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Hypertensive crisis :
Severe elevation of blood pressure, which must be
reduced immediately
Hypertensive emergency :
accompanied by acute target organ damage
BP must be reduced within minutes
Hypertensive urgency :
no acute organ damage
BP must be reduced within hours
Clinical Hypertension, Kaplan 2003
Definition
Not determined by BP level, but rather the
imminent compromise vital organ function
Formerly when :
180 mm Hg
systolic
110 mm Hg
diastolic
(stage III; WHO 2003)
Hypertensive emergency
Accelerated-malignant hypertension with papilledema
Cerebrovascular conditions
Hypertensive brain infarction with severe hypertension
Intracerebral / Subarachnoid
Cardiac conditions
Acute aortic dissection
Acute or impending myocardial infarction
Renal conditions
Renal crises from collagen-vascular diseases
Severe hypertension after kidney transplantation
Eclampsia
Surgical conditions
Severe hypertension in patients requiring immediate surgey
Severe epistaxis
5
Typical symptoms
Typical signs
Comment
Weakness, altered
motor skill(s)
Focal neruological
deficit(s)
Hypertension not
usually treated
Suibarachnoid hemorrhage
Headache,
delerium
Altered mental
status, meningeal
signs
Headache, altered
sensorium or
motor skills
Lacerations,
ecchymoses,
altered mental
status
Hypertensive
encephalopathy
Headache, altered
mental status
papilledema
Lumbar puncture
typically shows
xanthochromia or red
blood cells
Computed
tomographic (CT)
scan is helpful to
determine extent of
intracranial injury
Usually a diagnosis
of exclusion
Cardiac
ischemia/infraction
Chest discomfort,
nausea, vomiting
Abnormal EKG
(esp. T-wave
elevations)
hypertensive emergency
Typical symptoms
Typical signs
Comment
Shortness of
breath
Rales auscultated
in chest
Aortic dissection
Chest discomfort
Widened aortic
knob on chest xray
Bleeding,
tenderness at
suture lines
Bleeding at suture
lines
Pheochromocytoma
Headache,
sweating,
palpitations
Headache,
palpilations
Pallor, flushing,
rare skin signs
(phakomatoses)
tachycardia
Phentolamine is very
useful
Headache, uterine
irritability
Edema,
hyperreflexia
New treatment
guidelines exist
hypertensive emergency
Drug related
catecholamine excess
state
Preeclampsia / eclampsia
Echocardiogram,
chest CT, or
angiogram usually
needed to confirm
Often require
surgical revision of
vascular anastamosis
History regarding
drug exposure is key
Therapeutic guidelines
do not lower BP more than 25% over the first 1 hour
unless necessary to protect other organs
reduce the SBP of 160 mmHg, DBP of 100 mmHg, or
MAP of 120 mmHg, in the first 24 hours
begin the concomitant long-term therapy soon after
the initial emergency treatment
attempt the established normotension within a few
days
Dose
Onset of
actions
Duration
of action
Special indications
Diuretics
Furosemide
5-15 min
2-3 h
Ussually needed to
maintain efficacy of
other drugs
Vasodilators
Nitropruside
0.25-10.00
g/min/kg/min as i.v.
infusion
Immediate
1-2 min
Most hypertensive
emergencies; caution
with high intracranial
pressure or azotemia
Nitroglycerin
(Nitro-bid IV)
2-5 min
5-10 min
Coronary ischemia
Nicardipine
5-10 min
1-4 h
Most hypertensive
emergencies; caution
with acute heart failure
10
Dose
Onset of
actions
Duration
of action
Special indications
Hydralazine
10-20 mg i.v.
10-20 min
3-8 h
Enalaprilat
1.25-5.00 mg every 6 h
15 min
6h
5-15 mg i.v.
200-500 g/kg/min for 4
min, then 50-300
g/kg/min i.v.
20-80 mg i.v. bolus
every 10 min
2 mg/min i.v. infusion
1-2 min
1-2 min
3-10 min
10-20 min
Catecholamine excess
Aortic dissection, after
operation
5-10 min
3-6 h
Most hypertensive
emergencies except
acute heart failure
75-100 g/unit
5-10 min
3-6 h
Most hypertensive
emergency, high
caution with rebound
effect
Adrenergic
inhibitors
Phentolamine
Esmolol
Labetalol
Clonidin
11
Hypertensive encephalopathy
Eclampsia
Fenoldopam or nicardipine
12
Hypertensive Urgency
Potentially dangerous BP elevation, without
acute/life-threatening end organ damage
Blood pressure formerly S 180 mmHg, D 110 mmHg
Some of the circumstance :
High BP with retinal changes KW II
Preoperative, perioperative or post operative
condition
Pain-induced or stress induced hypertension
Hypertensive rebound
13
14
Sublingual drug
Still controversial / begin to avoid
Subsequent studies showed that the bioavailability of
sublingual nifedipione was negligible
FDA recommendations 1996 :
Nifedipine sublingual should be used with great
caution, if at al
Class
Dose
Onset
Duration (h)
Captopril (Capoten)
Angiotensinconverting
enzyme inhib.
25-50.0 mg
15 min
4-6
Clonidine (Catapres)
Central agonist
0.2 mg initially,
then 0.1 mg/h,
up to 0.8 mg
total
0.2-2.0 h
6-8
Furosemide (Lasix)
Diuretic
20-40 mg
0.5-1.0 h
6-8
Labetalol (Normodyne,
Trandate)
- and Blocker
100-200 mg
0.5-2.0 h
8-12
Nifedipine (procardia,
Adalat)
Calcium
channel
blocker
5-10 mg
5-15 min
3-5
Propanolol (Inderal)
-Blocker
20-40 mg
15-30 min
3-6
16
Severe Hypertension
BP > 180 / 110
Encephalopathy
Progressing target organ damage
Yes
(HT Emergency)
No
Admit to ICU
Baseline lab
New onset
(HT Urgency)
Parenteral Rx
Baseline lab
Oral Rx
Workup for
identifiable causes:
Renovascular HT
19