Malaysian Clinical Practice Guideline

Hypertension 2018 :

Severe Hypertension

Norseha Isnin
Pakar Perubatan Keluarga
Klinik Kesihatan Sultan
Ismail
Severe Hypertension
 Definition:

Persistent elevated SBP >180 mmHg and/or

DBP >110mmHg.
May present with:
* incidental finding in an asymptomatic non-
previously diagnosed patient
* treated hypertension on follow-up who are
asymptomatic
* patients with symptoms which may include:
• non-specific symptoms like headache, dizziness,
lethargy
• symptoms and signs of acute target organ
damage/complication.
( Include acute heart failure, acute coronary syndromes, acute renal
failure, dissecting aneurysm, subarachnoid haemorrhage, hypertensive
encephalopathy and preeclampsia/eclampsia (Refer to chapter 7.4
Hypertension and Stroke, chapter 7.6 Hypertension in Women)
Categorised of Severe Hypertension
(a) hypertensive urgencies hypertensive
(b) hypertensive emergencies crises

Large series of admission :

5.1% hypertensive crisis
( 76.6 % constitute hypertensive emergency)
Management:
Evaluation of patients include :
* thorough history
* physical examination
- signs of acute target organ damage /
complications
- causes of secondary hypertension
(Table 6A)
* laboratory investigations.
6.1 SPECIFIC MANAGEMENT
 Aim - to reduce BP in a controlled,
predictable and safe manner
 To avoid the onset or aggravating acute

coronary syndrome, cerebral or renal

ischaemia.
7.1.1 Asymptomatic Severe
Hypertension ( Previous CPG)
 Newly diagnosed - admission may be
necessary
 Drug adherence ( Poor compliance)

* drug regime reviewed

* oral combination therapy preferred.

DON’T reduce BP rapidly (within min to hours)

( Grade C) -may precipitate ischaemic events
6.1.2 Hypertensive Urgencies
Grade III or IV retinal changes
(accelerated and malignant hypertension)
 No overt acute target organ

damage/complication.

Flame shape
haemorrhage

Macular star papilloedema

Treatment Hypertensive Urgencies
 Admit patient.
 BP measurement repeated after 30

minutes of bed rest.

 Initial treatment - aim for about 25%

reduction in BP over 24hours but not lower

than 160/90 mmHg
 Oral combination drugs are effective ( Table

6-B)
6.2 Dangers of Rapid Reduction in BP
 Hypertensive urgencies - AVOID Rapid reduction of BP
(within minutes to hours) it may precipitate ischaemic
events.
 NO LONGER RECOMMENDED: Oral or sublingual drugs
with rapid onset of action can result in an uncontrolled BP
reduction. Several serious side effects have been reported
with the administration of sublingual fast-acting
nifedipine .
 However oral nifedipine retard CAN BE USED and has been
recommended as first line therapy for hypertensive
urgencies.
 Following stabilisation of patient’s BP, subsequent
management is tailored towards achieving optimal control
6.1.2 Hypertensive Emergencies
 Severe elevation of blood pressure
associated with new or progressive end
organ damage/complication
* acute heart failure
* dissecting aneurysm
* acute coronary syndromes
* hypertensive encephalopathy
* subarachnoid haemorrhage
* acute renal failure.
 May occur in BP < 180/110 mmHg,

particularly if the BP has risen rapidly.

Treatment Hypertensive Emergencies
 Admit patients for immediate intervention and
monitoring.
 Need to be reduce their BP rapidly based on

clinical scenarios - refer also to chapter 7.4

Hypertension and Stroke, and chapter 7.6
Hypertension in Women.
 BP needs to be reduced rapidly - BP reduced

by 10%-25% within certain minutes to hours

but not lower than 160/90 mmHg.
 Best achieved with parenteral drugs. (Table 13)
23.7.19 : Incidence at
KKOM …..

Pregnant lady @ 34/52

- HPTn / DM on
medication:
Methyldopa 500mg tds
Metformin 500mg BD
S/C Insulatard 10 u ON

c/o :- Headache 1/7

(frontal region )
No neck stiffness
No numbness of
limbs
- vomiting >5x today
-↓ Fetal movement
( only 6 kick)

O/E : BP 212/111 mmHg

P 82/min
( taken medication @ 9am)
Case spoken to MO at KK…

Instruction given :
Refer pt to KKSI stat

If you in this
situation how you
manage this
patient ??
THANK YOU