Title: Chief Rounds Management of Severe Hypertension
1Chief RoundsManagement of Severe Hypertension
- Lei Zhang, MD
- Sergio Zanotti, MD
- 7/20/09
2Case 1
- 56 y.o. male p/w severe chest pain for 2 hours.
Sudden onset, L chest, sharp, constant, radiated
to back, not related to food or activity - No f/c, no cough, no SOB, no HA, no abd pain, no
syncope - PMH HTN, OA, OSA, Hyperlipidemia
- Allergy NKDA
- SH quit smoking 10 years ago, occa ETOH
- FH HTN, stroke, CAD
3Case 1 (cont.)
- Medication
- HCTZ 25mg daily
- Lipitor 20mg daily
- Motrin PRN
- MultiVitamin
- PE 98.6 195/103 93 20 96 RA
- General anxious, c/o pain
- Head/Neck PERRLA, no JVD, no Bruit
- Chest CTA b/l
- Heart RRR, no M/G/R
- ABD soft, no tender, BS
- Ext no edema
4Case 1 ( cont.)
- Labs
- Na 136 K 3.8 Cl 104 CO2 22 BUN 14 Cr 0.9 Glu 100
Mg 1.9 Phos 2.3 - WBC 6.8 Hg 13.0 Plt 180 INR 1.1 PTT 23.6
- CE neg x1 ProBNP 133
- EKG NSR, No ST-T changes
- CXR
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6How would you approach this patient?
7Classification of Hypertension
BP Classification SBP (mm Hg) DBP (mm Hg)
Normal lt120 and lt80
Prehypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 hypertension 160 or 100
JNC 7. JAMA 20032892560
JNC 7. JAMA 20032892560
8Hypertensive Emergency
- Increased blood pressure
- Evidence of acute end-organ damage
- Requires immediate reduction of blood pressure
- Intravenous medications
- Invasive monitoring
9Organ Damage
Hypertensive encephalopathy Stroke Retinal
hemorrhages Papilledema
Myocardial ischemia Acute heart
failure Dissecting aortic aneurysm
Hematuria / RBC casts Renal failure
10Clinical Evaluation
- Physical exam
- Vital signs, blood pressure in both arms
- Fundoscopic examination
- Neurological exam
- Cardio-pulmonary exam
- Extremities
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12Clinical Evaluation
- Diagnostic tests
- BUN and creatinine
- Urine analysis
- EKG
- Chest x-ray
- Other tests (case based)
13 Key questions
- Should the blood pressure be lowered acutely?
- How much should the blood pressure be lowered?
- Which medication should be used to lower the
blood pressure?
14Should the blood pressure be lowered acutely?
15Does this patient have mental status
changes? Does this patient have new focal
findings? Do the optic fundi show papilledema,
hemorrhages, or exudates?
yes
no
Does the ECG show signs of cardiac ischemia? Is
there evidence of acute LV dysfunction?
yes
Hypertensive Emergency
no
Is the serum creatinine elevated? Does the UA
show red cells or red cells casts?
yes
no
No need to lower blood pressure acutely
16How much should the pressure be lowered?
17Autoregulation of blood flow
Cerebral Blood Flow
Hypertensive encephalopathy
Ischemia from hypoperfussion
60 120 180 Mean Arterial Pressure (mmHg)
18Autoregulation of blood flow
Cerebral Blood Flow
Normotensive
Hypertensive
60 120 180 Mean Arterial Pressure (mmHg)
19- Acute end-organ damage
- Lower MAP by 15-25 in first 2 hrs.
- MAP DBP 1/3(SBP-DBP)
20Back to our case
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25DeBakey Classification
Stanford Classification
26Mortality of Aortic Dissection
IRAD. JAMA 2000 283897.
27Acute Aortic Dissection
- Decrease aortic wall stress dp/dt max
- Vasodilator ? -blocker
28Principles guiding therapy
Forces that further dissection 1- Cardiac
Impulse (I Ft) max dP/dt 2- Systemic blood
pressure
Rushmer R. Initial Ventricular Impulse
Circulation 1964. Wheat et al. J of Thoracic
Cardiovascular Surgery 1965.
29Principles guiding therapy
Forces that further dissection 1- Cardiac
Impulse (I Ft) max dP/dt 2- Systemic blood
pressure
Increased by exercise, sympathetic, long
diastolic intervals Decreased by PVC, coronary
occlusion, hypotension, exsanguination
Rushmer R. Initial Ventricular Impulse
Circulation 1964.
30BP CO x SVR
heart rate x stroke volume
vasoconstriction
Nitroprusside Nicardipine Fenoldapam Nitroglycerin
Enalaprilat
Esmolol Labetalol
31Acute Aortic Dissection
- Indications for surgery
- Ascending aorta
- Rupture
- Leakage of blood
- Impaired blood flow to organ or limb
- Pain refractory to medical treatment
32Case 2
- 71 y.o. female woke up in the morning with R
sided weakness numbness - No f/c, no n/v, no CP/SOB, no mental status
change, no trouble with speech swallow - PMH HTN, DM, hyperlipidemia, overactive bladder
- Allergy PCN
- Med Lisinopril, ASA, Metformin, Zocor,
Glipizide, Detrol LA
33Case 2 ( cont.)
- SH nonsmoker, nondrinker, no drugs
- FH not significant
- PE 99.0 190/90 83 20 99 RA
- General NAD
- Head/Neck PERRLA, No Bruit, no JVD
- Chest CTA b/l
- Heart RRR, no M/G/R
- ABD soft, no T/D
- Ext no edema
- Neuro AAOx3, MS 3-4/5 R, 5/5 L, decrease
sensation on the R, reflex grossly nl,
34Case 2 ( cont.)
- Labs
- Na 140 K 4.0 Cl 110 CO2 21 BUN 12 Cr 1.0 Glu 150
Mg 2.0 Phos 2.3 - WBC 8.1 Hg 11 Plt 140 INR 1.1 PTT 28.4
- NL LFT
- EKG NSR, LVH
- CXR neg
- CT head
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36Should the blood pressure be lowered acutely in a
patient with stroke?
37Autoregulation is lost during acute neurologic
injury
Cerebral Blood Flow
Neurological injury
Normal
Chronic HTN
60 120 180 Mean Arterial Pressure (mmHg)
38Ischemic Penumbra
Normal Brain 50 mL/100 g/min
Penumbra region of brain with a gradient of
decreased CBF. Dysfunctional but SALVAGABLE.
39Penumbra Should we raise BP?
MRI / DWI
MRI / PWI
Fisher M, et al. Neurology 1999 521750
40Relationship between CBF and ICP
MAP (mm Hg)
Adapted from Rose J, Mayer S. Neurocritical Care
20043287-300
41Ischemic Stroke
- Potential hazards of elevated BP
- Increased edema formation
- Hemorrhagic transformation
- Potential hazards of low BP
- Infarct extension
- Penumbra
- Role for induced hypertension
42Acute Ischemic Stroke Patients not eligible for
thrombolytics
Clinical Parameter Treatment
SBP lt 220 or DBP lt 120 NO TREATMENT
SBP gt 220 or DBP 121-140 Labetalol or nicardipine to 10-15 reduction
DBP gt 140 Nitroprusside to 10-15 reduction More labetalol or nicardipine?
Adams HP Jr, et al. Stroke 2007381655-1711 Adams
H, et al. Stroke 200536916-923
43Are there any factors that would mandate a more
aggressive lowering of blood pressure in an acute
stroke?
44BP reduction and thrombolytics
- Systemic thrombolytics
- Diastolic HTN risk factor for ICH
- NINDS t-PA landmark clinical trial
- 20 pts required BP reduction prior to t-PA
- 67 pts required BP reduction after t-PA
- Intra-arterial thrombolytics
- No good data do not do if BP gt 180/100
45Acute Ischemic Stroke Patients eligible for
thrombolytics
Clinical Parameter Treatment
Prior to TPA
SBP gt 185 or DBP gt 110 Labetalol or nitropaste
During or after TPA
SBP 180-230 or DBP 105-120 Labetalol
SBP gt 230 or DBP 121-140 Labetalol or nicardipine
DBP gt 140 Nitroprusside
Adams HP, et al. Stroke. 2007381655-1711
46When is more aggressive BP lowering indicated?
Authority Urgent treatment indications
Stroke Council of the American Stroke Association acute myocardial infarction acute renal failure aortic dissection acute pulmonary edema hypertensive encephalopathy
European Stroke Initiative acute myocardial ischaemia acute renal failure aortic arch dissection cardiac insufficiency
Adams HP Jr, et al. Stroke 2003341056-1083 Hacke
W et al. Cerebrovasc Dis 200316311-337
47Case 3
- 66 y.o. male p/w worsening headache since last
night, found by family member of change of mental
status this afternoon - Nausea, blurry vision, confusion, and lethargy
- Ran out of medication for 2 days
- No f/c, no CP/SOB, no seizure, no weakness
- PMH HTN, COPD, hyperlipidemia, Gout
- Allergy NKDA
48Case 3 ( Cont. )
- Medication
- Advair inh
- Metoprolol
- Vasotec
- HCTZ
- Allopurinol
- Lipitor
- ASA
- SH
- ½ PPD for 20 years
- occasional ETOH
- FH
- HTN, Gout
49Case 3 ( cont. )
- PE
- 97.3 240/135 88 18 98
- Anxious, c/o HA, AAOx3 but slow mentation,
decrease memory - PERRLA, cotton-whool exudates, papilledema
- Neck supple, no bruit, no JVD
- Chest CTA b/l, no W/R/R
- Heart RRR, no M/G/R
- Abd soft, no tender, BS
- EXT trace edema b/l
- Neuro MS 5/5 all 4 ext, sensation intact, reflex
equal b/l, no focal deficit
50Case 3 ( cont. )
- Labs
- Na 130 K 3.5 Cl 99 CO2 22 BUN 44 Cr 1.4 Glu 135
Ca 9.8 Mg 1.7 Pho 2.2 - WBC 7.8 Hg 11.0 Plt 126 INR 1.0 PTT 26.4
- CE neg x1
- UA 1 prot, 1 est, 5 WBC, 2 RBC,
- NL LFT
- EKG NSR, LVH
- CXR cardiomegaly, no congestion
- CT head neg
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52Hypertensive Encephalopathy
- Cerebral dysfunction as a result of severely
increased blood pressure - Immediate lowering of blood pressure therapeutic
and diagnostic - Lack of improvement with lowered BP
- Ischemic/hemorrhagic stroke
- SAH
- CNS trauma, mass lesion, or infection
53Posterior Reversible Encephalopathy Syndrome
(PRES)
54Case 4
- 58 y.o. female sent to hospital by PCP for severe
hypertension - Went to PCP office for routine check-up
- Found to have BP 220/106
- Mild generalized HA for couple days
- No CP/SOB, no vision change, no edema, no
weakness
55Case 4 ( cont. )
- PMH
- HTN
- Asthma
- IBS
- Arthritis
- Cholecystectomy
- Histerectomy
- SH
- quit smoking 20 years
- occassional drinker
- FH
- HTN
- Asthma
- Allergy
- Sulfa, IV dye
- Medication
- Diovan
- Norvasc
- Albuterol inh
- Metamucil
- Motrin
56Case 4 ( cont. )
- Labs
- Na 136 K 4.0 Cl 100 CO2 23 Bun 13 Cr 0.9 Glu 103
Ca 10.0 Mg 2.5 Pho 2.7 - WBC 6.7 Hg 12 Plt 119 INR 1.2 PTT 28.1
- UA 1 prot, 1 est, 3 WBC, 1 RBC
- CE neg x1
- BNP 155
- LFT nl
- EKG NSR, nonspecific T wave changes
- CXR no acute disease
57Does this patient have mental status
changes? Does this patient have new focal
findings? Do the optic fundi show papilledema,
hemorrhages, or exudates?
yes
no
Does the ECG show signs of cardiac ischemia? Is
there evidence of acute LV dysfunction?
yes
Hypertensive Emergency
no
Is the serum creatinine elevated? Does the UA
show red cells or red cells casts?
yes
no
No need to lower blood pressure acutely
58Journal of Hypertension 2000