa ?a? ???
  e????a a?ast????µ?.

42
???G?OSS?? ??F??????? ? ???????? ?O? ??
????G???O? ??

• Fa???µe?? ?p????p??
• ???ß??µat??? ??????s?
• a) St???s? ?a??t?d??
• ß) ?µf?a?µa µ???a?d???
• ?) LVH µe µ???? ?????t?ta a??ste??? ?????a?.

43
SHOULD A MORATORIUM BE PLACED ON SUBLINGUAL
NIFEDIPINE CAPSULES GIVEN FOR HTN EMERGENCIES
AND PSEUDOEMERGENCIES ?

• Given the seriousness of the reported adverse
  events and the lack of any clinical documentation
  attesting to a benefit, the use of Nifedipine
  caps should be abandoned.
• E.Grossman et.al JAMA 1996 2761328-31

44
(No Transcript)
45
(No Transcript)
46
??????S???S ???S??S

• 6 ??S??????? ??????S
• 196 ??????S???S ???S??S
• 88 ( 45) lt180/100 mmHg
• 82 ( 42) 180-200/100-120 mmHg
• 25 ( 13) gt220/120 mmHg
• 5 (2.5) ??????S??? ?G??F?????T??? (e?sa????)

47
(No Transcript)
48
???????O??S? ???S?O? ?196

• 143 (73) ??F??????? ( 5-10 mg )
• 82 (42) F????S????? ( i.v, i.m, p.o )
• 19 (10) ????????? ( p.o, i.v )
• 18 (9) ???? ( p.o, ?p????ss??? )
• 68 (35) ??F??????? F????S?????
• 6 (3) ???? F????S?????
• 8 (4) ?????????S? ???S??S? ???????S?S ?GOG?S
  , ?????? ?GOG?S

49
S??????S??

• ??st???? ?? ?ate????t???e? ??aµµ?? ??a t??
  a?t?µet?p?s? t?? ?pe?tas???? ???s??, a??? a??µa
  ?a? ??a t?? ?d?a a?a?????s? ?a? d?????s? t??
  p??a?? a??????ta? ? e???s?a (?) de? a?????????ta?
  ap? t?? p?e????t?ta t?? ?? epe????t??
  pe??stat????.
• ? ?p????ss?a ??fed?p??? e?? ??t? apa???e?eta?,
  a?t??eta d?deta? sa? ?a?aµ??a ep? d??a??? ?a?
  ad????.
• ? ?µ?da ???as?a? ?p??tas?? t?? ??? ??e? e?????
  ?a? ?p?????s? ?a ße?t??se? t?? a?t?µet?p?s? t??
  ?pe?t/??? ???s?? st?? ????da