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Chief Rounds Management of Severe Hypertension

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Chief Rounds Management of Severe Hypertension Lei Zhang, MD Sergio Zanotti, MD 7/20/09 Case 1 56 y.o. male p/w severe chest pain for 2 hours. Sudden onset, L chest ... – PowerPoint PPT presentation

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Title: Chief Rounds Management of Severe Hypertension


1
Chief RoundsManagement of Severe Hypertension
  • Lei Zhang, MD
  • Sergio Zanotti, MD
  • 7/20/09

2
Case 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

3
Case 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

4
Case 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

5
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6
How would you approach this patient?
7
Classification 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
8
Hypertensive Emergency
  • Increased blood pressure
  • Evidence of acute end-organ damage
  • Requires immediate reduction of blood pressure
  • Intravenous medications
  • Invasive monitoring

9
Organ Damage
Hypertensive encephalopathy Stroke Retinal
hemorrhages Papilledema
Myocardial ischemia Acute heart
failure Dissecting aortic aneurysm
Hematuria / RBC casts Renal failure
10
Clinical Evaluation
  • Physical exam
  • Vital signs, blood pressure in both arms
  • Fundoscopic examination
  • Neurological exam
  • Cardio-pulmonary exam
  • Extremities

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12
Clinical 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?

14
Should the blood pressure be lowered acutely?
15
Does 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
16
How much should the pressure be lowered?
17
Autoregulation of blood flow
Cerebral Blood Flow
Hypertensive encephalopathy
Ischemia from hypoperfussion
60 120 180 Mean Arterial Pressure (mmHg)
18
Autoregulation 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)

20
Back to our case
  • A CT scan is performed.

21
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24
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25
DeBakey Classification
Stanford Classification
26
Mortality of Aortic Dissection
IRAD. JAMA 2000 283897.
27
Acute Aortic Dissection
  • Decrease aortic wall stress dp/dt max
  • Vasodilator ? -blocker

28
Principles 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.
29
Principles 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.
30
BP CO x SVR
heart rate x stroke volume
vasoconstriction
Nitroprusside Nicardipine Fenoldapam Nitroglycerin
Enalaprilat
Esmolol Labetalol
31
Acute Aortic Dissection
  • Indications for surgery
  • Ascending aorta
  • Rupture
  • Leakage of blood
  • Impaired blood flow to organ or limb
  • Pain refractory to medical treatment

32
Case 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

33
Case 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,

34
Case 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

35
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36
Should the blood pressure be lowered acutely in a
patient with stroke?
37
Autoregulation is lost during acute neurologic
injury
Cerebral Blood Flow
Neurological injury
Normal
Chronic HTN
60 120 180 Mean Arterial Pressure (mmHg)
38
Ischemic Penumbra
Normal Brain 50 mL/100 g/min
Penumbra region of brain with a gradient of
decreased CBF. Dysfunctional but SALVAGABLE.
39
Penumbra Should we raise BP?
MRI / DWI
MRI / PWI
Fisher M, et al. Neurology 1999 521750
40
Relationship between CBF and ICP
MAP (mm Hg)
Adapted from Rose J, Mayer S. Neurocritical Care
20043287-300
41
Ischemic Stroke
  • Potential hazards of elevated BP
  • Increased edema formation
  • Hemorrhagic transformation
  • Potential hazards of low BP
  • Infarct extension
  • Penumbra
  • Role for induced hypertension

42
Acute 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
43
Are there any factors that would mandate a more
aggressive lowering of blood pressure in an acute
stroke?
44
BP 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

45
Acute 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
46
When 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
47
Case 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

48
Case 3 ( Cont. )
  • Medication
  • Advair inh
  • Metoprolol
  • Vasotec
  • HCTZ
  • Allopurinol
  • Lipitor
  • ASA
  • SH
  • ½ PPD for 20 years
  • occasional ETOH
  • FH
  • HTN, Gout

49
Case 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

50
Case 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

51
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52
Hypertensive 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

53
Posterior Reversible Encephalopathy Syndrome
(PRES)
54
Case 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

55
Case 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

56
Case 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

57
Does 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
58
Journal of Hypertension 2000
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