1. Hypertensive Crisis:
Hypertensive Emergencies and Urgencies
6 กพ. 2554
พญ.เสาวนินทร์ อินทรภักดี
โรงพยาบาลเลิดสิน
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2. Definitions and classification of blood pressure levels (mmHg)
Category ESC 2007 JNC VII 2003
Optimal < 120 and < 80 Normal < 120 and < 80
Normal 120–129 and/or 80–84 Pre HT 120-139 or 80-99
High normal 130–139 and/or 85–89
Grade 1 HT 140–159 and/or 90–99 stage 1 HT 140-159 or 90-99
Grade 2 HT 160–179 and/or 100–109 stage 2 HT > 160 or > 100
Grade 3 HT > 180 and/or > 110
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3. Acute target organ damage
Brain :
Hypertensive encephalopathy
Cerebral infarction
Cerebral hemorrhage
Advanced retinopathy
Heart :
Acute coronary syndromes
Acute heart failure
Aorta :
Aortic dissection
Kidney:
Acute renal failure
Placenta :
Eclampsia 3

4. Triage of Pts with Severe HT
Hypertensive Urgencies or Emergencies
BP > 180/120 mmHg
a) hypertensive emergencies, often with BP >220/140
life-threatening organ dysfunction.
b) hypertensive urgencies
symptoms or modest organ damage,
c) severe HT
without symptoms or acute signs of organ damage
4

5. Hypertensive Emergencies
 Severe elevations in BP Examples
(>180/120 mmHg)  hypertensive encephalopathy
 Complicated by evidence of  Intracerebral hemorrhage,
impending or progressive  acute MI
target organ dysfunction.
 acute left ventricular failure
 Require immediate BP with pulmonary edema
reduction (not necessarily to
 unstable angina
normal) to prevent or limit
 dissecting aortic aneurysm,
target organ damage.
 eclampsia
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JNC VII 2003

6. Hypertensive Emergencies
 Catecholamine excess states
Pheochromocytoma crisis
Overdose with sympathomimetics or drugs with similar action
(phencyclidine, cocaine, phenylpropanolamine)
 Hypertension associated with acute renal failure
 Microangiopathic anemia
Manual of Hypertension of the European Society of Hypertension 2008
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7. Initial Evaluation of Patients with a
Hypertensive Emergency
History
 Prior diagnosis and treatment of
hypertension
 Intake of pressor agents: street
drugs, sympathomimetics
7

8. Initial Evaluation of Patients with a
Hypertensive Emergency
History
 Symptoms suggesting an acute
end-organ involvement
chest pain – myocardial infarction,
thoracic aortic dissection
back pain – thoracic aortic
dissection
dyspnea – acute pulmonary edema
neurological symptoms-
hypertensive encephalopathy,
stroke
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9. Initial Evaluation of Patients with a
Hypertensive Emergency
Physical examination
 Blood pressure – both upper limbs
 Funduscopy
 Cardiopulmonary status
AR, MR , signs of CHF
 Neurologic status
level of consciousness, focal sigh
of ischemia
 Body fluid volume assessment
 Peripheral pulses
9

10. Initial Evaluation of Pt with a Hypertensive
Emergency
Laboratory evaluation
 Hematocrit and blood smear (microangiopathic hemolysis)
 Urine analysis
 Automated chemistry: creatinine, glucose, electrolytes
 Electrocardiogram
 Chest radiograph (if heart failure or aortic dissection is suspected)
 CT brain in patients with neurological symptoms
 CT chest or MRI in patients with unequal pulses/ an enlarged
mediasternum
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11. 11

12. Initial Evaluation of Pt with a Hypertensive
Emergency
Laboratory evaluation
 Plasma renin activity and aldosterone (if primary aldosteronism is
suspected)
 Plasma renin activity before and 1 h after 25 mg captopril (if renovascular
hypertension is suspected)
 Spot urine or plasma for metanephrine (if pheochromocytoma is
suspected)
12

13. Critical Degree of
Hypertension
Local effects Systemic effects
(prostaglandins, free (Renin-angiotensin,
radicals) catechol, vasopressin)
Endothelial damage
Pressure natriuresis
initiation and progression
Platelet deposit of
accelerated-malignant HT
Hypovolemic
Mitogenic and migration
factors
Further increase in
Myointimal proliferation vasopressors
Further rise in
blood pressure and
vascular damage
Tissue ischemia
13

14. Clinical Characteristics of Accelerated-
Malignant Hypertension
 Blood pressure: usually >140 mm Hg diastolic
 Funduscopic findings :
accelerated HT - grade 3 retinopathy ( hemorrhages,
exudates)
malignant HT - grade 4 retinopathy (papilledema)
 Neurologic status: headache, confusion, somnolence,
stupor, vision loss, focal deficits, seizures, coma
 Renal status: oliguria, azotemia
 Gastrointestinal status: nausea, vomiting 14

15. Hypertensive encephalopathy
Pathophysiology
 When mean arterial pressures > 180 mm Hg,
vessels are stretched and dilated— producing
generalized vasodilation
 Breakthrough of cerebral blood flow ,
hyperperfuses the brain under high pressure,
with leakage of fluid into the perivascular
tissue, leading to cerebral edema
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16. Hypertensive encephalopathy
 A sudden, marked elevation
of BP
 Severe headache and
altered mental status,
reversible by reduction of BP
 Encephalopathy is more
common in previously
normotensive individuals
whose pressures rise
suddenly 16

17. MRI hypertensive encephalopathy
T 1-weighted images
 Posterior reversible
leukoencephalopathy
syndrome
finding : edema of the white
matter of the parieto-occipital
regions
 hypertensive brainstem encephalopathy
finding : pontine abnormalities 17

18. Goal of Hypertensive Emergencies Rx
LIMIT ORGAN DAMAGE
 Almost all hypertensive emergencies are caused or
exacerbated by intense systemic vasoconstriction, often
with profound blood volume reduction
 goal of therapy is to reduce vasoconstriction while
maintaining adequate perfusion of target organs
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19. Treatment of Hypertensive Emergencies
 Admitted to an ICU for continuous monitoring of BP and iv
administration of an appropriate agent
 The initial goal of therapy in hypertensive emergencies is to
reduce mean arterial BP by no more than 25 percent (within
minutes to 1 hour)
 If clinical is stable, reduce BP to 160/100–110 mmHg within
the next 2–6 hours
 Further gradual reductions toward a normal BP can be
implemented in the next 24–48 hours.
19
JNC VII 2003

20. Exceptions
 acute aortic dissection
 acute stroke in evolution (for which no BP
lowering is generally recommended)
JNC VII 2003
20

21. Acute aortic dissection
Initial management of thoracic aortic dissection should be
directed at decreasing aortic wall stress by controlling HR and
BP :
 In the absence of contraindications, Iv beta blockade should
be initiated and titrated to a target heart rate < 60 /min
 If systolic blood pressures > 120 mm Hg after adequate heart
rate control has been obtained, then iv angiotensin-converting
enzyme inhibitors and/or other vasodilators should be
administered .
2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM
Guidelines for the Diagnosis and Management of Patients With 21
Thoracic Aortic Disease. Circulation. 2010;121:1544-1579.

22. Acute Ischemic Stroke
The American Heart Association recommends
 Treatment with intravenous labetalol or nicardipine
 Started when BP values are above 220/120mmHg
 The target BP should be a 10–15% lowering of BP
 In patients candidates to treatment with intravenous
tissue plasminogen activator BP should be
maintained below 185/110mmHg.
Guidelines for the early management of patients with ischemic stroke.
A Scientific Statement from the Stroke Council of the American Stroke Association.
22
Stroke 2003; 34:1056–83.

23. Acute STEMI
Relative contraindications for thrombolytics
 History of chronic, severe, poorly controlled hypertension
 Severe uncontrolled hypertension on presentation (SBP
> 180 mm Hg or DBP >110 mmHg)
ACC/AHA Guidelines for the Management of Patients With
ST-Elevation Myocardial Infarction 2004
23

24. Management of ICH
 Emergency diagnosis and assessment of ICH
and its cause
 Medical RX – correct coagulopathy
 Inpatient management and prevent of
secondary brain injury
General monitoring
Management of glucose
Seizures
 Procedures /surgery – clot removal
 Prevent of recurrent – Rx hypertension
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25. HYPERTENSION could contribute to hydrostatic
expansion of the hematoma, peri-hematoma edema, and
rebleeding
25

26. Guidelines for Treating Elevated BP in Spontaneous ICH
1. If SBP is 200 mm Hg or MAP is 150 mm Hg
aggressive reduction of BP with continuous intravenous infusion, with
frequent BP monitoring every 5 min.
2. If SBP is 180 mm Hg or MAP is 130 mm Hg and there is the
possibility of elevated ICP, then consider monitoring ICP and reducing BP
using intermittent or continuous intravenous medications while
maintaining a cerebral perfusion pressure 60 mm Hg.
3. If SBP is 180 mm Hg or MAP is 130 mm Hg and there is not
evidence of elevated ICP, then consider a modest reduction of BP
(MAP of 110 mm Hg or target BP of 160/90 mm Hg) using intermittent or
continuous intravenous medications to control BP and clinically
reexamine the patient every 15 min
Guidelines for the Management of Spontaneous ICH
A Guideline for Healthcare Professionals 26
From the American Heart Association/American Stroke Association 2010

27. Drug Useful for Hypertensive Emergencies
Agent Dose Onset/ Duration of Precautions Special indication
vasodilators of action action
Sodium 0.25–10.00 Immediate/ 1-2 min Nausea, vomiting, Most hypertensive
nitroprusside µg/kg/min as muscle twitching; emergencies ,
i.v. infusiona; thiocyanate caution with high
maximal intoxication, ICP or azotemia
dose for 10 methemoglobinemia
min only acidosis, cyanide
poisoning;
bags, bottles, and
delivery sets must be
light resistant
Glyceryl 5–100 µg as 2-5 min 5-10 min Headache, Coronary ischemia
trinitrate i.v. infusion tachycardia, vomiting,
flushing,
methemoglobinemia;
requires special
delivery systems due
to the drug's binding to
polyvinyl chloride 27
tubing

28. Drug Useful for Hypertensive Emergencies
Agent Dose Onset/ of Duration of action Precautions Special indication
vasodilators action
Nicardipine 5–15 mg/h 5-10 min/ 15–30 min, but may Tachycardia, Most hypertensive
Calcium i.v. infusion exceed 4h after nausea, vomiting, emergencies ,
channel prolonged infusion headache, possible except in acute
blocker protracted heart failure ;
hypotension after caution with
prolonged infusions coronary ischemia
,
Fenoldopam 0.1–0.3 < 5min 30 min Headache, Most hypertensive
dopamine mg/kg/min tachycardia, emergencies ,
agonist (D1- i.v. infusion flushing, local caution with
receptors) phlebitis glaucoma
28
JNC VII 2003

29. Drug Useful for Hypertensive Emergencies
Agent Dose Onset/ of Duration of Precautions Special
vasodilators action action indication
Hydralazine 10–20 mg as i.v. 10 -20 min iv 1-4 h iv Tachycardia, Eclampsia
bolus 20-30 min im 4-6 h im headache,
10–40 mg i.m.; vomiting,
repeat every 4–6 h aggravation of
angina pectoris
Enalaprilat 1.25 – 5 mg every 6 15–30 min 6-12 hr Renal failure in Acute LV
h i.v. / patients with failure; avoid
bilateral artery in acute MI
stenosis,
hypotension
29
JNC VII 2003

30. Drug Useful for Hypertensive Emergencies
Agent Dose Onset of Duration Precautions Special indication
Adrenergic action of action
inhibitors
Labetalol 10–80 mg as i.v. 5–10 min 3–6 h Bronchoconstriction Most hypertensive
Alpha1, beta 1 bolus every 10 , heart block, emergencies ,
and beta 2 min; up to 2 orthostatic except acute heart
receptor mg/min as i.v. hypotension, failure
antggonist infusion vomiting, scalp
tingling
Esmolol 500 µg/kg bolus 1-2 min 10–30 min First-degree heart Aortic dissection,
Beta 1receptor injection i.v. or block, congestive perioperative
antagonist 50 –100 heart failure,
µg/kg/min by asthma
infusion ; may
repeat bolus after
5 min or increase
infusion rate to
300 µg/ kg/min
Phentolamine 5–15 mg as i.v. 1–2 min 10-30 min Tachycardia, Catecholamine
bolus orthostatic excess
hypotension, 30
flushing JNC VII 2003

31. Drug Useful for Hypertensive Emergencies
Agent Dose Onset/ of Duration of action Precautions Special indication
vasodilators action
Urapidil 20 -60 3-4 min/ 6-10 h Sedation
Alpha blocker mg iv
,central bolus
sympatholytic
effect via
stimulation of
serotonin
5HT(1A)
receptors
Clevidipine 0.1–0.3 < 5min 30 min Headache, Most hypertensive
Calcium mg/kg/mi tachycardia, emergencies ,
channel n i.v. flushing, local caution with
clocker infusion phlebitis glaucoma
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JNC VII 2003

32. Drugs of choice and relative contraindications
for hypertensive emergencies
Condition Drug(s) of choice Relative
contraindications/cautions
Acute pulmonary Nitroglycerin + loop diuretic Beta-blockers, verapamil
edema Nitroprusside + loop diuretic
Acute coronary Nitroglycerin + beta-blocker Hydralazine
syndromes Nitroprusside + beta-blocker
Hypertensive Nitroprusside, labetalol, Centrally acting sympatholytic
encephalopathy nicardipine agents
Dissecting aortic Nitroprusside + beta-blocker Isolated use of pure vasodilators
aneurysm
Intracranial Labetalol, nicardipine Nitroprusside with caution,
hemorrhage nifedipine
32
Manual of Hypertension of the European Society of Hypertension 2008

33. Drugs of choice and relative contraindications
for hypertensive emergencies
Relative
Condition Drug(s) of choice
contraindications/cautions
Ischemic stroke Nitroprusside, labetalol, Nifedipine
nitroglycerin
Adrenergic crisis Labetalol, phentolamine + Beta-blocker monotherapy
beta-blocker
Acute renal Fenoldopam, nicardipine Diuretics with caution
impairment
Eclampsia MgSO4, hydralazine, Nitroprusside
methyldopa
Subarachnoid Nimodipine Nitroprusside with caution
hemorrhage
33
Manual of Hypertension of the European Society of Hypertension 2008

34. Hypertensive Urgencies
 severe elevations in BP Examples include
without progressive target upper levels of stage II HT
associated with
organ dysfunction
 severe headache
 shortness of breath
 Epistaxis
 severe anxiety
JNC VII 2003
34

35. Hypertensive Urgencies
 Severe uncomplicated essential hypertension
 Severe uncomplicated secondary hypertension
 Postoperative hypertension
 Hypertension associated with severe epistaxis
 Drug-induced hypertension
 Rebound hypertension (i.e., sudden withdrawal of clonidine)
 Cessation of prior antihypertensive therapy
 Severe hypertensive crises related to anxiety, panic attacks or pain
Manual of Hypertension of the European Society of Hypertension 2008 35

36. Treatment of Hypertensive Urgencies
 Agents that reliably cause an immediate fall in BP
include captopril (25-50 mg), central sympatholytics
(clonidine 0.1–0.2 mg), labetalol (200–400 mg), and
amlodipine (2.5–5 mg)
 initiation of therapy with two oral agents is appropriate to
lower BP to an intermediate target over 24 to 72 hours
 Appropriate follow-up within 3 days.
36

37. Oral Drugs for Hypertensive Urgencies
Drug Initial dose Onset Duration Adverse effects
Captopril 25–50 mg 15–45 min 6–8 h Renal failure in bilateral artery
stenosis
Labetalol 200–400 mg 30–120 min 2–12 h Orthostatic hypotension,
bronchoconstriction
Clonidine 0.150–0.300 mg 30–60 min 8–16 h Hypotension, dry mouth
Prazosin 1–2 mg 60–120 min 8–12 h Syncope (first dose), orthostatic
hypotension, tachycardia
Nicardipine 20–40 mg 30–60 min 8–12 h Headache, tachycardia, flushing
Amlodipine 5–10 mg 60–120 min 12–18 h Headache, tachycardia, flushing
37
Manual of Hypertension of the European Society of Hypertension 2008

38. Treatment of Severe HT (asymptomatic)
 immediate normalization of the BP is not necessary
 it is usually appropriate to prescribe a two-drug therapy
 identify individuals at risk for secondary hypertension
 counsel the patient on the importance of long-term BP
control
 schedule follow-up within 1 week or less.
38

39. ALGORITHM FOR TRIAGE AND
MANAGEMENT
Severe hypertension Hypertensive urgency Hypertensive emergency
BP >180/120 mm Hg >180/120 mm Hg Often >220/140 mm Hg
Symptoms Often asymptomatic Severe headache Prolonged chest
Headache Shortness of breath pain/unstable angina
Anxiety Edema Motor impairment/neurologic
deficit
Altered mental status
Uncontrollable bleeding
Workup results No target organ Target organ Pulmonary edema/heart
damage/clinical damage/clinical failure
cardiovascular disease cardiovascular disease Acute MI
may be present Cerebrovascular accident
Encephalopathy
Renal insufficiency
Preeclampsia
Renal failure
Aneurysm 39

40. ALGORITHM FOR TRIAGE AND
MANAGEMENT
Severe hypertension Hypertensive urgency Hypertensive emergency
BP >180/120 mm Hg >180/120 mm Hg Often >220/140 mm Hg
Acute management Initiate/resume Lower BP with oral or Order baseline laboratories
medication(s) parenteral agents as Initiate intravenous line
Increase dosage of underlying conditions Monitor vital signs
inadequate agent warrant May initiate disease-a
Observe for 1–3 h Adjust current therapy appropriate parenteral
Observe for 3–6 h therapy in the emergency
room
Plan Arrange follow-up >72 h Arrange follow-up Immediate admission to
If no prior evaluation, evaluation (24–72 h) intensive care unit
schedule appointment Treat to appropriate goal BP
Additional diagnostic studies
as warranted
40

41. A 44 –year –old Thai male
Chief compliant : Dyspnea, cyanosis
Present illness : Underlying disease HT, CKD, Irregular RX
3 hr prior to admission : chest pain with dyspnea
Physical exam
General appearance : Dyspnea and cyanosis
Vital sign : BP 220/120 mmHg HR 120/min regular RR 28/min
T 37 C O2 sat room air 85%
HEENT : Unremarkable
Neck : Jugular distension
41

42. Cardiovascular : heart PMI at 5 th ICS mid clavicular line
normal S1S2 no murmur no gallop
Lung : rales both lungs
Abdomen : No hepatosplenomegaly not tender
Extremities : N edema
Neurologic : Normal
Lab :
Hb 14 wbc 3220/mm3 platelet 329,000 /mm3
BUN 39.7 ng/dL Creatinine 3.44 ng/mL
Troponin I 4.6
42

43. Problem list
1. NSTEMI with CHF
2. CKD
3. Hypertensive emergency 43

44. First Rx
a. O2 therapy
b. IV Furosemide
c. IV Morphine
d. IV Nitroglycerine
Which antihypertensive drug ?
a. IV Nitroglycerine
b. IV Beta blocker
c. IV Nicardipine
d. IV Nitroprusside
44