HYPERTENSION Emergencies & Urgencies

Dr. Suresh Menon MD ( Int. Med.)

Definitions
Emergencies
Symptomatic Acute End-Organ Damage Diastolic B.P. usually >130 mmHg

Urgencies
Asymptomatic NO Acute End-Organ Damage Diastolic B.P. usually >110 mmHg; Systolic B.P. usually >180 mmHg

This is a Hypertensive Emergency

Begin to look for other causes of symptoms

Begin Treatment!

Principles of Therapy
Lower B.P. over hours
Initial goal B.P. 160s/90s

Too rapid lowering may cause dire consequences (CVA, MI) May take several days to get to reasonable levels Avoid medications that cannot be controlled (sublingual nifedipine)

Hypertensive Emergencies: Treatment

For most patients the greatest risk of treating a hypertensive emergency is the risk of accompanying hypotension.

Treat with short acting, easily titratable, I.V. drug.

Parenteral Drugs for Treatment of Hypertensive Emergencies

Drug Dosage Onset Duration Adverse Indic.(I) Effects Contrain.(C)
1-2 min. N/V,mus. twitch., cyanide, thiocyan. tox. intracran. pressure I: CHF, aortic dissect., catechol. C: hepatic, renal insuff. HA, I: coronary dizziness, dis., CHF vomit., C: CVA methemglo. intracran. tolerance pressure

Vasodilators
Nitroprus- 0.3-10 1-2 min. side mcg/kg/min IV infusion

Nitroglycerin (IV)

5-100 2-5 min. mcg/kg/min

3-5 min.

Parenteral Drugs for Treatment of Hypertensive Emergencies

Diazoxide

(Hyperstat
IV)

1-3 mg/kg (up to 150 mg) IV bolus, q515 min; repeat q424 hr as needed

2-4 min

3-12 hr

Nausea, hypotension, flushing, tachycardia, hyperglycemia, aggravation of angina, fluid retention

C: Syndromes of coronary insufficiency, (unless used with betablocking agent), cerebrovascul ar accident, hypersensitivity to sulfonamides

Parenteral Drugs for Treatment of Hypertensive Emergencies

Fenoldopam 0.1-1.7 mesylate micrograms/kg/min (Corlopam) IV infusion 5-15 1-4 hr Headache, dizziness, min flushing,
I: Severe hypertension with increased renal insuffiintraocular ciency pressure, hypokalemia, C: Glaucoma dose-related tachycardia

Hydralazine 10-20 mg IV or IM 10-20 3-8 hr Tachycardia, I: CHF flushing, C: Coronary HCl bolus, repeat q4-6 hr min headache, insufficiency, (Apresoline) as needed (maximum
dose, 40 mg) vomiting, aggravation of angina

aortic dissection, cerebrovascular accident (may increase intracranial pressure)

Parenteral Drugs for Treatment of Hypertensive Emergencies

Enalaprilat 1.25-5 mg q6 15
(Vasotec I.V.) hr IV min 6 hr Precipitous drop in blood pressure in high-renin states, variable response I: CHF C: Use with caution in patients with severe renal insufficiency
(not receiving dialysis)

Nicardipine 5-15 mg/hr 5-20 IV infusion min HCl

(Cardene)

1-2 Tachycardia, hr headache, flushing, local phlebitis

C: Greater than firstdegree heart block, CHF

Parenteral Drugs for Treatment of Hypertensive Emergencies

Adrenergic Inhibitors
Phentolamine (Regitine) -blocker 5-20 mg IV, repeat as necessary 1-2 min 10-30 Tachycardia, I: min nausea, Catecholamine flushing, excess abdominal C: Syndromes pain, of coronary aggravation insufficiency of angina 10-20 Hypotension, I: Syndromes of min nausea, coronary bradycardia insufficiency or heart C: Greater than block, first-degree dizziness heart block, CHF

Esmolol 200-500 1-2 HCl micrograms/kg/ min (Brevibloc) min over 1-4 min, then 50-300 micrograms/kg/ min IV infusion

Parenteral Drugs for Treatment of Hypertensive Emergencies

Labetalol HCl (Normodyne, Trandate) - blocker 20-80 mg IV bolus, repeat as needed (maximu m dose, 300 mg); or 2 mg/min IV infusion 2-10 min 2-4 hr Hypotension, nausea, itching, scalp tingling, dizziness I: Syndromes of coronary insufficiency, catecholamine excess C: > firstdegree heart block, CHF, bronchial asthma

Fenoldopam: Indications
In-hospital, short-term (up to 48 hours) management of severe hypertension when rapid, but quickly reversible, emergency reduction of blood pressure is clinically indicated, including malignant hypertension with deteriorating end organ function. Transition to oral therapy with another agent can begin at any time after blood pressure is stable during fenoldopam infusion.

Physiologic Effects Fenoldopam

Does not cross BBB Systemic Vasodilation

Metabolized by conjugation No P450 interaction

Coronary Vasodilation without steal (in animals) Reflex tachycardia

RBF Na excretion H2O excretion Maintains GFR during BP lowering

Mesenteric vasodilation Mucosal PO2 (in animals)

Fenoldopam: Adverse Events

Headache Flushing Nausea EKG Abnormalities Tachycardia Vomiting Dizziness Extrasystoles Dyspnea

Hypotension
Hypokalemia

Nicardipine: Characteristics
Dihydropyridine Reflex tachycardia Useful when -Blockers contraindicated Water soluble and light stable
(allows for IV infusion)

Slow onset and offset Arterial catheter not mandatory May accumulate Variable duration of hypertensive effect Good in patients with renal disease

Nitroprusside
Onset 1-4 min., half-life Toxicity related to 1-2 min. total dose Metabolized by RBC S&S: met. acidosis, to cyanide then by confusion, air hunger, liver to thiocyanate, hyper-reflexia, cleared by kidneys confusion, and Caution with hepatic seizures. &/or renal disease Reversible by hydroxycobalamine, sodium nitrate, (?) methylene blue

Therapy Hypertensive Urgencies

Oral meds. Preferred
Close monitoring Fast follow-up Start with short acting forms
(not Ca+2 channel blockers)

Drugs for Urgencies

Clonidine -Blockers, - Blockers Captopril, Enalapril Minoxidil (if already on -blocker & diuretic) Hydralazine

Drug Related Malignant Hypertension

MAO Inhibitors Cold Preparations Withdrawal Antihypertensive Meds
Clonidine, -Blockers

Street Drugs
Cocaine, PCP