Emergency Department Evaluation and Treatment of Hypertension

What is Hypertension?
Systolic blood pressure >140 mm Hg or Diastolic blood pressure >90 mm Hg

Why is it important to treat Hypertension?

Hypertension significantly increases the risk of cardiovascular disease: Stroke CAD CHF Renal insufficiency/failure

The Framingham Study

Patients 45 74 years old followed for a mean of 18 years

Results of the Framingham Study:

The risk of a cardiovascular event rises progressively with both systolic and diastolic blood pressure The yearly risk of a cardiovascular event is higher for older patients At all ages and blood pressures, men are at a slightly higher risk than women

What is the Impact of treating Hypertension ?

In the first few years of treatment :

14% reduction in CAD incidence 42% reduction in stroke incidence >50% reduction in CHF incidence

Category Optimal Normal High-Normal Hypertension Stage 1 Stage 2 Stage 3

Classification of Blood Pressure for Adults >18 years old

Systolic <120 <130 130-139 or Diastolic and <80 and <85 85-89

140-159 or 160-179 or >179

90-99 100-109 or >109

All of these classifications can be made only after two BP measurements made during two subsequent visits

Confounding factors in Determining the Presence of Chronic Hypertension in the Emergency Department
Pain Anxiety Concurrent illness

Categories of Hypertensive Disease Presenting to Emergency Departments:

Hypertensive Emergencies Hypertensive Urgencies Chronic Hypertension

Hypertensive Emergencies
Severe hypertension plus new or acutely progressive end-organ dysfunction

Examples of Hypertensive Emergencies

Cardiovascular Acute left ventricular failure AMI Crescendo angina Aortic dissection

Examples of Hypertensive Emergencies

Cerebrovascular Encephalopathy Intracranial hemorrhage Symptomatic papilledema

Examples of Hypertensive Emergencies

Other Eclampsia/pre-eclampsia Drug induced Acute renal failure

Treatment of Hypertensive Emergencies

Be aggressive I.V. medications these must be individualized to the specific situation: - Beta blocker and nitroglycerine for aortic dissection - Magnesium and Hydralazine for eclamsia -nitroglycerine for severe CHF

What is the goal of therapy?

Lower the patients blood pressure over 30-60 minutes to the lowest level that will adequately profuse their brain. Because of cerebral autoregulation, this should be no less than 25% - 30% of their mean arterial blood pressure

mean arterial blood pressure

MAP = Diastolic BP + ( systolic BP diastolic BP) 3

For someone with BP = 270/150 MAP = 150 + (270-150) = 150+40 = 190 3 Therefore, a reasonable goal would be a MAP of (190) x .75 = 142

Hypertensive Urgencies
Severe hypertension without significant acute end organ damage These patients are at risk of complications weeks to months in the future not immediately

Hypertensive Urgencies
Hypertensive patients: Awake, alert,with normal neurologic exams, complaining of headache and dizziness, blurred vision (without papilledema), Proteinuria with normal urea and creatinine Epistaxis without coagulopathy

Hypertensive Urgencies
THE MOST IMPORTANT THING FOR THESE PATIENTS IS TO RULE OUT A HYPERTENSIVE EMERGENCY Then evaluate their complaint as for any other patient

Hypertensive Urgencies
There is no evidence for benefit and there is anecdotal evidence for harm to asymptomatic patients whose BP is treated hourly until their urgent hypertension responds.
Principles of Ambulatory Medicine, 5th ed. 1999

Hypertensive Urgencies

The goal is to control the patients hypertension over the next 24-72 hours

Hypertensive Urgencies
Evaluation: K+ Urea/creatinine Chest X-ray Urinalysis EKG

Hypertensive Urgencies
Treatment For uncomplicated hypertension, to date the only treatments proven in placebo controlled trials are diuretics (for example, hydrochlorothiazide) and beta blockers (for example metoprolol). Initial monotherapy with either agent is appropriate.
6th report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure, Arch Intern Med, 1997.

Hypertensive Urgencies
Treatment Oral long-acting calcium channel blockers, ace inhibitors, clonidine, or other diuretics and extended observation can be appropriate

Hypertensive Urgencies
Treatment Special Cases: Type I diabetes with proteinuria ACE inhibitors Congestive heart failure ACE inhibitors, diuretics History of myocardial infarction Beta blockers

Hypertensive Urgencies
Treatment There is no need for the patient to have a normal blood pressure in order to go home. The end-point is to solve the patients complaint, not the patients blood pressure Follow-up for repeat BP check in 72 hours with GP.

Hypertension - Treatment
Calcium Channel Blockers The short acting dihydropyridines (this includes Nifedipine) are no longer recommended for treatment of hypertension because of a significant association with myocardial infarction. The long-acting preparations (Adalat Retard) are still O.K.
The risk of myocardial infarction associated with antihypertensive drug therapies. JAMA 274:620-625, 1995

Hypertension - Treatment
Calcium Channel Blockers There are many reports of sublingual nifedipine causing harm due to acute hypotension.
Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA 276:1328-1331, 1996

Chronic Hypertension
No real indication to treat acutely Requires two subsequent visits to truly diagnose IF you choose to treat, current recommendations are diuretics or beta blockers.