Recent Management of Hypertensive Emergencies

Wiguno Prodjosudjadi
Division of Nephrology and Hypertension Department of Internal Medicine, Faculty of Medicine University of Indonesia Dr. Ciptomangunkusumo General Hospital Jakarta

Hypertensive Emergencies
Severe Hypertension Acute Impairment of Organ System

Emergency Unit

Severe hypertension without target organ damage

Hypertensive Urgencies
Severe Hypertension

Severe Hypertension

Potential Risk of Acute Organ Damage

Hypertensive Emergencies
Hypertensive encephalopathy

Intracranial bleeding
Left heart failure

Acute myocard infark

Acute dissecting aorta

Eclampsia

Malignant hypertension

Clinical Manifestations of Hypertensive Encephalopathy

Severe headache

Nausea and vomiting

Visual disturbances Confusion Focal and generalized weakness Focal or generalized seizure Focal neurological signs

Intracerebral Bleeding

Clinical Manifestations of Aortic Dissection

Pain in the chest, back or abdomen Abrupt, severe, persistent and may migrate down-ward Discrepancies between pulses Murmur of aortic insufficiency Neurological deficits Mediastinal widening on chest X ray

Type of Aortic Dissection

Type A

Type B
Chest 1991 ; 99 : 724-29

Pathophysiology of Hypertensive Emergencies

Acute Increase of BP on Target Organ

Blood Pressure Arteriolar Vasoconstriction

Normal CBF
Transudate leak Arteriolar damage

Acute Blood Pressure

Vasoconstriction Autoregulation

Acute Blood Pressure

Increase cardiac workload

CHF

Acute Blood Pressure

Renal system impairment & Failure of Autoregulation

Arteriosclerosis Fibrinoid necrosis

http://www.emedicine.com/emerg/topic267.htm

Proposed Role of Passive Dilatation and Disruption of the Blood Brain Barrier

Hypertension, 1988 ; 12 : 89-95

Putative Vascular Pathophysiology of Hypertensive Emergencies

Lancet 2000 ; 356 : 41117

Fibrinoid Necrosis

Mechanisms of Malignant Hypertension

Critical degree of Hypertension Endothelial damage Increase in vasoconstrictors (renin-angiotensin, vasopressin Catecholamines) Further blood pressure increase Pressure natriuresis Hypovolemia Fibronoid necrosis & intimal proliferation Further release of vasoconstrictors

Platelet and fibrin deposition

Intravascular hemolysis

Increase in BP and Ischemia

JASN, 1998 ; 9 :133

Hyperplastic Arteriolitis in Malignant Hypertension

Silver Stain

Distal Renal Interlobular Artery in a 48 Years Old

Atlas of Heart Diseases, 1994 : Vol. 1

Management of Hypertensive Emergencies

Principles in the Management of Hypertensive Emergencies

Minimizing TOD due to high blood pressure

Avoid deleterious effects of drug treatment

Purpose of treatment :
Over minutes to hours : BP should be lowered by up to 25% MAP

or DBP should be lowered up to 100 -110 mmHg

Intravenous antihypertensive drugs is needed

Parenteral Drugs for Treatment of Hypertensive Emergencies

Sodium nitroprusside

Nicardipine HCl
Nitroglycerine

Enalaprilat
Hydralazine HCl Diazoxide Labetalol HCl

Treatment of Hypertensive Emergencies

Type of Hypertensive Encephalopathy Intracranial hemorrhage Left ventricular failure Drug of Choice Nitroprusside Labetalol Nitroprusside, Diuretic, ACE-I Alternative or Second line drug Labetalol Nitroglycerin Nitroglycerin

Acute myocardial infarction

Dissecting aortic aneurysm Eclampsia

Nitroglycerin, Betablockers
Beta-blockers, Nitroprusside Hydralazine, labetalol

Nitroprusside, labetalol
Labetalol, Verapamil Nifedipine
JASN 1998;9(1):133-142

Intravenous Antihypertensive Drugs Available in Indonesia

Clonidine Nicardipine HCl Diltiazem HCl Nitroglicerin Diazoxide, Nitroprusside

Clonidine
Available in 150 g per 2 ml ampul Maximal dose was 900 g / 24 hours Dilute 300 - 900 g in 5% Dextrose (250 cc)

given IV micro-drip infusion or syringe pump

Dose titration is based on the level of blood pressure 24 Hours after BP target was reached, change to oral antihypertensive therapy

Intravenous Antihypertensive Drugs Available in Indonesia

Clonidine Nicardipine HCl Diltiazem HCl Nitroglicerin Diazoxide, Nitroprusside

Nicardipine HCl
Available in 2 mg (2 ml) and 10 mg (10 ml) per ampul

Can be administered as bolus injection ( 10-30 g/Kg

BW), IV micro-drip infusion or by syringe-pump IV micro-drip infusion with a starting dose 5 mg/hr; the

dose can be increased every 15 minutes by 2,5 mg/hr

up to 15 mg/hr (maximal dose) After target of BP was reached, reduce the dose by 3 mg/hr and then change to oral antihypertensive therapy

Intravenous Antihypertensive Drugs Available in Indonesia

Clonidine Nicardipine HCl Diltiazem HCl Nitroglicerin Diazoxide, Nitroprusside

Diltiazem HCl
Available in 10 mg and 50 mg per ampul Can be administered as bolus injection (0,25 mg/kg BW over period of 3 minutes, with maximal dose 20 mg) Second bolus can repeated 15 minutes after first

bolus (0,35 mg/kgBW with maximal dose of 25 mg).

For IV drip infusion starting dose is 10 mg/hr which can be increased up to 15 mg/hr (maximal)

Bolus I.v. 0.2 mg/kg 10 Drip infusion 50 mg/hour 20 Drip infusion 30 mg/hour 30 Drip infusion 5-10 mg/hour Every 30-60 minutes observation 10% MBP reduction From Baseline

20% MBP reduction From Baseline

Target MBP Level

Switch to Oral DILTIAZEM 180SR

Intravenous Antihypertensive Drugs Available in Indonesia

Clonidine Nicardipine HCl Diltiazem HCl Nitroglicerin Diazoxide, Nitroprusside

Nitroglycerin
Can be given by IV drip infusion with the rate of

5-100 gr/minutes
Dose titration is based on the level of BP

Onset of action is 2-5 minutes and the duration of

action is 3-5 minutes Indication : hypertensive emergencies (with angina pectoris or MCI) and lung edema

Intravenous Antihypertensive Drugs Available in Indonesia

Clonidine Nicardipine HCl Diltiazem HCl Nitroglicerin Diazoxide, Nitroprusside

Diazoxide
Recommended dose 300 mg or 5 mg/Kg BW IV bolus with small dose (75-150 mg) is safe and effective

Prognosis of Hypertensive Emergencies

Untreated hypertensive emergencies : the 1 year
mortality rate is more than 90%

All patients presenting with hypertensive

emergencies in ER : the median survival duration is 144 months All presenting hypertensive emergencies : the 5year survival rate is 74%

Conclusions
In hypertensive emergencies the blood pressure

should be lowered aggressively over minutes to hours

The purpose of antihypertensive treatment to prevent

target organ damage due to high blood pressure and

minimizing the risk of hypoperfusion

Various intravenous antihypertensive drugs can be

selected