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Hypertensive Crises
Hypertensive Crises
Hypertensive Crises
8/26/08
Severe Hypertension:
Definitions
Hypertensive Emergency: Very high BP with
acute end-organ damage or a clinical setting that
could be immediately life-threatening therefore
need to lower BP in a matter of minutes with
parenteral drugs in an ICU
Hypertensive Urgency: Very high BP without
acute end-organ damage or only retinal changes,
therefore BP can be lowered in hours to days,
preferably slowly, sometimes in an outpatient
setting
3
2
Headaches
Visual symptoms
Malaise, fatigue
Weight loss
Dyspnea
Abdominal
discomfort
Neurologic
symptoms
Objective
Retinopathy
hypokalemia
Hyperaldosteronism
Microangiopathic
hemolytic anemia
Heart failure
Hematuria
proteinuria
MS03-11829
Malignant Hypertension:Epidemiology
In the U.S. the number of hospital admissions with
malignant hypertension as primary diagnosis increased
from about 16,000 to 32,000 between 1982 and 1993
In a multiracial population in England the incidence rate
was not changed from 1970 to 1993
More common in males(2:1), blacks (4-6:1), smokers
(R.R.5:1)
Younger subjects: 57% are 30-50 years old, very rare after
age 65
In one series only 14% of patients had had hypertension for
more than 10 years
Malignant
Hypertension:Treatment
Goal of therapy is to decrease blood
pressure to diastolic BP of 100-105 mm Hg
in a matter of hours with maximal initial
fall in BP no greater than 25%
Oral therapy can be used if only retinal
changes are present
Initial parenteral therapy indicated if
cardiovascular, neurologic, renal or other
visceral involvement present
Parenteral Therapy in
Malignant Hypertension
Neurologic syndromes
Acute pulmonary edema
Acute myocardial infarction
Rapidly failing vision
Rapid deterioration of kidney
function
Abdominal emergency
Malignant Hypertension:
Prognosis
If treated optimally survival at 4 years is
90%, or higher if treated at an early stage
Prognosis worse if there is acute kidney
injury or if there is delayed diagnosis
Patients can recover life-sustaining kidney
function even if they need acute dialysis
Complications: ESKD, loss of vision
Causes of death: cerebral hemorrhage,
heart failure, abdominal catastrophe
Thromboembolic stroke
Transient ischemic attack
Cerebral hemorrhage
Hypertensive encephalopathy
(posterior reversible encephalopathy
syndrome)
Subarachnoid hemorrhage
Hypertensive Encephalopathy
Acute neurologic syndrome characterized by:
Marked, usually sudden blood pressure
Headache
Nausea and vomiting
Visual complaints
Altered mental status
+/- papilledema or retinal exudates and hemorrhages
+/- transient neurological deficits
Head MRI: subcortical/cortical edema mainly in
posterior location; no infarction or hemorrhage
Dramatic improvement with blood pressure
Breakthrough Theory of
Hypertensive Encephalopathy
Blood Pressure
Failure of Autoregulation
Forced Vasodilatation
(Sausage String Pattern)
Endothelial
Permeability
Hyperperfusion
Capillary Hydrostatic
Pressure
CEREBRAL EDEMA
Hypertensive Encephalopathy
(Headache, Nausea, Vomiting,
Altered Mental Status, Convulsions)
Nolan CR. Malignant Hypertension and Other Hypertensive Crises. In: Diseases of the Kidney and Urinary Tract, 7 th Ed., RW
Schrier, Ed. Lippincott Williams & Wilkins,, Philadelphia, 2001.
Hypertensive Crises:
Cardiologic Causes
Acute Aortic Dissection: Must lower MAP and the
maximal rate of rise of the pressure (dp/dt). First
Beta blockade and then nitroprusside to achieve
a low SBP 100-120mm Hg
Acute Pulmonary Edema: Nitroprusside or
nitroglycerin with a loop diuretic. Try to achieve
BP of 130/80 if possible. Avoid hydralazine and
Beta-blockers
Angina Pectoris or Acute MI: Nitroglycerin; can
add labetalol. Avoid drugs that increase cardiac
work (hydralazine)
Hypertensive Crisis
Principles of Management
Beware of pseudo emergencies
More complications now reported from overzealous
treatment than from under-treatment in hospitalized
patients
Use oral drugs unless there is a true hypertensive
emergency or if oral drugs cannot be taken
Achieving a normal blood pressure is not necessary
except in rare circumstances (aortic dissection)
Accept high blood pressure in patients with certain
neurologic conditions; follow such patients with the
neurologist
If oral therapy is chosen, avoid intermittent IV/SL or
transcutaneous medication
Severe Hypertension
BP > 180/120
Encephalopathy
Progressing target organ damage
YES
NO
(HT Emergency)
New onset
(HT Urgency)
Admit to ICU
Baseline lab
Parenteral Rx
Baseline lab
Oral Rx
Reinstitute oral Rx
Follow closely
Workup for
identifiable causes:
Renovascular HT
Kaplan NM. Hypertensive Crises. In: Kaplans Clinical Hypertension, 8th Ed. W. Neal, Ed. Lippincott Williams &
Wilkins, Philadelphia, 2002