{"id":577,"date":"2020-02-16T22:06:38","date_gmt":"2020-02-16T16:36:38","guid":{"rendered":"https:\/\/medicineplexus.com\/?p=577"},"modified":"2020-02-16T22:06:38","modified_gmt":"2020-02-16T16:36:38","slug":"treatment-of-hypertensive-crisis","status":"publish","type":"post","link":"https:\/\/medicineplexus.com\/treatment-of-hypertensive-crisis\/","title":{"rendered":"Treatment of Hypertensive Crisis"},"content":{"rendered":"\n<p><strong>Hypertensive Crisis<\/strong><\/p>\n\n\n\n<p>systolic blood pressure (SBP) level \u2265180 mmHg and\/or a diastolic blood pressure (DBP) level \u2265 120 mmHg with or without acute target organ damage (TOD).<\/p>\n\n\n\n<p><strong>Hypertensive Urgency<\/strong><\/p>\n\n\n\n<ul><li>It is defined as elevation BP greater than 180\/120 mm Hg, without signs of Target Organ Damage (TOD).<\/li><li>Presenting symptoms include headache, shortness of breath, anxiety, and epistaxis.<\/li><\/ul>\n\n\n\n<p><strong>Hypertensive Emergency<\/strong><\/p>\n\n\n\n<ul><li>It is defined as elevation of BP greater than 180\/120 mm Hg in presence of <strong><u>signs of TOD<\/u><\/strong><\/li><\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"349\" height=\"301\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-180.png?w=349\" alt=\"\" class=\"wp-image-578\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-180.png 349w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-180-300x259.png 300w\" sizes=\"(max-width: 349px) 100vw, 349px\" \/><\/figure>\n\n\n\n<ul><li>Global burden &#8211; 24% &amp; 21% of male &amp; females with HTN (SBP&gt;=140 OR DBP&gt;=90).<\/li><\/ul>\n\n\n\n<p>India &#8211; Prevalence of HTN is 25% in urban &amp; 10% in rural people in India of which 20.6% are men &amp; 20.9% women.<\/p>\n\n\n\n<p>Causes<\/p>\n\n\n\n<ul><li>Non-adherence to anti-hypertensive medication<\/li><li>Renovascular Disease<\/li><li>Pheochromocytoma<\/li><li>Hyperaldosteronism<\/li><li>Drug Induced hypertension<\/li><li>Eclampsia\/pre-eclampsia<\/li><li>Vasculitis<\/li><\/ul>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"355\" height=\"311\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-181.png?w=355\" alt=\"\" class=\"wp-image-579\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-181.png 355w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-181-300x263.png 300w\" sizes=\"(max-width: 355px) 100vw, 355px\" \/><\/figure>\n\n\n\n<p>Diagnosis<\/p>\n\n\n\n<ul><li>History \u2013 Hypertension, Medications, Substance abuse, Comorbid conditions<\/li><li>BP \u2013 Both arms, Supine &amp; Standing (Aortic dissection)<\/li><li>Cardiac &#8211; ECG, Cardiac Enzymes, 2D-echo, X-ray<\/li><li>Renal \u2013 Serum Creatinine &amp; BUN, Liver Enzymes<\/li><\/ul>\n\n\n\n<p><strong>Management<\/strong><\/p>\n\n\n\n<ul><li>Not addressed in recent JNC-8<\/li><li>Current recommendations based on<ul><li>JNC-7 guidelines<\/li><\/ul><ul><li>ACC\/AHA 2017<\/li><\/ul><\/li><\/ul>\n\n\n\n<p><strong>Normalisation of BP is usually <u>not recommended<\/u><\/strong><\/p>\n\n\n\n<ul><li>Sudden fall in BP may cause acute hypoperfusion of vital organs &amp; results in myocardial ischemia, hemiplegia, or&nbsp; acute renal failure.<\/li><\/ul>\n\n\n\n<p><strong>Hypertensive Urgency<\/strong><\/p>\n\n\n\n<ul><li>Remember: Start Low, Go Slow<\/li><li>Fully titrate before adding second med<\/li><li>Titrate to effect (or side effect)<\/li><li>Treatment with an oral, short-acting agent such as Captopril, Labetalol<\/li><li>Increasing dose, Use of combination<\/li><\/ul>\n\n\n\n<p><strong>Goal of Therapy: Hypertensive Emergency<\/strong><\/p>\n\n\n\n<ul><li>&lt;1hr \u00e0 Reduce Systolic Blood Pressure(SBP) \u2264 25%<ul><li>2-6hr \u00e0 if stable, reduce to 160\/100\u2013110 mmHg<\/li><\/ul><ul><li>24-48hr \u00e0 Well tolerated &amp; stable toward normal BP<\/li><\/ul><\/li><\/ul>\n\n\n\n<p><strong>Pharmacotherapy<\/strong><\/p>\n\n\n\n<ol type=\"1\"><li><strong><u>Vasodilators<\/u><\/strong><ol><li>Sodium nitroprusside<\/li><\/ol><ol><li>Nitro-glycerine<\/li><\/ol><ol><li>Nifedipine<\/li><\/ol><ol><li>Nicardipine<\/li><\/ol><ol><li>Clevidipine<\/li><\/ol><ol><li>Fenoldopam<\/li><\/ol><ol><li>Hydralazine<\/li><\/ol><ol><li>Enalaprilat<\/li><\/ol><\/li><li><strong><u>Adrenergic inhibitors<\/u><\/strong><ol><li>Labetalol<\/li><\/ol><ol><li>Esmolol<\/li><\/ol><ol><li>Phentolamine<\/li><\/ol><\/li><\/ol>\n\n\n\n<p><strong>Sodium Nitroprusside &#8211; <\/strong>MOA \u2013 Preload &amp; afterload<\/p>\n\n\n\n<ul><li>Arteriolar &amp; venous dilation, cerebral vasodilation<\/li><li>DOSE- 0.3\u20130.5 mcg\/kg\/min IV infusion, max &#8211; 10 mcg\/kg\/min<\/li><\/ul>\n\n\n\n<p>Ultra short acting -1-2min, t \u00bd 3-4 minutes<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"277\" height=\"164\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-182.png?w=277\" alt=\"\" class=\"wp-image-580\" \/><\/figure>\n\n\n\n<ul><li>Adverse Effect\/Precaution-<\/li><li>Cyanide &amp; thiocyanate toxicity prolonged infusion,&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/li><li>Thiosulfate &#8211; to prevent cyanide toxicity<\/li><li>Bottle is covered with an opaque wrapping<\/li><li>Continuous BP monitoring<\/li><li>Use \u00e0 Aortic dissection,&nbsp; Acute LVF<\/li><\/ul>\n\n\n\n<p><strong>Nitroglycerin<\/strong><\/p>\n\n\n\n<ul><li>MOA- Greater preload reduction than afterload, Decreases coronary vasospasm<\/li><li>DOSE- 5-100mcg\/min, Titrate up 10mcg every 5 mins<\/li><\/ul>\n\n\n\n<p>Onset 2-5min, Half life \u2013 4min<\/p>\n\n\n\n<ul><li>Adverse Effect\/Precaution- Headache, Tachycardia, Tolerance, Continuous BP monitoring<\/li><\/ul>\n\n\n\n<p>C\/I- Head trauma\/Cerebral haemorrhage, with PDE-5 inhibitors<\/p>\n\n\n\n<ul><li>Uses &#8211; Acute HF,&nbsp; Acute coronary syndrome.<\/li><\/ul>\n\n\n\n<p><strong>Oral\/Sublingual Nifedipine<\/strong><\/p>\n\n\n\n<ul><li>MOA- Peripheral &amp; coronary arteriolar dilator, Potential hypotension and\/or reflex cardiac stimulation<\/li><\/ul>\n\n\n\n<p>Sudden uncontrolled &amp; severe reductions in BP,&nbsp; may precipitate&nbsp; cerebral, renal &amp; myocardial ischemic events<\/p>\n\n\n\n<ul><li>\u201cInappropriate physician habits in prescribing nifedipine capsules in hospitalized patients\u201d<\/li><li><strong>Cardiorenal Advisory Committee <\/strong><strong>of FDA has concluded&nbsp; \u201cthat practice of administering SL\/oral nifedipine abandoned because this is not safe nor efficacious<sup>1<\/sup><\/strong><\/li><\/ul>\n\n\n\n<p><strong>Nicardipine<\/strong><\/p>\n\n\n\n<ul><li>MOA- L-type Ca<sup>++<\/sup> channel blocker \u2013 selective Arterial vasodilator, Cerebral &amp; Coronary vasodilatation<\/li><li>DOSE- Start 5mg\/hr IV infusion, titrate every 15min to max 15mg\/hr<\/li><\/ul>\n\n\n\n<p>Duration of action 15-30min,<\/p>\n\n\n\n<p>Adverse Effect\/Pr\u00e9caution- Worsen\/cause HF, &nbsp;Reflex tachycardia<\/p>\n\n\n\n<ul><li>Uses &#8211; Ideal for CNS emergencies, Renal Disease<\/li><\/ul>\n\n\n\n<p><strong>Clevidipine<\/strong><\/p>\n\n\n\n<ul><li>MOA- <strong>3<sup>rd<\/sup> gen (L-type) CCB, arterial vasodilator FDA approval (2008<\/strong>), Injectable emulsion<\/li><li>DOSE- Start 1-2mg\/hr with rapid titration to max 32mg\/hr<\/li><\/ul>\n\n\n\n<p>Ultra short t1\/2 &#8211; 1 min, Duration of action 5-15min, PPB -99.9%<\/p>\n\n\n\n<ul><li>Adverse Effect\/Precaution- Atrial fibrillation, C\/I \u2013 Allergies (soy &amp; egg products), Defective lipid metabolism<\/li><li>Uses &#8211; <strong>All HTN emergencies (Safe in Renal &amp; Hepatic dysfunction)<\/strong><\/li><\/ul>\n\n\n\n<p><strong>Fenoldopam<\/strong><\/p>\n\n\n\n<ul><li>MOA- Peripheral&nbsp; Dopamine-1&nbsp; agonist(DA1). 10 \u2013fold more potent renal vasodilator than Dopamine<\/li><li>DOSE- 01-0.3mcg\/kg\/min infusion, Max infusion rate \u2013 1.6mcg\/kg\/min (Titratable, Predictable &amp; Stable)<\/li><li>Adverse Effect\/Precaution- Tachycardia, Headache, Hypokalemia. Caution with glaucoma.<\/li><li>Advantages- All HE, Renal insufficiency patients &nbsp;Strokes (combination with Nicardipine)<\/li><\/ul>\n\n\n\n<p><strong>Hydralazine<\/strong><\/p>\n\n\n\n<ul><li>MOA- Direct arteriolar dilator, opening high conductance Ca2+-activated K+ channels<\/li><\/ul>\n\n\n\n<p><strong>Delayed onset, Unpredictable hypotensive effect<\/strong><\/p>\n\n\n\n<ul><li>DOSE- Dose: 10-20 mg I V, repeated in 30 mins, 10-40mg IM. <strong>Not titratable<\/strong><\/li><li>Adverse Effect\/Precaution- TACHYCARDIA,&nbsp; Drug-induced Lupus syndrome<\/li><\/ul>\n\n\n\n<p>Aggravation of angina, Sodium &amp; water retention<\/p>\n\n\n\n<ul><li>Advantages- Eclampsia<\/li><\/ul>\n\n\n\n<p><strong>Enalaprilat<\/strong><\/p>\n\n\n\n<ul><li>MOA- Active component of Enalapril,&nbsp; ACE inhibitor<\/li><li>DOSE- 1.25-5mg IV every 6hr. Difficult to titrate<\/li><li>Adverse Effect\/Precaution- Excessive fall in BP, C\/I- Acute MI, Renal Disease,&nbsp; Pregnancy, Volume depletion<\/li><li>Use &#8211; Acute LVF , Expensive<\/li><\/ul>\n\n\n\n<p><strong>Esmolol<\/strong><\/p>\n\n\n\n<ul><li>MOA- Cardio selective \u03b2 Blocker<\/li><li>DOSE- Loading dose 500mcg\/kg over 1 min, Infusion of 50-300mcg\/kg\/min<\/li><li>Adverse Effect\/Precautions- Bradycardia<\/li><\/ul>\n\n\n\n<p>C\/I- 1<sup>st<\/sup> degree heart block, COPD, CKD<\/p>\n\n\n\n<ul><li>Uses- Aortic Dissection, Cardioprotective in CVS emergencies<\/li><\/ul>\n\n\n\n<p><strong>Labetalol<\/strong><\/p>\n\n\n\n<ul><li>MOA- Selective \u03b11 and non-selective \u03b2 blocker (1:7)<\/li><\/ul>\n\n\n\n<p>Maintains cardiac output, Cerebral, renal, coronary blood flow, Reduces SVR<\/p>\n\n\n\n<ul><li>DOSE- 20-80mg IV Bolus every 10min, or infusion of 2mg\/min to max of 300mg.<\/li><li>Adverse Effect\/Precautions- Exacerbate CHF, C\/I \u2013 COPD, Heart Block, decompensated HF<\/li><li><strong>uses- PIH, Pheochromocytoma<\/strong><\/li><\/ul>\n\n\n\n<p><strong>Phentolamine<\/strong><\/p>\n\n\n\n<ul><li>MOA- \u03b1 adrenergic blocker<\/li><li>DOSE- Bolus 5-20mg IV every 5min,<\/li><li>Adverse Effect\/Precaution- Tachycardia, flushing, Postural Hypotension<\/li><\/ul>\n\n\n\n<p>C\/I- use with PDE-5 inhibitors, Renal Impairment<\/p>\n\n\n\n<ul><li>Advantages- Pheochromocytoma, Cocaine associated HPT crisis<\/li><\/ul>\n\n\n\n<p><strong>Management of Hypertensive Emergency with TOD<\/strong><\/p>\n\n\n\n<p><strong>Pulmonary Edema (LVF)<\/strong><\/p>\n\n\n\n<ul><li>Nitroglycerin 5 mcg\/min.<\/li><li>Sodium Nitroprusside (reduces preload) -0.3 to 0.5 mcg\/kg\/min<\/li><li>IV Diuretic (reduces preload &amp; afterload)- 40mg IV<\/li><li>Morphine \u2013 Vasodilator &amp; Sympatholytic<\/li><li>Clevidipine infusion 1\u20132 mg\/h, max 32 mg\/h.<\/li><li><strong>Low EF <\/strong><strong>\u00e0 Avoid beta blockers\/Negative inotropes<\/strong><\/li><\/ul>\n\n\n\n<p><strong>Acute Myocardial Infarction<\/strong><\/p>\n\n\n\n<ul><li>Reduce MAP by 20 -25% of baseline<\/li><li>Nitrates should be given till symptoms subside or until DBP&lt;100<\/li><li>Drug of choice: Nitroglycerine 5 mcg\/min, Labetalol (or Esmolol), Nicardipine &#8211; 5 mg\/h<\/li><li><strong>Avoid Hydralazine <\/strong><strong>&#8211; Increase myocardial O<sub>2<\/sub> demand<\/strong><\/li><\/ul>\n\n\n\n<p><strong>Acute Aortic Dissection<\/strong><\/p>\n\n\n\n<ul><li>OK to aggressively reduce BP (&lt;120\/80)<\/li><li>Reducing the shear stress on aortic wall<\/li><li>Aim of treatment to reduce SBP as rapidly as possible down to 100-110 mmHg &amp; to control tachycardia<\/li><li>1<sup>st<\/sup> Esmolol then Nitroprusside<\/li><li>Hydralazine is C\/I<\/li><\/ul>\n\n\n\n<p><strong>Ischemic Stroke<\/strong><\/p>\n\n\n\n<ul><li>Blood Pressure -Systolic &gt; 185 or diastolic &gt; 110 mm Hg<\/li><li>Labetalol 10 to 20 mg IV over 1 to 2 min may repeat x 1&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; or<\/li><li>Nicardipine infusion, 5 mg\/h, titrate up by 0.25 mg\/h to max dose 15 mg\/h<\/li><li>Desired blood pressure obtained, reduce to 3 mg\/h<\/li><li>If BP not controlled or diastolic BP &gt;140 mm Hg, consider IV sodium nitroprusside<\/li><\/ul>\n\n\n\n<p><strong>Sympathetic crises<\/strong><\/p>\n\n\n\n<ul><li>PATHOLOGY- Pheochromocytoma, Monoamine oxidase inhibitor + tyramine, Cocaine\/amphetamines overdose.<\/li><li>GOAL- Reduce MAP by ~25% over several hours<\/li><li>DOC- Phentolamine: 5-15mg IV bolus or drip 5-10mcg\/kg\/min<\/li><\/ul>\n\n\n\n<p>Beta-blocker- Labetalol (control tachycardia)<\/p>\n\n\n\n<p>Benzodiazepines &#8211; Helpful in cocaine\/amphetamine overdose<\/p>\n\n\n\n<p><strong>Pre-eclampsia and Eclampsia<\/strong><\/p>\n\n\n\n<ul><li>PATHOLOGY- Systemic arterial vasoconstriction (Including Placental)<\/li><li>Defined as SBP = 140\/90 mmHg or greater, OR a 20 mmHg rise in SBP or 10 mmHg rise in DBP from baseline<\/li><li>Restlessness &amp; hyper-reflexia , seizures, proteinuria<\/li><li>GOAL- D<em><u>elivery of the fetus and placenta<\/u><\/em><\/li><li>DOC- MgSO4: 4-6gm over 15 minutes IV, drip 1-2gm\/hr<\/li><li>Hydralazine: 5-10mg IV, drip 5-10mg\/hr<\/li><li>Labetalol: 20mg IV, repeat prn q 10 mins, drip 1-2mg\/min<\/li><\/ul>\n\n\n\n<p><strong>Intracerebral Hemorrhage<\/strong><\/p>\n\n\n\n<p>Rise in BP due to increased ICP &amp; irritation of ANS<\/p>\n\n\n\n<ul><li>GOAL- Treatment based on clinical\/radiographic evidence<\/li><\/ul>\n\n\n\n<p>Raised ICP \u2013 MAP&lt;130 (1st 24hrs)<\/p>\n\n\n\n<p>No raised ICP \u2013 MAP&lt;110<\/p>\n\n\n\n<p>To prevent re-bleeding &amp; reduce edema.<\/p>\n\n\n\n<p>BP &gt;180\/105 mmHg , benefit from gradual 20-25% reduction in BP<\/p>\n\n\n\n<ul><li>DOC- IV Nicardipine 2mg bolus, then 4-15mg\/hr (treat SAH )<\/li><\/ul>\n\n\n\n<p>Nimodipine PO 60mg q 4hr (to reverse vasospasm<strong>)<\/strong><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"636\" height=\"477\" src=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-183.png?w=636\" alt=\"\" class=\"wp-image-581\" srcset=\"https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-183.png 636w, https:\/\/medicineplexus.com\/wp-content\/uploads\/2020\/02\/image-183-300x225.png 300w\" sizes=\"(max-width: 636px) 100vw, 636px\" \/><\/figure>\n","protected":false},"excerpt":{"rendered":"<p>Hypertensive Crisis systolic blood pressure (SBP) level \u2265180 mmHg and\/or a diastolic blood pressure (DBP) level \u2265 120 mmHg with or without acute target organ damage (TOD). Hypertensive Urgency It is defined as elevation BP greater than 180\/120 mm Hg, without signs of Target Organ Damage (TOD). Presenting symptoms include headache, shortness of breath, anxiety,[&#8230;]\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","footnotes":""},"categories":[3],"tags":[],"_links":{"self":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/577"}],"collection":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/comments?post=577"}],"version-history":[{"count":0,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/posts\/577\/revisions"}],"wp:attachment":[{"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/media?parent=577"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/categories?post=577"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medicineplexus.com\/wp-json\/wp\/v2\/tags?post=577"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}