Emergency Department Evaluation and Treatment of Hypertensio

7/28/2019 Emergency Department Evaluation and Treatment of Hypertensio

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Emergency DepartmentEvaluation and Treatment

of Hypertension


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What is Hypertension?

Systolic blood pressure >140 mm

Hg or Diastolic blood pressure >90 mm

Hg


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Why is it important to treatHypertension?

Hypertension significantly

increases the risk of cardiovascular disease:

Stroke

CADCHF

Renal insufficiency/failure


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The Framingham Study

Patients 45 74 years oldfollowed for a mean of 18 years


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Results of the FraminghamStudy:

The risk of a cardiovascular event rises

progressively with both systolic anddiastolic blood pressureThe yearly risk of a cardiovascular event is

higher for older patients At all ages and blood pressures, men are ata slightly higher risk than women


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What is the Impact of

treating Hypertension ?In the first few years of treatment :

14% reduction in CAD incidence42% reduction in stroke incidence>50% reduction in CHF incidence


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Classification of BloodPressure for Adults >18

years oldCategory Systolic DiastolicOptimal


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All of these classifications canbe made only after two BP

measurements made duringtwo subsequent visits


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Confounding factors in

Determining the Presence of Chronic Hypertension in the

Emergency Department

Pain

Anxiety Concurrent illness


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Categories of HypertensiveDisease Presenting to

Emergency Departments:

Hypertensive Emergencies Hypertensive Urgencies

Chronic Hypertension


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Hypertensive Emergencies

Severe hypertension plus new or acutely progressive end-organ

dysfunction


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Examples of Hypertensive

Emergencies

Cardiovascular Acute left ventricular failure AMICrescendo angina

Aortic dissection


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Examples of HypertensiveEmergencies

Cerebrovascular EncephalopathyIntracranial hemorrhageSymptomatic papilledema


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Examples of HypertensiveEmergencies

Other Eclampsia/pre-eclampsiaDrug induced

Acute renal failure


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Treatment of Hypertensive

Emergencies Be aggressive

I.V. medications these must beindividualized to the specific situation:- Beta blocker and nitroglycerine for aortic

dissection- Magnesium and Hydralazine for eclamsia-nitroglycerine for severe CHF


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What is the goal of therapy?

Lower the patients blood pressure over 30-60 minutes to the lowest level that willadequately profuse their brain.

Because of cerebral autoregulation, thisshould be no less than 25% - 30% of their mean arterial blood pressure


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mean arterial bloodpressure

MAP = Diastolic BP + ( systolic BP diastolicBP)

3


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For someone with BP = 270/150

MAP = 150 + (270-150) = 150+40 = 1903

Therefore, a reasonable goal would be aMAP of (190) x .75 = 142


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Hypertensive Urgencies

Severe hypertension without significantacute end organ damage

These patients are at risk of complicationsweeks to months in the future notimmediately


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Hypertensive patients:

Awake, alert,with normal neurologicexams, complaining of headache anddizziness, blurred vision (withoutpapilledema),

Proteinuria with normal urea andcreatinine

Epistaxis without coagulopathy


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THE MOST IMPORTANT THING FORTHESE PATIENTS IS TO RULE OUT AHYPERTENSIVE EMERGENCY

Then evaluate their complaint as for anyother patient


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There is no evidence for benefit and thereis anecdotal evidence for harm toasymptomatic patients whose BP istreated hourly until their urgenthypertension responds.

Principles of Ambulatory Medicine, 5 th ed. 1999


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The goal is to control the patientshypertension over the next 24-72 hours


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Evaluation: K+

Urea/creatinineChest X-rayUrinalysis

EKG


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Treatment For uncomplicated hypertension, to date theonly treatments proven in placebo controlled

trials are diuretics (for example,hydrochlorothiazide) and beta blockers (for example metoprolol). Initial monotherapy witheither agent is appropriate.

6 th report of the Joint National Committee onDetection, Evaluation, and Treatment of High BloodPressure, Arch Intern Med, 1997.


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TreatmentOral long-acting calcium channel blockers,ace inhibitors, clonidine, or other diureticsand extended observation can beappropriate


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Treatment Special Cases: Type I diabetes with proteinuria ACE

inhibitors Congestive heart failure ACE inhibitors,

diuretics History of myocardial infarction Beta

blockers


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Treatment There is no need for the patient to have a

normal blood pressure in order to gohome.

The end- point is to solve the patientscomplaint, not the patients blood pressure

Follow-up for repeat BP check in 72 hourswith GP.


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Hypertension - Treatment

Calcium Channel BlockersThe short acting dihydropyridines (this includes

Nifedipine ) are no longer recommended for treatment of hypertension because of asignificant association with myocardial infarction.The long-acting preparations (Adalat Retard) arestill O.K.

The risk of myocardial infarction associated withantihypertensive drug therapies. JAMA 274:620-625,1995


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Hypertension - Treatment

Calcium Channel BlockersThere are many reports of sublingualnifedipine causing harm due to acutehypotension.

Should a moratorium be placed on

sublingual nifedipine capsules given for hypertensive emergencies andpseudoemergencies? JAMA 276:1328-1331,1996


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Chronic Hypertension

No real indication to treat acutely Requires two subsequent visits to truly

diagnose IF you choose to treat, current

recommendations are diuretics or betablockers.

Documents

Emergency Department Evaluation and Treatment of Hypertensio