1) Hypertension is defined as blood pressure ≥140/90 mmHg or taking antihypertensive medication. It is classified into stages based on clinic blood pressure readings and confirmed by ambulatory blood pressure monitoring or home blood pressure monitoring. 2) Hypertensive emergencies require immediate treatment to reduce blood pressure within hours to prevent end organ damage, while hypertensive urgencies allow slower reduction over 24-48 hours without evidence of organ damage. 3) Treatment of hypertension involves non-pharmacologic measures and a stepped approach starting with ace inhibitors, calcium channel blockers, or thiazide diuretics and adding additional agents as needed to control blood pressure.

1. ARTERIAL HYPERTENSION
DR.MAGDI AWAD SASI
29/12/205 7TH OCTOPER HOSPITAL
CCU TEAM
BMC---EMERGENCY COURSE

3. Hypertension
 “A systolic blood pressure (SBP) of
≥140 mm Hg, diastolic blood pressure
(DBP) of ≥ 90 mm Hg or taking
antihypertensive medication”
In nondiabetic non CRD.

4. • Clinic BP ≥ 140/90 mmHg & subsequent ABPM
daytime average or HBPM average BP≥ 135/85
mmHg
Stage 1
• Clinic BP >= 160/100 mmHg and subsequent
ABPM daytime average or HBPM average BP ≥
150/95 mmHg
Stage 2
• Clinic systolic BP ≥ 180 mmHg, or clinic
diastolic BP ≥ 110 mmHgStage 3

5. Diagnosing hypertension
 If a BP reading is ≥ 140 / 90 mmHg; patients should be
offered ABPM to confirm the diagnosis.
 Patients with a BP reading of ≥ 180/110 mmHg should be
considered for immediate treatment.
 Ambulatory blood pressure monitoring (ABPM):
 At least 2 measurements per hour during the person's usual
waking hours (for example, between 08:00 and 22:00). Use
the average value of at least 14 measurements.
 If ABPM is not tolerated or declined HBPM should be offered.

6. Home blood pressure monitoring (HBPM):
 For each BP recording, two consecutive
measurements need to be taken, at least 1 minute
apart and with the person seated.
 BP should be recorded twice daily, ideally in the
morning and evening.
 BP should be recorded for at least 4 days, ideally
for 7 days.
 Discard the measurements taken on the first day
and use the average value of all the remaining
measurements.

7. PRAUCATION Measuring Blood Pressure
 REST---Pt. should be seated in a chair
back supported, with arm bared and at
heart level
 Pts. should refrain from smoking or
caffeine intake 30 minutes prior to BP
measurement.

8.  Measurement should begin after at
least 5 minutes of rest
 Appropriate cuff size should be used to
ensure accurate measurement; the
bladder of the cuff should encircle at
least 80% of the arm.

9.  Use of a mercury sphygmomanometer
preferred
 A recently calibrated aneroid
manometer or a validated electronic
device can be used

10. Follow-up Recommendations
Initial BP
SBP DBP Follow-up
<130 <85 Recheck in 2y
130-139 85-89 Recheck in 1y
149-159 90-99 Confirm in 2m
160-179 100-109 Eval/refer 1m
> 180 > 110 Eval/refer
immediately

11. Evaluation of Patients with HTN
 1)Identify known causes of HTN
 2)Assess for the presence OR absence
of target organ damage and
cardiovascular disease

12. DM OBESITY
SEDENTARY
LIFE
DRUGS
ENDOCRINE
CAUSES

13. ADVICE:
STOP • Predisposing cause before starting treatment
Search
• For end organ damage by H ; C.F. ,INVES
SELECT • Select the proper drugs

14. Proper
drug
+cheap
tolerated
availableUPDATE
frequency

15. TREATMENT :
 ABPM/HBPM ≥ 135/85 mmHg (i.e. stage 1 hypertension):
Treat if < 80 years of age AND target organ damage:
Established cardiovascular disease, renal disease, diabetes or a
10year cardiovascular risk equivalent to 20% or greater.
 ABPM/HBPM ≥ 150/95 mmHg (i.e. stage 2 hypertension):
Offer drug treatment regardless of age.
For patients < 40 years consider referral to exclude secondary causes.

16. Step 1 treatment:
 Patients < 55-years-old: ACE inhibitor
 Patients > 55-years-old or of Afro-Caribbean
origin: CCBs (C)

17. Step 2 treatment
ACE inhibition + calcium channel blocker(A +C)

18. Step 3 treatment
 Add a thiazide diuretic (D, i.e. A + C + D)
 NICE now advocate using either chlorthalidone (12.5-25.0 mg once
daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once
daily) in preference to a conventional thiazide diuretic such as
bendroflumethiazide.
 NICE define a clinic BP ≥ 140/90 mmHg after step 3 treatment with
optimal or best tolerated doses as resistant hypertension.
 They suggest step 4 treatment or seeking expert
advice.

19. Step 4 treatment:
 Consider further diuretic treatment.
 If potassium < 4.5 mmol/l add
spironolactone 25mg OD.
 If potassium > 4.5 mmol/l add higher-dose
thiazide-like diuretic ttt.
 If further diuretic therapy is not tolerated, or
is contraindicated or ineffective, consider an
alpha- or beta-blocker. If BP still not
controlled seek specialist advice.

20. Centrally acting antihypertensives
 1) Methyldopa: used in the management of
hypertension during pregnancy.
 2) Clonidine: the antihypertensive effect is mediated
through stimulating alpha-2 adrenoceptors in the
vasomotor centre.
 3) Moxonidine (Physiotense ® 0.2 mg tab): used in
the management of essential hypertension when
conventional antihypertensive have failed to control
blood pressure

21. NICE NEW RECOMMENDATION
 In the past there was overtreatment of 'white coat'
hypertension. The use of ambulatory blood pressure
monitoring (ABPM) aims to reduce this. There is also
good evidence that ABPM is a better predictor of
cardiovascular risk than clinic blood pressure
readings.
 Calcium channel blockers are now considered
superior to thiazides.
 Bendroflumethiazide is no longer the thiazide of
choice.

22.  βB is not recommended as a 1st or 2nd line anti-
hypertensive agent, particularly in obese population
because of its association with impaired glucose
tolerance.
 The NICE guidelines on HTN advise against using
beta-blockers as routine 'first line' therapy for
uncomplicated hypertension.

23. GOAL OF CONTROL BP:
 Goal BP less than 130/85 mmHg for
patients with DM, CKD and established
CVD like IHD. (BHS).
 While in non-diabetic patients with CVD,
the target BP is less than 140/90
mmHg. (JNC) and (ACC/AHA)

24. WHAT IS IMPORTANT?
 NOT the degree of BP elevation
BUT
The clinical status of the patient that defines an
emergency.
The degree of target organ involvement
that determines the rapidity with which
the BP is lowered

25. Hypertensive crisis
 Defined as a critical elevation in blood
pressure in which diastolic pressure >120
mm Hg. The presence of acute or
ongoing end-organ damage constitutes a
hypertensive emergency, whereas the
absence of such complications is
known as a hypertensive urgency.

26. Hypertensive emergencies
 Are associated with end-organ damage and need to be
treated immediately.
 Require a reduction in blood pressure within a few hours,
usually using intravenous medications given in an intensive
care unit.

27. Hypertensive urgencies
HTN that requires control within hours but
without evidence of end-organ damage.
((Asymptomatic))
 Require prompt medical attention, but blood pressure can
be lowered over 24 to 48 hours, sometimes in a closely
monitored outpatient setting.
It Can usually be managed by oral agents.

28. Malignant HTN
It is Marked HTN with papilledema, retinal
hemorrhages or exudates (basically a
subset of hypertensive emergency)

29. Goal of treatment for hypertensive emergency is :
 Reduction of DBP to 100-110 mmHg
OR
 Reduction in MAP by 20-25%,
whichever is the greater number, over
the first 2-6 hours .

30. VesselmuscleHeart
CVS
LVH
MI
AF
LVF CCF

31. CVS EFFECT OF HTN:
HTN
LVH
D.FAILURE
ANGINA
PECTORIS
IHD
MI LVF
CCF
AF

32. End-Organ Damage in Hypertensive Emergencies
Brain
Hypertensive Encephalopathy
Ischemic Stroke
Hemorrhagic Stroke
Subarachnoid Hemorrhage
Retina
Hemorrhages
Exudates
PapilledemaCardiovascular
System
Unstable Angina
Acute Heart Failure
Acute Myocardial
Infarction
Aortic Dissection
Kidney
Hematuria
Proteinuria
Decreasing Renal
Function
References: 1. Varon J, Marik PE. Chest. 2000;118(1):214-227. 2. Rynn KO et al. J Pharm Prac. 2005;18(5):363-376.

33. Causes of hypertensive emergencies :
1. Essential HTN
2. A. Renal parenchymal disease: Acute GN, TTP/HUS, vasculitis
B. Renovascular disease: Renal artery stenosis
3. Endocrine: Pheo, Cushing’s, renin-secreting tumor
4. Drugs: Cocaine, amphetamines most common; reported with
epo, cyclosporine; anti-hypertensive withdrawal
5. Pregnancy: Eclampsia
6. CNS disorders: head injury, CVA, increased ICP h. Autonomic
hyperreactivity: Guillain-Barre, porphyria

34. Presentation:
 Dyspnea
 Chest pain
 Palpitation
 Parasthesia /numbness
 Heaviness/ paralysis
 Confusion
 Sever sudden headache

35. What is the risk of rapid reduction of BP?
1. Ischemic cardiac event
2. Ischemic cerebral event
3. Retinal artery occlusion
4. Acute renal deteioration

36. SERIOUS HTN INVESTIGATION
 Blood suger
 RFT
 CBC
 ECG
 CXR
 CARDIAC ENZYMES
 CT scan brain if CNS compliant

37. MAP
 is considered to be the perfusion pressure seen by organs in the body.
 It is believed that a MAP is greater than 60 mmHg is enough to sustain
the organs of the average person(normally between 65 and 110 mmHg).
MAP may be used similarly to Systolic blood pressure in for target blood
pressure.
 Both have been shown advantageous targets for sepsis, trauma, stroke,
intracranial bleed, and hypertensive emergencies.
 If the falls below this number for an appreciable time, vital organs will not get
enough Oxygen perfusion, and will become hypoxic, a condition called ischemia.

38.  Total Peripheral Resistance (TPR) is represented mathematically
by the formula:
 R = ΔP/Q[2]
R is TPR. ΔP is the change in pressure across the systemic circulation
from its beginning to its end. Q is the flow through the
vasculature (equal to cardiac output)
 In other words:
Total Peripheral Resistance =
(Mean Arterial Pressure - Mean Venous Pressure) / Cardiac Output

39. MAP= DP +1/3(SP-DP)
 Therefore, Mean arterial pressure can be determined
from:[3]
MAP= ( CO X SVR ) + CVP
where:
 CO is cardiac output
 SCR is systemic vascular resistance
 CVP is central venous pressure and usually small enough
to be neglected in this formula.

40.  Equation: MAP = [(2 x diastolic)+systolic] / 3
 Diastole counts twice as much as systole because 2/3 of
the cardiac cycle is spent in diastole. An MAP of about 60 is
necessary to perfuse coronary arteries, brain, kidneys.
 Usual range: 70-110

41. Optimal Properties of a Parenteral Antihypertensive
Agent
 Rapid onset of action
 Predictable dose response
 Titratable to desired BP
 Minimal dose adjustments
 Minimal adverse effects
 No association with coronary steal or increased ICP
 Ease of use and convenience

42. Available Parenteral Agents to
Treat Hypertensive Emergencies
 Calcium Chanel Blockers
 Nicardipine
 Clevidipine
 Adrenergic Receptor
Blockers
 Esmolol
 Labetalol
 Vasodilators
 Hydralazine
 Nitrovasdilators
 Nitroglycerin
 Nitroprusside
 ACE Inhibitor
 Enalaprilat

43. TR Malignant hypertension
 Classically: severe headaches, nausea/vomiting, visual
disturbance
 However chest pain and dyspnoea common presenting
symptoms
 Papilledema
 Severe: encephalopathy (e.g. seizures).

44. Fundus Photos

45.  Management:
Reduce diastolic but no lower than 100mmHg within 12-24 hrs
Bed rest
Most patients: oral therapy e.g. atenolol
If severe/encephalopathy: IV sodium nitroprusside / labetalol

46. AMI
 Admit
 Analgesia
 Angised S/L
 Assurance
 Drug benefit his pain and BP
 ACE –I ; B blocker ,?diuretic

48. ACUTE LVF/PUL.EDEMA
 Assure
 Admit
 Air—100% O2
 Analgesia if conscious---venlitor
 Diuretics and monitor urine out put
 RFT---- if no urine----Dialysis
 Treat the underlying cause

49.  Nitroglycerin SL /topical /Drip
dilates capacitance vessels ((low dose))
dilates arterioles ((high dose))
 Enalaprilat
 Lasix low survival rate with diuretics alone
 Nitoprsside drip
 Goals –reduce BP /20-30% ,diuresis

50. Acute aortic dissection TR:
 Avoid arteriodilators /venodilators
 Urgent admission
 Analgesia --Morphine
 Start B.Blockers-Esmolol bolus and drip
Diltiazem /verapamil OK if B blocker
cant be used
 Nicardipine drip (( AFTER BB ))
 Nitroprusside drip ((AFTER BB))

51. AAD CONT.
 Main stay of therapy:
B blocker + Vasodilator
GOAL:
SBP 100-120
HR < 60 /min
Reduction of shear forces by
decreasing BP + HR

53. DIAGNOSIS - BP >140/90
MOSTLY YOUNG PRIMIS / >35, IN 3RD TRIMESTER
(NOT BEFORE 20 WEEKS)
A) HYPERTENSION OF PREGNACY -
BP >140 / 90 mmHg ALONE OR WITH MILD OEDEMA
B) PREECLAMPSIA -
B.I) MILD PREECLAMPSIA -
BP <160/100, MILD OEDEMA
TYPES-
1) PREGNANCY INDUCED
HYPERTENSION (PIH)
HYPERTENSION DURING PREGNANCY

54. DIAGNOSIS - BP >140/90
B.II) SEVERE PREECLAMPSIA -
BP >160/110, MARKED OEDEMA, PROTEINURIA 2+,
HEADACHE,VISUAL DISTURBANCES, ABDOMINAL
PAIN, OLIGURIA, THROMBOCYTOPENIA,BILIRUBIN,
LIVER ENZYMES, CREATININE, FOETAL GROWTH
RETARDATION, PULMONARY OEDEMA--
C) ECLAMPSIA -
WITH CONVULSION
TYPES-
1) PREGNANCY INDUCED
HYPERTENSION (PIH)
HYPERTENSION DURING PREGNANCY

55. The target BP in patients with pre-existing
hypertension is < 150/100 mmHg
OR
140/90 mmHg in the presence of end organ failure.

56.  . As in patients with longstanding
HTN aggressive BP control may
compromise placental function, so
diastolic blood pressure should be
preserved > 80 mmHg. Any increase
in BP above baseline should prompt
a search for new pre-eclampsia

57. Consensus guidelines recommend treating blood pressure
> 160/110 mmHg although many clinicians have a lower
threshold.
75 mg of aspirin daily from 12 weeks.
Oral/ IV labetalol is now first-line following the 2010
NICE guidelines.
 Nifedipine, or hydralazine can be used as alternatives after
considering sideeffect profiles for the woman, foetus and
new-born baby.
 Delivery of the baby is the most important and definitive
management step.
 MgSo4 is used peri-delivery to reduce the risk of
seizures, and may have adjunctive effects on lowering
BP and would be considered as the potential next step
after BP lowering by IV labetalol. (Firstly Labetalol IVI
then MgSo4 IVI).

58. PRECLAMPSIA TR
 MgSo4 –seizures
 Labetolol bolus
 Nifedipine PO
 Nicardipine may be better
 Hydralazine ??
 GOALS:
 < 160/110
 <150/100 if platelets < 100000/mm3

60. IV Treatment of Acute Hypertension Is a Vital Consideration in
Neuroemergencies
Abbreviations: AIS, acute ischemic stroke; ICH, intracerebral hemorrhage; IV, intravenous; aSAH, aneurysmal subarachnoid
hemorrhage; SBP, systolic blood pressure.
References: 1. Jauch EC et al. Stroke. 2013;44(3):870-947. 2. Antihypertensive Treatment of Acute Cerebral Hemorrhage
(ATACH) Investigators. Crit Care Med. 2010;38(2):637-648. 3. Connolly ES et al. Stroke. 2012;43(6):1711-1737.

61. Key Considerations for Choosing an Antihypertensive Agent
in Acute Stroke

62. Primary Effects of Available Agents

63. What the Guidelines State…
Abbreviations: AHA, American Heart Association; ASA, American Stroke Association; aSAH, aneurysmal subarachnoid hemorrhage;
BP, blood pressure; DBP, diastolic blood pressure; IV, intravenous; SBP, systolic blood pressure.
References: 1. Connolly ES et al. Stroke. 2012;43(6):1711-1737. 2. Jauch EC et al. Stroke. 2013;44(3):870-947. 3. CARDENE I.V.
(nicardipine hydrochloride) Premixed Injection Prescribing Information. Cary, NC: Cornerstone Therapeutics Inc.; 2013.
63

65. ACUTE ISCHEMIC STROKE TR
 Labetolol
 Nicardipine
 If fibrinolytic therapy planned ,treat if >
185/110 mmHg
 Must avoid worsening ischemia by
dropping BP too much
 No more than 10-15% first 24hours.

66. SAH / ICH
 Labetolol
 Nicardipine , ?Nimodipine
 Esmolol
 Caution:
Maintain CPP while preventing rebleeding
SBP < 160 mmHg (( MAP < 130mmHg)
SBP > 120 mmHG to maintain CPP
Evidence of ICP increaesing = maintain MAP 130mmHg

67.  MAIN CONCEPTS OF TREATMENT OF
HTN EMERGENCIES IN GENERAL:

68. Note that these recommendations are more consensus-
of-experts quality than true RCT-proven guidelines a.
Hypertensive emergencies
 Require ICU admission, A-line, and
aggressive BP control, usually with IV
agents
 Goal is reduction of BP to DBP of 100-
110 mmHg (but reduce MAP by no
more than 20-25% of initial) over first
2-6 hrs.

69.  Careful monitoring for worsening of CNS
status:
 Rx choices:
 1. Sodium nitroprusside (Nypride):
Usual first line therapy. Can cause cyanate or thiocyanate
toxicity (after 24-48 hours of rx), which is more of a worry in
patients with underlying renal or hepatic dysfunction. Onset
immediate, duration of action 1-2 minutes.

70.  2. Labetalol: Both alpha- and beta-blocking
properties.
 3. Fenoldopam: Peripheral D1-receptor agonist that
causes direct vasodilation, renal-arterial dilation, and
natriuresis.
 4. Others: hydralazine, IV nitroglycerin, nicardipine
iii. Special situations: 1. Eclampsia: Deliver the baby;
MgSO4 2. CVA: More permissive HTN

71. Alternative
drug(s
Drug(s) of choiceEmergency
Nitroprusside,
labetalol
Nitroglycerin, BBAcute coronary
syndrome
Nitroprusside ;
ACEinhibitors
furosemide Nitroglycerin,Acute pulmonary edema
Labetalol, nicardipinNitroprusside, fenoldopamHypertensive
encephalopathy
Nitroprusside
nicardipin
LabetalolIntracranial
hemorrhage
Labetalol, esmolol,
trimethapha
followed by nitroprusside
B.BLOCKER
Aortic dissection
LABRTOLOLPhentolamine;
nitroprussid with B-blocker
Adrenergic crises
Nicardipine, labetalolHydralazinePre-
eclampsia/eclampsia

72. NOTROPRUSSIDE
 Arterio & venodilator
 Decreases preload & after load
 Potential as a general vasodilator to increased
ICP
 Dose 0.3–10mcg/kg/minute in D5W
Increase by 0.5mcg/kg/min and titrate.
Onset –seconds
Duration:1—2 min

73.  Caution :>2mcg/kg/min may lead to CN
toxicity
 Avoid –renal /hepatic failure
,neurovascular emergrncies ,increased
ICP
 Recommended when all else fails

74. LABETALOL
 B blocker & weak alpha 1 effects
without reflex tacchycardia
 Commonly used
 Broad applications
 Exceptios – cocaine intoxication ,CCF
 Bolus 10—20mg IV over 2min
 40—80 mg –10min intervals upto 300mg total
 Check BP 5 & 10 min after bolus

75. LABETOLOL
 Infusion –2mg /min and titrate to response
upto 300mg
 Effect—2—5min 15 min and lasts 2-4 hours
 Avoid :
CCF ,CHB ,Bronchspasm ,Bradycardia
coronary or cerebral arteriosclerosis, renal
impairment, or documented hypersensitivity.

76. Captopril
 Sublingual use 25–50mg has
gainedpopularity in ED, Especially
useful patients with HTN and CHF
 Cautions include symptomatic
hypotension increasing especially
following the first dose.. in HTN crisis
associated with CHF or myocardial
ischemia.Adverse reactions include ACE
inhibitor-induced cough, angioedema

77. METOPROLOL
 Indicatio : Acute CS
 5 mg q 5-15 min upto 15 min

78. NIFEDIPINE
 DISCOURAGED IN HYPERTENSIVE
EMERGENCIES AS IT CAN EXPAND THE
INFARCTION ZONE
 MAY BE USED IN PRE-ECLAMPSIA

79. CLEVIDIPINE
 3rd generation CCB
 Ultra-short
 Arteriolar vasodilator
 Cardiac surgery
 T1/2 <1min
 May be beneficia in future

80. Hydralazine
 Dose 5–20mg IV q4–6hours prn initial.
 dose;increase dose.Change to PO as
soon as possible.
 Used in the treatment of eclampsia

81. NICARDIPINE
 Initial infusion 5mg/hour, titrate
2.5mg/hou every 5–15
minutes.Maximum 15mg/hour
 maintenance 3mg/hour

82.  Contraindications include aortic
stenosis, or previous hypersensitivity to
calcium channel blockers.
Pheochromocytoma 0.5–2mg boluses
repeated as needed. Pre-
eclampsia/eclampsia, initial dose
1mcg/kg/minute, titrate 0.5mg/hour
(usual dose 0.7mcg/kg/minute)

83. Fenoldopam
 Dopamine 1 agonist
 Continuous infusion (inability to bolus may
preclude its use in the ED)
 Dose. 0.1–1.6mcg/kg/minute titrate every 15
min (usual dose 0.3mcg/kg/minute)
 Onset 5 min ,Peak 15 min
 Duration: 30—60 min
 Improves cr.clearance and urine flow
 PT with renal impairement

84.  Application in
 Renal
 Neurologic HTN emergencies
 SE---flushing ,dizziness ,vomiting

85. PHENTOLAMINE
 Alpha 1 & a 2 blocker
 Bolus : 5-20 mg IV / 5 min
 Infusion : 0.2-0.5 mg/min
 Indications :
Cocaine intoxication ,Pheochromocytoma
May induce----MI ,CVA

86.  Must protect from light by wrapping in
aluminum foil.
 Contraindications include documented
hypersensitivity, idiopathic hypertrophic subaortic
stenosis (IHSS), atrial fibrillation or flutter. Caution
in renal or hepatic insufficiency, as levels may
increase and can cause cyanide or thiocyanate
toxicity, especially with prolonged use and with
doses greater than 4mcg/kg/ minute.Arterial
invasive monitoring recommended

87. NITROGLYCERIN
 Venodilator ,reduces preload ,CO ,cardiacwork
 Dose 5–10mcg/minute IV titrating upward by
5q 3-5min upto 20mcg/min THEN 10mcg/min
q 3-5 min upto 299mcg/min to keep SBP >
90mmHg decrease MAP by 25%.
 Continuous 0.1–1mcg/kg/minute IV infusion.
Doses may reach over 100mcg/minute
pending hemodynamic tolerance.

88. NITROGLYCERIN
 Onset : 2 min
 Duration : 1 hr
 Avoid :
Renal /cerebral hypoperfusiion ,Viagra
Side effects include headache, or
hypotension, tachycardia.

89. ENALAPRILAT
 ACE I only IV
 Application CHF /ACS
 Test dose 0.625mg hypotension common with first dose
 Bolus 1.25mg over 5 min q 4-6hr
 Onset within 15 min
 Max effect 1—4 hrs
 Avoid in pregnancy ,angiedema