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Hypertensive Emergencies. Jason R. Frank MD MA(Ed) FRCPC Department of Emergency Medicine. HTN – What’s the Big Deal?. KEY objectives: Differentiate malignant HTN from secondary conditions Conduct initial HTN lowering treatment. OBJECTIVES: - PowerPoint PPT Presentation
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Hypertensive Emergencies
Jason R. Frank MD MA(Ed) FRCPCDepartment of Emergency Medicine
HTN – What’s the Big Deal?
MCC OBJECTIVES – HTN EMKEY objectives:• Differentiate malignant HTN
from secondary conditions• Conduct initial HTN lowering
treatment
OBJECTIVES:• Differentiate non-localizing
neurologic symptoms• Determine presence of other
hypertensive emergencies• Interpret clinical & lab
findings• Conduct an effective
management plan, including specific Rx
Case 1
• 50 woman sent in by community MD & pharmacist for “HTN emergency”
• Pharmacy BP = 190/90• Extremely worried,
otherwise well• Q: What is the clinical
definition of HTN?
Case 2
• 65 male drove in from cottage• Feeling unwell• Flagged at triage with BP
200/100• Forgot BP meds at home…
missed 3 days
• Q: What is a “hypertensive urgency”?
Case 3
• 72 male with chronic HTN, PAFib, and arthritis.
• Referred to CDU with elev BP “for observation”.
• 180/115 at rest• Progressive SOB over the am.
• Q: What is the definition of a “hypertensive emergency”?
Case 4
• 45 CEO of an IT firm• Presents with cp, SOB,
intense anxiety• Sweating, tacky, BP
200/120• Admits to cocaine
• Q: Management?
Case 5• 33 F 1 week post-partum• Epigastric pain• Seizure• BP 160/95, P90, T37.2
• Q: Dx? Management?
Case 6
• 60 M presents with tearing RSCP
• Rad to back• Assoc with L headache
and R leg weakness• BP 190/100, P 95
• Q. Management?
This Session: HTN EM1. Define HTN
2. Classify HTN
3. Provide a DDx for the acutely hypertensive patient, including 2ndary causes
4. Describe the findings of a patient with a HTN emergency
5. Describe high-utility tests for HTN EM
6. Describe the management of each of the categories of HTN
7. Describe at least 2 controversies in the management of HTN EM
HYPERTENSION
Standard Definition• Based on 3 measurements, each 1 wk apart
> 140 systolic> 90 diastolic
Most important #: Diastolic MAP = 1/3 Systolic, 2/3 Diastolic
Define HTN?Joint National
Commission VIVII 2003
“Pre-HTN”
HTN Defined:
Primary or Secondary• Majority (90-95%) essential HTN• Of Secondary: ½ have a potentially curable cause
HTN in the Population vs the ED?
HTN in the Population vs the ED?
• Primary HTN– Chronic– “Essential”– >95%– >25% of NA pop’n– 50% adhere to Rx– 75% not optimal– More un-Dx
• Pre-HTN
Thinking about a HTN Definitions:
• Pre-HTN……………........• Primary chronic………….• Transient ………………..• Secondary……………….• “Tertiary” ...………………
• Malignant………….........• Also: accelerated, severe, crisis,
etc
• 130-139/80-89• >140/90• white coat, anxiety, pain, etc• Pathologic organ cause• Iatrogenic, ingestion,
withdrawal, etc • Bad (enceph & retinal)
HTN in the ED – a Taxonomy
• Transient HTN• Chronic HTN• HTN Urgency• HTN Emergency• HTN-associated Crisis
Transient HTN - Examples
• Anxiety• Pain• EtOH-withdrawal• White-coat
HTN “Urgency”
• HTN “threatening” end organ damage• “End organs at risk”
• Various definitions: DBP>110, DBP>115, DBP>120
• Goal: lower BP over hours; rarely requires treatment
• Concern: bogus category, may lead to harm (eg CVAs)-see Gallagher 2003
Malignant Hypertension
Severe HTN
& Evidence of acute end-organ damage
• Diastolic BP usually > 130 mm Hg or MAP > 160• Relative rise much more important than #• Affects 1% of hypertensive patients
MAP is What Matters:• At normal resting heart rates MAP can be approximated using
the more easily measured systolic and diastolic pressures, SP and DP
• or equivalently
• or equivalently
• where PP is the pulse pressure: SP − DP-Wikipedia
“The Delta Diastolic Threatens Death”
The change in DBP accounts for most of the change in MAP
“∆ DBP is where it is at”
(for the ED setting)
Hypertensive Emergency?
Volhard & Fahr, 1914
HTN Emergency
Acute elevation in MAP causing end organ damage:• ARF• CHF, ACS• Encephalopathy (>160 MAP)• CVA, ICH• Hemolysis• Retinal
– All have DBP >120…Mortality ~90% historically
HTN Emergency – Organ Incidence?
Acute elevation in MAP causing end organ damage:• CVA (24.5%)• CHF (22.5%)• Encephalopathy (16.3%)• ACS (12%)• ICH (4.5%)• ARF (?)• Hemolysis (?)• Retinal (?)
From Zampaglione, 1996
HTN Emergency
Pathophysiology:
• Failure of autoreg• Rapid rise in SVR• Endothelial injury• Arteriolar necrosis• Ischemia• …Cascade
Secondary HTN DDx
Secondary HTN
Increased CO• RF with fluid
overload• Acute renal disease• Hyperaldosteronism• Cushing’s syndrome• Coarctation of the
Aorta
Increased vascular resistance
• Renal Artery Stenosis• Pheochromocytoma• Drugs• Cerebrovascular (CVA,
ICH, SAH)
Renal Artery Stenosis• most common treatable cause (1-5%)• compromised renal perfusion => activation of RAA • 2 pt groups:
– Elderly with atherosclerotic disease– Young females with fibromuscular dysplasia
• Clinical: abdo bruit (40-80%), retinopathy, HTN resistant to Rx, hypoK
Aldosteronism
• Uncommon but treatable• Na retention, volume expansion, increased CO• Hypernatremia & Hypokalemia typical• Primary: Adrenal adenoma, hyperplasia• Secondary: Cushing’s, CAH, exogenous
mineralcorticoids
Pheochromocytoma
• Tumour, usually in adrenal medulla• Produces xs catecholamines (epi, NE)• Paroxysmal HTN…difficult to recognize• Episodic HTN, HA, palpitations, diaphoresis, anxiety…
not a panic attack!• Easy to diagnose: elevated urinary catecholamines,
metanephrines, vandillylmandelic acid
Coarctation of the Aorta• Rare but early surgical intervention can improve
prognosis• Clinical triad:
1) upper extremity HTN2) systolic murmur over back3) delayed femoral pulses
Drugs
• Cocaine, amphetamines• ETOH withdrawal• Withdrawal from clonidine, beta blocker• MAOI + tyramine containing foods or certain Rx
(meperidine, TCA, ephedrine)– Tyramine causes release of NE– Usually rapidly destroyed by MAO
Secondary HTN• Neuro:– Autonomic dysfunction (eg GBS, cord injuries)– CNS insult (HI, ICH)
• Renal:– Renovascular stenosis– Renal disease (eg GN, Chronic pyelo)
• Endocrine:– Pituitary tumours / ectopic ACTH– Pheochromocytoma; renin tumours; Hyperaldosteronism (egCushings)– Hyper & hypo thyroid & thyroid storm
• Vascular:– Coarctation of the Ao– Vasculitis; Collagen-vascular (eg Scleroderma)– Pre-/Eclampsia
• Sleep apnea
Iatrogenic / Lifestyle HTN (aka “tertiary”)
Too Much:• Tyramine-MAOI• Glucocorticoids• Thyroxine• Fluid overload• NSAIDS• Sympathomimetics
Too Little:• Clonidine withdrawal• Anti-HTN withdrawal• EtOH withdrawal
HTN – associated Crisis
• HTN is a critical issue relating to an emergency Dx:
• Aortic Dissection• Pre/Eclampsia• ICH• CVA• Cocaine
HTN in the ED – a Taxonomy 2
• Pre-HTN• Chronic HTN• Transient HTN• HTN Emergency• HTN-associated Crisis
• 1’, 2’, 3’
Case 1
• 50 yo woman sent in by community MD & pharmacist for “HTN emergency”
• Pharmacy BP = 190/90
• Extremely worried, otherwise well
Case 2
• 65 male drove in from cottage
• Feeling unwell• Flagged at triage
with BP 200/100• Forgot BP meds at
home…missed 3 days
Case 3
• 72 yo male with chronic HTN, PAFib, and arthritis.
• Referred to CDU with elev BP “for observation”.
• 180/115 at rest• Progressive SOB
over the am.
DDx for the ED Hypertensive Patient
• Transient: pain, anxiety, sympathetic outflow• Chronic essential: poorly controlled• Chronic secondary: renovasc, pyelo, GN, pituitary, thyroid• Iatrogenic: fluid overload, pressors• OD/Ingestion: tyramine-MAOI, cocaine, amphetamines, • HTN-associated crises: Ao dissection, PIH, ICH, CVA, etc• HTN emergencies: CNS, ACS, CHF, retinal, RBCs
Assessment of the ED Hypertensive Pt?
Assessing the HTN Patient in the ED:
• Hx HTN & Tx• Rx use• PMHx• Symptoms of end-
organ damage• Pain
• Confirm BP • Good BP reading• End-organ damage• Heart sounds• Pulses• Fundoscopy
ED HTN Testing?
Testing for ED HTN:
• CBC, 7• EKG• CXR• Urine• CT head prn
r/o HTN emergency
ED HTN Management
HTN Management by Category:• Pre-HTN………………
• Chronic HTN………….
• Transient HTN………..
• HTN Emergency…......
• HTN-associated Crisis.
• Advise
• Advise, note, po Rx prn
• Assess, observe, benzo prn
• Assess, lower 20% ~1 hour
• Dx-specific tx
Anti-HTN agents in ED: Rosen
Key Agents for Canadian EM Practice:
• Metoprolol• Labetolol• Nitroglycerine
Also:• Nitroprusside• Magnesium• Esmolol• Phentolamine• Ramipril
• 25-100 po; 5 – 20 IV• 20 mg bolus IV to max 300 mg• 5-100 ug/min
• 0.25-10 ug/kg/min [Lancet, 1949]• 2-6g, then 2g/hr infusion• Load 500ug/kg/ 1min, then 50ug/kg/min, titrate• 5-10 mg/min• 2.5-5 mg po
Therapeutic Goals:• Do no harm!• End cascade• Ensure perfusion
– Risk further ischemia when BP dropped below >20% preTx
– Maintain CPP
Controversies & Issues
1. Few ED studies for HTN2. Accuracy of BP3. Missed Dx4. HTN “Urgency”5. Epistaxis6. Should EP’s treat?7. Best agents8. What benefit?
Case 1
• 50 yo woman sent in by community MD & pharmacist for “HTN emergency”
• Pharmacy BP = 190/90• Extremely worried,
otherwise well• Q: What is the clinical
definition of HTN?
Case 2
• 65 male drove in from cottage• Feeling unwell• Flagged at triage with BP
200/100• Forgot BP meds at home…
missed 3 days
• Q: What is a “hypertensive urgency”?
Case 3
• 72 yo male with chronic HTN, PAFib, and arthritis.
• Referred to CDU with elev BP “for observation”.
• 180/115 at rest• Progressive SOB over the am.
• Q: What is the definition of a “hypertensive emergency”?
Case 4
• 45 yo CEO of an IT firm• Presents with cp, SOB,
intense anxiety• Sweating, tacky, BP
200/120• Admits to cocaine
• Q: Management?
Case 5• 33 F 1 week post-partum• Epigastric pain• Seizure• BP 160/95, P90, T37.2
• Q: Dx? Management?
Case 6
• 60 M presents with tearing RSCP
• Rad to back• Assoc with L headache
and R leg weakness• BP 190/100, P 95
• Q. Management?
This Session: HTN EM1. Define HTN
2. Classify HTN in the ED setting
3. Provide a DDx for the acutely hypertensive ED patient, including 2ndary causes
4. Describe the findings of a patient with a HTN emergency
5. Describe high-utility tests for HTN in the ED
6. Describe the management of each of the categories of HTN in the ED
7. Describe at least 2 controversies in the management of HTN in the ED
HTN in the ED – a Taxonomy
• Pre-HTN• Chronic HTN• Transient HTN• HTN Emergency• HTN-associated Crisis
• 1’, 2’, 3’
**DO NO HARM**
“Treat patients, not numbers”
HTN – What’s the Big Deal in the ED?
Hypertension in the ED
Jason R. Frank MD MA(Ed) FRCPCDEM Academic Half Day
December, 2009