Nisarg Shah, M.D.

1
Hypotension and Hypertension

• Nisarg Shah, M.D.
• May, 2005

2
Hypotension

• Inadequacy of tissue oxygen supply versus demand
  resulting in global tissue hypoperfusion

3
Hypotension4 types of shock

• Hypovolemic - inadequate circulating volume
• hemorrhage
• fluid depletion

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Hypotension4 types of shock

• Cardiogenic inadequate cardiac pump function
• arrhythmia
• MI, dilated CM, decreased output from sepsis
• mechanical VSD, aortic stenosis

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Hypotension4 types of shock

• Obstructive extra cardiac obstruction to blood
  flow
• pericardial tamponade
• pulmonary embolism
• severe pulmonary hypertension

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Hypotension4 types of shock

• Distributive peripheral vasodilation and
  maldistribution of blood flow
• sepsis
• drug overdose
• anaphylaxis
• neurogenic
• endocrinologic

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Hypotension

• Find the type and treat cause
• history vomiting, bleeding, CP, fever,
  medication use
• physical temp, heart rate, skin color,
  jugular veins, respiratory rate

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Hypertension
9
Overview
Approach to patients Urgency vs
Emergency ED Management Goals of ED treatment
Pharmacotherapy Specific Treatments The
Discharged Patient

• History
• Pathophysiology
• Definitions
• Hypertension
• Hypertensive Urgency
• Hypertensive Emergency

10
History

• 1628
• William Harvey describes blood circulation

1733 Stephen Hales first measures blood
pressure
1816 Rene Laennec invents the stethoscope
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History

• Measuring blood pressure
• Sphygmograph, 1863

Sphygmomanometer, 1898
Karotkoff, 1905
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History

• Hypertension
• Osler, 1912
• Simple HTN without disease
• Atherosclerosis with associated hypertension
• Chronic nephritis with secondary hypertension
• Framingham and VA studies, 1970s
• Joint National Committee on Detection,
  Evaluation, and Management of High Blood Pressure

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Pathophysiology
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Pathophysiology

• Essential Hypertension 94
• Prevalence gt50
• Unknown cause
• Secondary Hypertension 6
• Prevalence 6
• Renal
• Endocrine
• Miscellaneous

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Pathophysiology

• Prevalence increases with
• Age
• Male gender
• Obesity
• African American race

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Pathophysiology

• Interestingly

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Pathophysiology

• The old renin-angiotensin-aldosterone system...

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Aside

• Leading cause of office visits and the leading
  use of prescription drugs (aside from vicoden) in
  the U.S.
• Over 100,000,000 office visits in 1997
• HOWEVER
• - only 2/3 of Americans with HTN are aware of dx
• - almost 75 of known HTNsives are not
  controlling BP under 140/90
• - only 50 of known HTNsives are taking their
  meds as prescribed

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Definitions
20
Definitions

• JNC-VI, 1997
• Optimal lt120 / and lt80
• Normal lt130 / and lt85
• High-Normal 130-139 / or 85-89
• Stage I 140-159 / or 90-99
• Stage II 160-179 / or 100-109
• Stage III 180 / or 110

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Definitions thankfully simplified
JNC-VII, 2003 NORMAL lt120/ and
lt80 Pre-Hypertension 120-139/ or 80-89 Stage
I 140-159 / or 90-99 Stage II gt160 / or
100-109
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Definitions

• Hypertensive Urgency
• Hypertensive Emergency
• Accelerated Hypertension
• Malignant Hypertension
• Accelerated-Malignant Hypertension

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Definitions

• Hypertensive Crisis
• Urgency or Emergency

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Hypertensive Urgency

• Severe elevation of blood pressure
• Generally DBP gt115-130
• No progressive end organ damage

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Hypertensive Emergency

• Severe elevation of blood pressure
• Generally occurs with DBP gt130
• WITH significant or progressive end organ damage
• Hypertensive Encephalopathy
• CVA Ischemic versus hemorrhagic
• Acute Aortic Dissection
• Acute LVF with Pulmonary Edema
• Acute MI / Unstable Angina
• Acute Renal Failure
• Eclampsia

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Urgency vs. Emergency

• Urgency
• No need to acutely lower blood pressure
• May be harmful to rapidly lower blood pressure
• Death not imminent
• Emergency
• Immediate control of BP essential
• Irreversible end organ damage or death within
  hours

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Approach to Patients
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Approach to patients

• Recheck blood pressure!
• Appropriate size cuff.
• Cuff not over clothing
• Check in all limbs
• History
• Prior crises
• Renal disease
• Medications
• Compliance
• MAO inhibitors
• Recreational drugs

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Approach to patients

• Physical Exam
• What do you see?
• Signs of end organ damage?

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End organ damage

• Neuro
• Cardiac
• Renal

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Neuro

• Hypertensive encephalopathy
• Severe Headache
• AMS
• Nausea/Vomiting
• Papilledema
• Visual Changes
• Seizures
• Focal Neurological Deficits
• Ischemic vs hemorrhagic CVA

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Fundoscopy
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Fundoscopy/ Neuro
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Fundoscopy/ Vascular
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Fundoscopy/ Vascular
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Cardiac

• Cardiac ischemia
• Chest pain
• EKG for ischemic changes
• Acute left ventricular failure
• Pulmonary edema
• Rales
• Hypoxia
• SpO2
• EKG for left ventricular strain pattern
• Aortic regurge murmur
• CXR?

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Renal

• Electrolytes
• BUN/Cr
• Chronic failure/insufficiency vs acute failure
• Cause vs effect
• UA with micro
• Protein
• Blood
• Casts

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Goals of Treatment
39
Goals of Treatment

• Prevent end organ damage
• NOT normalize BP
• Exceptions??
• IV fluids
• Forced natriuresis
• Saline may help blunt renin-angiotensin response

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Goals of Treatment

• Harington, et al, BMJ 1959
• 94 cases over 7 years
• Immediate normalization of BP
• 12 not included in study
• 30 / 82 with significant neurologic sequelae
• Ledingham, et al, QJM 1979
• Case series of 10 patients
• All with papilledema
• All with neurologic sequelae
• 3 deaths during treatment

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Goals of Treatment
WHY ?
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Cerebral Autoregulation

• Strandgaard, et al. BMJ 1973

Lancet, Hpertensive Emergencies, 2000
356(9227)411-417
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Cerebral Autoregulation

• Strandgaard, et al. BMJ 1973

Cerebral blood flow
60 mmHg
160 mmHg
120 mmHg
MAP
Adapted from Chest, 2000 118214-227
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Goals of Treatment

• Within 1-2 hrs
• Lower MAP 20-25
• CONTROLLED
• IV titratable meds
• Sublingual Nifedipine
• Too effective
• Hydralazine
• Not titratable
• Eclampsia

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Pharmacotherapy
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Pharmacotherapy

• Nitroprusside
• Arterial venous dilator
• Decreases afterload and preload
• No direct negative inotropy or chronotropy
• Kinetics
• Onset seconds
• Duration 1-2 min
• 1/2 life 3-4 min
• Increased ICP (?)
• Toxic metabolites
• Takes days to accumulate

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Pharmacotherapy

• Nitroglycerine
• Weak anti-hypertensive
• Vasodilator
• At high doses dilates arteriolar smooth muscle
• Better dilation of coronary conductance arteries
• Kinetics
• Onset 1-2 min
• Duration 3-4 min
• Tolerance
• Headache, Tachycardia, Nausea, Vomiting,
  Hypotension

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Pharmacotherapy

• Enalaprilat
• IV ACE inhibitor
• Improves cardiac index and stroke volume without
  affecting HR
• Degree BP reduction associated with pretreatment
  plasma renin activity
• Kinetics
• Onset 15 min
• Duration 6 hours

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Pharmacotherapy

• Esmolol
• Ultra-short acting
• Cardioselective ß1-blocker
• Rapidly metabolized by plasma esterase
• Negative chronotropy/inotropy
• Kinetics
• Onset 1-5 min
• Duration 10-20 min

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Pharmacotherapy

• Labetolol
• Selective Post-synaptic a blockade
• Non-selective ß blockade
• a ß 17
• Maintains cardiac output
• Decreased PVR without reflex tachycardia
• Maintains cerebral, renal coronary blood flow
• Kinetics
• Onset 2-5 min
• Peak 5-15 min
• Duration 4-8 hrs

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Pharmacotherapy

• Nicardipine
• Dihydropyridine Ca channel blocker
• Decreases afterload
• Maintains cardiac output
• No reflex tachycardia
• Kinetics
• Onset 5-15 min
• Duration 4-6 hrs
• May increase ICP

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Pharmacotherapy

• Phentolamine
• Non-selective a blockade
• Reflex tachycardia
• Kinetics
• Onset 1-2 min
• Duration up to 15 min
• May induce angina or MI
• Use mainly limited to catecholamine induced
  hypertension

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Pharmacotherapy

• Fenoldopam
• Dopamine DA-1 agonist
• No a1 or ß1 activation
• Increases renal blood flow
• 10 times more potent renal vasodilator than
  dopamine
• Increases Na excretion
• Kinetics
• Onset lt5 min
• Peak 15 min
• Duration 30-60 min

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Specific Treatment
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Hypertensive Encephalopathy

• Nitroprusside
• Fenoldopam
• Nicardipine
• Labetolol
• Symptoms of encephalopathy should improve with
  treatment

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CVA

• Nicardipine
• Labetolol
• Fenoldopam
• Decrease DBP no more than 20 in 24hrs
• Nitroprusside increases ICP
• Commonly used
• NOT recommended

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Cardiac Ischemia

• Nitroglycerine
• Nitroprusside
• Fenoldopam
• Nifedipine
• Reflex tachy
• Increases myocardial O2 demand
• May aggravate ischemia

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Acute LVF

• Nitroprusside
• Afterload reduction
• Fenoldopam
• Nitroglycerine
• If ischemia is suspected
• Furosemide
• Loop diuretic
• Opioids

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Acute Aortic Dissection

• Nitroprusside
• Nicardipine, Fenoldopam
• Afterload reduction
• Increases ventricular contraction velocity
• Requires ß blockade
• Esmolol, metoprolol
• Labetolol
• Goal SBP 100 mmHg
• Monitor patient closely

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Acute Aortic Dissection

• ß-block FIRST!
• Esmolol
• Metoprolol

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Sympathetic Crisis

• Nicardipine
• Nitroprusside
• Phentolamine
• Cocaine / Amphetamines / PCP
• Pheochromocytoma
• MAOI with TCAs or tyramine containing foods
• Spinal cord syndromes
• Labetolol
• Increases seizures in animal models
• Does not alleviate cocaine induced coronary
  vasospasm

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Acute Renal Failure

• Nicardipine
• Nitroprusside
• Use with caution
• toxic metabolites...
• Thiocyanate excreted via kidneys
• Fenoldopam
• Labetolol

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Eclampsia

• Hydralazine
• Used historically
• Arterial vasodilator
• Maintains placental blood flow
• Nicardipine
• Labetolol
• Magnesium

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The Discharged Patient
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The discharged patient

• JNC-VII Recommendations
• Stage 1
• Thiazide diuretic
• Consider ACEI, ARB, BB, CCB
• Stage 2
• Combination tx
• Thiazide ACEI, ARB, BB, CCB
• Compelling Indications...

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The discharged patient

• JNC-VII Recommendations
• Compelling Indications
• URGENCY
• ALL PATIENTS WITH HTN URGENCY BEING DISCHARGED
  HOME SHOULD BE PLACED ON COMBINATION THERAPY AND
  HAVE RAPID FOLLOW UP.
• THIAZIDE
• ACEI / ARB / BB / CCB

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The discharged patient

• JNC-VII Recommendations
• Compelling Indications
• CHF
• Asymptomatic with ventricular dysfunction
• ACE / BB
• Symptomatic ventricular dysfunction / end-stage
  dz
• ACEI / BB / ARB with loop diuretic
• Regression of LVH with aggressive management
• Not seen with direct vasodilators
• Hydralazine / minoxidil

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The discharged patient

• JNC-VII Recommendations
• Compelling Indications
• STABLE ANGINA
• BB / (CCB)
• ACS (USA/AMI)
• BB / ACEI
• POST-MI
• ACEI / BB / AA

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The discharged patient

• JNC-VII Recommendations
• Compelling Indications
• DIABETES
• COMBINATION THERAPY
• THIAZIDE
• ACEI / ARB
• slow progression of nephropathy
• reduce albuminuria
• ARBs reduce progression
• BB / CCB (and above)
• reduce CVD stroke

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The discharged patient

• JNC-VII Recommendations
• Compelling Indications
• CHRONIC KIDNEY DZ
• ACE / ARB
• 35 rise in Creatinine is acceptable
• withhold if hyperkalemia

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The discharged patient

• JNC-VII Recommendations
• Compelling Indications
• CEREBROVASCULAR DZ
• COMBINATION THERAPY
• ACEI THIAZIDE DIURETIC
• Reduces risk of recurrent stroke

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The discharged patient

• JNC-VII Recommendations
• Compelling Indications
• AFRICAN AMERICANS
• Monotherapy
• CCB / Diuretic
• Reduced response to monotherapy
• BB / ACEI / ARB
• Eliminated when combined with diuretic

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The discharged patient

• Follow up...
• Stage I
• 140-159 / or 90-99
• Stage II
• gt160 / or 100
• Higher
• 180 / 110

Follow-up
2 Months
1 Months
lt 1 week
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Questions...

• Comments