Hypertension

1
Hypertension

• Resting BP consistently
• gt140 mmHg systolic or
• gt90 mmHg diastolic

2
Epidemiology

• 20 of adult population
• 35,000,000 people
• 25 do not know they are hypertensive
• Twice as frequent in blacks than in whites
• 25 of whites and 50 of blacks gt 65 y/o

3
Types

• Primary (essential) hypertension
• Secondary hypertension

4
Primary Hypertension

• 85 - 90 of hypertensives
• Idiopathic
• More common in blacks or with positive family
  history
• Worsened by increased sodium intake, stress,
  obesity, oral contraceptive use, or tobacco use
• Cannot be cured

5
Secondary Hypertension

• 10 - 15 of hypertensives
• Increased BP secondary to another disease process

6
Secondary Hypertension

• Causes
• Renal vascular or parenchymal disease
• Adrenal gland disease
• Thyroid gland disease
• Aortic coarctation
• Neurological disorders
• Small number curable with surgery

7
Hypertension Pathology

• Increased BP ? inflammation, sclerosis of
  arteriolar walls ? narrowing of vessels ?
  decreased blood flow to major organs
• Left ventricular overwork ? hypertrophy, CHF
• Nephrosclerosis ? renal insufficiency, failure

8
Hypertension Pathology

• Coronary atherosclerosis ? AMI
• Cerebral atherosclerosis ? CVA
• Aortic atherosclerosis ? Aortic aneurysm
• Retinal hemorrhage ? Blindness

9
Signs/Symptoms

• Primary hypertension is asymptomatic until
  complications develop
• Signs/Symptoms are non-specific
• Result from target organ involvement
• Dizziness, flushed face, headache, fatigue,
  epistaxis, nervousness are not caused by
  uncomplicated hypertension.

10
HTN Medical Management

• Life style modification
• Weight loss
• Increased aerobic activity
• Reduced sodium intake
• Stop smoking
• Limit alcohol intake

11
HTN Medical Management

• Medications
• Diuretics
• Beta blockers
• Calcium antagonists
• Angiotensin converting enzyme inhibitors
• Alpha blockers

12
HTN Medical Management

• Medical management prevents or forestalls all
  complications
• Patients must remain on drug therapy to control BP

13
Categories of Hypertension

• Hypertensive Emergency (Crisis)
• acute ? BP with sx/sx of end-organ injury
• Hypertensive Urgency
• sustained DBP gt 115 mm Hg w/o evidence of
  end-organ injury
• Mild Hypertension
• DBP gt 90 but lt 115 mm Hg w/o symptoms
• Transient Hypertension
• elevated due to an unrelated underlying condition

14
Hypertensive Crisis

• Acute life-threatening increase in BP
• Usually exceeds 200/130 mmHg

15
Hypertensive Emergency

• Severe hypertension associated with end organ
  damage
• Malignant hypertension (htn with retinal
  hemorrhages, exudates or papilledema, also renal
  involvement)
• Hypertensive encephalopathy
• Subarachnoid/Intracerebral hemorrhage
• Acute pulmonary edema
• Dissecting aneurysm
• Angina

16
Hypertensive Urgency

• Diastolic bp equal to or above 130 mm Hg
• No signs of end organ damage

17
When you are called..

• Ask about mental status changes, chest pain
• Obtain all vital signs
• Determine the reason for admission
• Ask about the patients blood pressure over the
  last 24 hours

18
When you get to the bedside

• Measure the bp again in BOTH ARMS
• jvd, thyromegaly, fundoscopic exam
• New cardiac murmer, S3, S4, tachycardia
• Renal or aortic bruits
• Edema to the extremities
• Brief mental status exam, gross motor exam

19
If you determine this to be a hypertensive
urgency

• There is no evidence of end organ damage
• There is NO PROVEN BENEFIT to rapid reduction in
  bp in asymptomatic patients.
• Aggressive antihypertensive therapy can induce
  cerebral or myocardial ischemia

20
If you determine this to be a hypertensive
urgency

• Your goal is to get the patient to around 160/110
  mmHg over several hours with conventional oral
  therapy

21
Labs

• Lytes, BUN/CR
• Cardiac enzymes if pt has angina/chf
• CXR if indicated if pt in angina/chf
• EKG if indicated if pt has angina/chf
• CT head if signs of encephalopathy

22
Causes

• Sudden withdrawal of anti-hypertensives
• Increased salt intake
• Abnormal renal function
• Increase in sympathetic tone
• Stress
• Drugs
• Drug interactions
• Monoamine oxidase inhibitors
• Toxemia of pregnancy
• Pheochromocytoma

23
Signs/Symptoms

• Restlessness, confusion, AMS
• Vision disturbances
• Severe headache
• Nausea, vomiting

• Seizures
• Focal neurologic deficits
• Chest pain
• Dyspnea
• Pulmonary edema

24
Hypertensive Crisis Can Cause

• CHF
• Pulmonary edema
• Angina pectoris
• AMI
• Aortic dissection

25
Hypertensive Emergencies
Stroke Encephalopathy
Aortic Dissection
Decompensated Heart Failure
Acute Coronary Syndrome
Acute Renal Failure
26
Hypertensive Crisis Management

• Immediate goal lower BP in controlled fashion
• No more than 30 ? in first 30-60 mins
• Not appropriate in all settings
• Oxygen
• Monitor ECG
• Drug Therapy
• Targeted at simply lowering BP, OR
• Targeted at underlying cause

27
Drug Therapy Possibilities

• Sodium Nitroprusside
• Potent arterial and venous vasodilator
• Vasodilation begins in 1 to 2 minutes
• 0.5 ?g/kg/min by continuous infusion, titrate to
  effect
• increase in increments of 0.5 ?g/kg/min
• 50 mg in 250 cc D5W
• Effects easily reversible by stopping drip
• Continuous hemodynamic monitoring required
• Cover IV bag/tubing to avoid exposure to light
• Used primarily when targeting lower BP only

28
Drug Therapy Possibilities

• Nitroglycerin
• Vasodilator
• Nitropaste simplest method
• 1 to 2 inches of ointment q 8 hrs
• easy to control effect but slow onset
• Sublingual NTG is faster route
• 0.4 mg SL tab or spray q 5 mins
• easy to control but short acting
• NTG infusion, 10 - 20 mcg/min
• seldom used for hypertensive crisis
• Commonly used prehospital when targeting BP
  lowering only especially in AMI

29
Drug Therapy Possibilities

• Nifedipine
• Calcium channel blocker
• Peripheral vasodilator
• 10 mg Sublingual
• Split capsule longitudinally and place contents
  under tongue or puncture capsule with needle and
  have patient chew
• Used less frequently today! Frequently in past!
• Concern for rapid reduction of BP resulting in
  organ ischemia

30
Drug Therapy Possibilities

• Furosemide
• Loop Diuretic
• initially acts as peripheral vasodilator
• later actions associated with diuresis
• 40 mg slow IV or 2X daily dose
• most useful in acute episode with CHF or LVF
• Often used with other agents such as NTG

31
Drug Therapy Possibilities

• Hydrazaline
• Direct smooth muscle relaxant
• relax arterial smooth muscle gt venous
• 10-20 mg slow IV q 4-6 hrs initial dose 5 mg for
  pre-eclampsia/eclampsia
• Usually combined with other agents such as beta
  blockers
• concern for reflex sympathetic tone increase
• Most useful in pre-eclampsia and eclampsia

32
Drug Therapy Possibilities

• Metoprolol, orLabetalol
• decrease in heart rate and contractility
• Dose
• Metoprolol 5 mg slow IV q 5 mins to total 15 mg
• Labetalol 10-20 mg slow IV q 10 mins
• Metoprolol is selective beta-1
• minimal concern for use in asthma and obstructive
  airway disease
• Labetalol both alpha beta blockade
• Most useful in AMI and Unstable angina

33
Hypertensive Emergency

• Enalapril
• IV prep of ACE Inhibitor
• Response is variable (probably b/c these pts have
  variable plasm renin activity)
• Contraindicated in pregnancy
• Start at 1.25 mg iv and up to 5 mg iv q 6 hrs
• Onset of action 15 minutes, peak effect 4 hrs
• Duration of action 12-24 hours

34
Hypertensive Crisis Management

• Avoid crashing BP to hypotensive or normotensive
  levels!
• Ischemia of vital organs may result!

35
Hypertensive Crisis Management

• Must assure underlying cause of ?BP is understood
• HTN may be helpful to the patient
• Aggressive treatment of HTN may be harmful

What patients may have HTN as a compensatory
mechanism?