Hypertensive Urgency and Emergency

Question 1

Hypertensive Emergency?

Answer 1

Systolic BP>180 and/or diastolic >120 with evidence of end organ damage

Question 2

Hypertensive Urgency?

Answer 2

Systolic BP>180 and/or diastolic >120 with no evidence of end organ damage

Question 3

End organ damage?

Answer 3

CV System- MI, unstable angina, acute heart failure, Aortic Dissection
Renal- Acute Renal Failure
Neuro- Encepalopathy, stroke, hemorrhage
Heme- Microangiopathic Hemolytic anemia

Question 4

Increased BP? (regulation)

Answer 4

Increased firing of baroreceptors in carotid bodies and aorta
-decreased sympathetic output, increased parasympathetic outflow

Question 5

Decreased Sympathetic outflow?

Answer 5

less NE, decreased alpha receptor activity, vasodilate, decreased PVR, decreased BP

Question 6

Decreased Beta 1 receptor activity?

Answer 6

ventricular myocardium, decreased force of contraction
SA node, decreased heart rate

both lead to decreased cardiac output, decreased blood pressure

Question 7

Asses for end organ damage?

Answer 7

Auscultate the heart, auscultate the lungs, precuss lungs, pulse check, inspect neck, inspect legs

Question 8

Mortality?

Answer 8

one year mortality untreated hypertensive emergency is 70-90%
with treatment decreases to 10%
Five year mortality following untreated hypertensive emergency approaches 100%

Question 9

Why does Hypertension urgency/ emergency develop?

Answer 9

• Untreated or undertreated primary or secondary hypertension
• medication noncompliance
• rebound phenomenon from abrupt cessation of anti-hypertensives
• Illicit drug use (cocaine, amphetamines)
• Hormones: thyroid, pheochromocytoma, pregnancy
• Idiopathic: exact mechanism of de novo development of Hypertensive Urgency/Emergency

Question 10

Compelling indication/contradindication for certain drugs: Acute MI

Answer 10

Beta blockers, ACEI/ARBs, Nitrates

Question 11

Compelling indication/contradindication for certain drugs: Acute Renal Failure

Answer 11

No ACEI/ARBs (except scleroderma renal crisis)

Question 12

Compelling indication/contradindication for certain drugs: Acute Heart Failure

Answer 12

No beta blockers or CCBs

Question 13

Compelling indication/contradindication for certain drugs: Aortic Dissection

Answer 13

Beta Blockers

Question 14

Compelling indication/contradindication for certain drugs: Cocaine/ Pheochromoctyoma

Answer 14

No beta blockers (leaves alpha receptors unopposed)

Question 15

Compelling indication/contradindication for certain drugs: Pregnancy

Answer 15

Labetolol, Hydralazine (no ACEI/ARBs), Magnesium Sulfate

Question 16

Hypertensive Urgency treatment?

Answer 16

Short acting oral anti-hypertensives given in emergency department or outpatient setting with observation for a few hours, maybe discharged at home, follow up appointment in 1-2 days with primary doctor must be confirmed prior to discharge

Question 17

Treatment strategy to Hypertensive Emergency?

Answer 17

ICU admission, IV agent used

First hour: up to a 25% reduction in MAP
Subsequent 6 hours: SBP 160 mmHg and DBP 100-110 mmHg
Next 24-48 hrs: trend towards normotension

Question 18

Calculate MAP?

Answer 18

(2/3) DP + (1/3) SP

Question 19

Treatment strategy caution for Hypertensive Emergency?

Answer 19

Aggressive treatment is waranted but aggressive drop in BP leads to: stroke, hypotension/syncope, MI/angina and worsening renal failure