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Definition
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 2!
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Definition
• "ot determined by BP level, but rather theimminent compromise vital organ function
• #ormerly when :
– systolic ≥ $% mm Hg– diastolic & $$ mm Hg
'stage ((() *H+ 2!
-he Kidney and Hypertension, Ba.ris, 2/
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High blood pressure in asymptomaticchronic hypertension
(S "+- 0 H1P3-"S(4 C3(SS
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Precipitating factors in hypertensive crisis
1. Accelerated sudden rise in blood pressure inpatient with preexisting essential hypertension
2. Renovascular hypertension
3. lo!erulonephritis"acute#. $cla!psia%. &heochro!ocyto!a'. Antihypertensive withdrawl syndro!es
(. )ead in*uries+. Renin secreting tu!ors,. -ngestion of cathecola!ine precursor in patients
taing /A0 inhibitors
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)ypertensive e!ergency
• Accelerated"!alignant hypertension with papillede!a• erebrovascular conditions
)ypertensive brain infarction with severe hypertension-ntracerebral ubarachnoid
• ardiac conditionsAcute aortic dissectionAcute or i!pending !yocardial infarction
• Renal conditionsRenal crises fro! collagen"vascular diseasesevere hypertension after idney transplantation
• $cla!psia• urgical conditions
evere hypertension in patients re4uiring i!!ediate surgey• evere epistaxis
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Sign and symptom in various types of hypertensive emergency
-ype ofhypertensive emergency
-ypical symptoms -ypical signs Comment
0cute stro.e in evolution
'thrombotic or embolic
*ea.ness, altered
motor s.ill's
#ocal neruological
deficit's
Hypertension not
usually treated
Suibarachnoid hemorrhage Headache,
delerium
0ltered mental
status, meningeal
signs
5umbar puncture
typically shows
6anthochromia or redblood cells
0cute head in7ury8trauma Headache, altered
sensorium or
motor s.ills
5acerations,
ecchymoses,
altered mental
status
Computed
tomographic 'C-
scan is helpful to
determine e6tent of
intracranial in7uryHypertensiveencephalopathy
Headache, alteredmental status
papilledema 9sually a diagnosisof e6clusion
Cardiac
ischemia8infraction
Chest discomfort,
nausea, vomiting
0bnormal K
'esp; -
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-ype ofhypertensive emergency
-ypical symptoms -ypical signs Comment
0cute left ventricular
failure8pulmonary edema
Shortness of
breath
3ales auscultated
in chest
0ortic dissection Chest discomfort *idened aortic
.nob on chest 6<
ray
chocardiogram,
chest C-, or
angiogram usuallyneeded to confirm
3ecent vascular surgery Bleeding,
tenderness at
suture lines
Bleeding at suture
lines
+ften re=uire
surgical revision of
vascular anastamosis
Pheochromocytoma Headache,sweating,
palpitations
Pallor, flushing,rare s.in signs
'pha.omatoses
Phentolamine is veryuseful
>rug related
catecholamine e6cess
state
Headache,
palpilations
tachycardia History regarding
drug e6posure is .ey
Preeclampsia 8 eclampsia Headache, uterine
irritability
dema,
hyperrefle6ia
"ew treatment
guidelines e6ist
Sign and symptom in various types of hypertensive emergency
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/anage!ent of )ypertensive e!ergency
eneral principle 5
• the goal is6 inhibit the progression of organda!age
• parenteral drugs !ust be used• balance the benefit and the organ perfusion6
particularly brain6 !yocardiu! and idney
?(?S Cardiovascular uide, 2@
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7herapeutic guidelines
• do not lower 8& !ore than 2%9 over the first 1 hourunless necessary to protect other organs
• reduce the 8& of 1': !!)g6 D8& of 1:: !!)g6 or/A& of 12: !!)g6 in the first 2# hours
• begin the conco!itant long"ter! therapy soon afterthe initial e!ergency treat!ent
• atte!pt the established nor!otension within a fewdays
MIMS Cardiovascular Guide, 2005
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&arenteral drugs for treat!ent of hypertensive e!ergency
Drug Dose Onset ofactions Durationof action Special indications
Diuretics
Furosemide
20-40 mg in 1-2 min,repeated and higherdoses with renalinsufficiency
5-15 min 2- h !ssually needed tomaintain efficacy ofother drugs
"asodilators#itropruside
0$25-10$00µg%min%&g%min as i$'$
infusion
(mmediate 1-2 min )ost hypertensi'eemergencies* cautionwith high intracranialpressure or a+otemia
#itroglycerin
#itro-id (".
5-100 µg%min as i$'$
infusion
2-5 min 5-10 min /oronary ischemia
#icardipine 5-15 mg%h i$'$ 5-10 min 1-4 h )ost hypertensi'eemergencies* cautionwith acute heart failure
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Drug Dose Onset ofactions
Durationof action
Special indications
ydrala+ine 10-20 mg i$'$ 10-20 min - h clampsia* caution withhigh intracranialpressure
nalaprilat 1$25-5$00 mg e'ery 3 h 15 min 3 h cute left 'entricularfailure
drenergicinhiitors
hentolamine
smolol
6aetalol
5-15 mg i$'$
200-500 µg%&g%min for 4
min, then 50-00
µg%&g%min i$'$
20-0 mg i$'$ olus
e'ery 10 min2 mg%min i$'$ infusion
1-2 min
1-2 min
5-10 min
-10 min
10-20 min
-3 h
/atecholamine e7cess
ortic dissection, afteroperation
)ost hypertensi'e
emergencies e7ceptacute heart failure
/lonidin 85-100 µg%unit 5-10 min -3 h )ost hypertensi'eemergency, highcaution with reoundeffect
&arenteral drugs for treat!ent of hypertensive e!ergency
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Condition Preerred anti!"#ertensive a$ent
%cute #ul&onar" ede&a 'enoldo#a& or nitro#russide in co&(ination )it!
nitro$l"cerin *u# to 60 µ$+&in and a loo# diuretic
%cute &"ocardial isc!e&ia -a(etalol or es&olol in co&(ination )it!
nuitro$l"cerin *u# to 60 µ$+&in
."#ertensive ence#!alo#at!" -a(etalol, nicardi#ine, or enoldo#a&
%cute aortic dissection -a(etalol or co&(ination o nicardi#ine orenoldo#a& and es&olol or co&(ination onitro#russide )it! eit!er es&ool or intravenous&eto#rolol
/clasia -a(etalol or nicardi#ine ."dralaine &a" (e used
in a nonIC settin$
%cute renal ailure+ &icroan$io#at!icane&ia
'enoldo#a& or nicardi#ine
S"at!etic crisis+cocaine overdose era#a&il, diltiae&, or nicardi#inein co&(ination)it! a (enodiae#ine
7able Reco!!ended antihhypertensive agents for hypertensivecrisis
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)ypertensive ;rgency
• &otentially dangerous 8& elevation6 withoutacutelife"threatening end organ da!age
• 8lood pressure for!erly ≥1+: !!)g6 D ≥11: !!)g
• o!e of the circu!stance 5
– )igh 8& with retinal changes
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/anage!ent of )ypertensive urgency
• oal 5 prevent to the target organ da!age
• 7herapeutic consideration 5
– ;se oral drugs
– ub lingual drug >?• Reach the 8& 1':1:: !!)g in 2# hours6 nor!al
after 2#"#+ hours
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ublingual drug• till controversial begin to avoid• ubse4uent studies showed that the bioavailability of
sublingual nifedipione was negligible• @DA reco!!endations 1,,' 5
Bifedipine sublingual should be used with greatcaution6 if at al A
Ba.ris, Kidney and Hypertension 2/
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-able +ral drugs for hypertensive urgencies
Drug /lass Dose Onset Duration h.
/aptopril /apoten. ngiotensin-con'ertingen+yme inhi$
25-50$0 mg 15 min 4-3
/lonidine /atapres. /entral -
agonist
0$2 mg initially,
then 0$1 mg%h,up to 0$ mg
total
0$2-2$0 h 3-
Furosemide 6asi7. Diuretic 20-40 mg 0$5-1$0 h 3-
6aetalol #ormodyne,
9randate.
- and -
:loc&er
100-200 mg 0$5-2$0 h -12
#ifedipine procardia,dalat.
/alciumchannelloc&er
5-10 mg 5-15 min -5
ropanolol (nderal. -:loc&er 20-40 mg 15-0 min -3
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athways for management of patients with se'ere hypertension, defined as
lood pressure :. in e7cess of 10%110 mmg$
Se'ere ypertension
: ; 10 % 110
ncephalopathy
rogressing target organ damage
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-H 3(H- #+93
$;3ight medicine
2;3ight indication
!;3ight dose
/;3ight patient
C03 -+ -H 0>43S ##C-
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