27th Annual Update in Emergency Medicine

Hypertension in the ED - management tips that will bring

down your own BP February 24, 2014

Clare Atzema, MD MSc FRCPC Staff Physician, Sunnybrook Health Sciences Centre

Core Scientist, ICES Annals of Emergency Medicine Decision Editor

Disclosures •  No industry funding •  Funded by several Canadian federal

research agencies – Heart and Stroke Foundation of Canada – CIHR

Objectives 1)  To review the myriad of ways that

hypertension can present in the ED 2)  To revisit your drug armamentarium for

managing hypertension in the ED 3)  To examine how the latest evidence

impacts the ED management of these patients

Working in the ED…Which of these 5 patients require BP treatment?

•  VS: hr 100, BP 209/105, RR 20, temp 36.9oC 1)  Patient A: 65 y o!with n/v & confusion 2)  Patient B: 73 y o"with sudden onset SOB, pink

sputum & chest pressure 3)  Patient C: 56 y o!with sharp chest & back pain 4)  Patient D: 64 y o"with a 6-hr of right-sided

weakness 5)  Patient E: 51 y o" with a mild headache,

concerned about her BP level

Patient A 1)  Patient A: 65 y o!with n/v & confusion •  VS: hr 100, BP 209/105, RR 20, temp 36.9oC •  CINETVDATE / VINDICATE

–  Infectious? –  DKA? –  Tox? –  Post-ictal? –  Intracranial goober? –  Hypertensive Encephalopathy

Patient A – Hypertensive Encephalopathy

•  A diagnosis of exclusion •  Intracranial etiology?

–  Imaging to r/o ischemic CVA –  Usually focal signs & sx

– Triad: 1.  severe hypertension 2.  altered mental status 3.  papilledema

Patient A •  Hypertensive Encephalopathy

–  What is it? •  Cerebral hyperperfusion, increased vascular permeability,

resultant edema

–  Early (24-48 hrs): •  Headache (anterior, constant), n/v, +/- visual disturbances •  Stage II/III retinal findings

– Cotton-wool spots: fluffy white-ish lesions (nerve fiber layer infarcts)

–  Exudates: well-defined yellow patches (lipids, from basement membrane leakage)

–  Flame hemorrhages

Retinopathy in hypertensive crisis

Patient A •  Hypertensive Encephalopathy

–  Early (24-48 hrs): •  Headache (anterior, constant), n/v, +/- visual disturbances •  Stage II/III retinal findings

– Cotton-wool spots: fluffy white-ish lesions (nerve fiber layer infarcts)

–  Exudates: well-defined yellow patches (lipids, from basement membrane leakage)

–  Flame hemorrhages –  Late (48 hrs +):

•  Confusion, lethargy, � LOC, seizures •  Papilledema (stage IV retinal findings)

Patient A •  Hypertensive Encephalopathy

– Treatment •  Lower the BP (confirms diagnosis) •  Goal 20-25% reduction / 2-6 hrs

" DBP goal 100-105 mm Hg / 2-6 hrs –  Labetalol

•  20 mg slow push (2 minutes) –  Based on result, repeat or double (20/40/80/160) q10min – Max 300mg

–  No Nitroprusside •  May increase cerebral blood flow

Patient B Patient B: 73 y o"with sudden onset SOB, pink sputum & chest pressure • VS: hr 100, BP 209/105, RR 20, temp 36.9oC • CINETVDATE / VINDICATE

–  P.E.? –  Infectious? –  Cancer? –  Boerhaave’s? –  HF secondary to BP

Patient B •  Treatment

•  Treat the BP (which will address the HF)

– Nitroglycerin •  Sprays, drip

1.  Start: 10-20 mcg/min 2.  Titrate: Increase 5-10 mcg/min q 5-10 minutes 3.  Usual dosage: 50-200 mcg/min (max 500 mcg/min)

•  +/- BiPAP/CPAP •  +/- Furosemide

–  If total body fluid overloaded

•  +/- Nitroprusside

Patient C Patient C: 56 y o!with sharp chest & back pain • VS: hr 100, BP 209/105, RR 20, temp 36.9oC • CINETVDATE / VINDICATE

–  P.E.? –  ACS? –  Infectious? –  Pneumomediastinum? –  Boerhaave’s? –  Pneumothorax? –  Aortic dissection

Patient C •  Aortic Dissection

– Symptoms: •  Sharp c.p.

– May migrate

•  Neck (often anterior) or jaw pain –  Aortic arch involvement / extension into great vessels

•  Intrascapular pain – Descending aorta

•  Abdominal pain – Descending aorta, below diaphragm

Patient C •  Aortic Dissection

– Symptoms: •  End organ manifestation

– RV AMI – Tamponade – Ischemic stroke (carotids, vertebrals) – Mesenteric ischemia – RF – Ischemic Limb (5 Ps)

Patient C •  Aortic Dissection

–  Signs: •  BP difference in arms, Pulse deficit •  AR

–  diastolic murmur –  bounding pulses, wide pulse pressure –  +/- HF

•  Tamponade –  muffled heart sounds, hypotension, pulsus paradoxus, jugular

venous distention, Kussmaul sign

•  Horner’s syndrome –  ptosis, miosis, anhidrosis

Patient C •  Aortic Dissection

–  Diagnostic tests •  Lab

–  Leukocytosis – D-dimer + –  (Cr �, trop �)

•  ECG –  If proximal propagation, RV AMI (inf leads, V4R)

•  CT angiogram –  TEE – MRI –  Aortography

Patient C •  Treatment: � shearing forces to decrease the

intimal tear & propagation of dissection •  Exception to 25% Rule

– Goal SBP 100-120 mm Hg

1)  Labetalol •  20 / 40 / 80 / 160 (slow push / 2 min, q10min)

Æ Hr 60 bpm

2)  Add Nitroprusside •  0.5 mcg/kg/min, up to 2.0 mcg/kg/min

– Good iv site – Mixed properly, aluminum cover

Patient C – Asthmatic?

•  Esmolol for mild/mod RAD –  Load 250-500 mcg/kg IVP/1-3 min, then initiate infusion

50-100 mcg/kg/min – May repeat loading dose or increase infusion up to 300

mcg/kg/min

•  Diltiazam

– Severe AR? – Use BB cautiously (blocks compensatory tachycardia)

– Pain control / analgesia – Art line (arm with higher BP)

Patient D Patient D: 64 y o"with a 6-hr of right-sided weakness •  VS: hr 100, BP 209/105, RR 20, temp 36.9oC •  CINETVDATE / VINDICATE

–  SAH –  ICH –  Intracranial mass –  Hypoglycemia –  Ischemic CVA

Patient D •  Treatment

•  Treat at all? – Even v brief episodes hypotension " worse outcomes – AHA/ASA 2007: “Antihypertensive(s)… should be

withheld unless the SBP is >220 mm Hg or DBP is >120 mm Hg”

» Goal: � 15% / over the first 24 hours Æ  If use, choose agent that is easily titrated, with minimal vasodilatory

effects on cerebral blood vessels

1) Labetalol »  10-20 mg / 1-2 min, repeat q10min, max 300mg

2) Nicardipine »  5 mg/h, � 2.5 mg/h q5-15min, max 15 mg/h

•  Stroke. 2007;38:1655-1711

Patient D •  Treatment

–  If thrombolysis eligible, goal SBP 185 mm Hg 1)  Labetalol

–  10-20 mg / 1-2 min, may repeat q10min x 1

OR 2)  Nitro paste 1” - 2”

OR 3)  Nicardipine

–  5 mg/hr, titrate up by 2.5 mg/hr at 5-15 minute intervals, maximum dose 15 mg/hr

Æ If BP not reduced & maintained at SBP ≤185 & DBP ≤110 mm Hg, do not administer tPA

Patient D – ICH? •  Treatment

•  AHA/ASA 2007: “If SBP>180 mm Hg (or MAP>130) & no evidence of elevated ICP, consider lowering the BP to target 160 mm Hg”

–  INTERACT 1 trial, ATACH trial: rapid (6 hrs) SBP reduction to 140  mmHg associated with � hematoma expansion

–  INTERACT 2: No difference –  ATACH II: in progress

•  Labetalol •  Nicardipine

Patient D – SAH? •  Treatment

– Damned if you do, damned if you don’t

1)  Schmidt et al, Stroke, 2011 –  n = 134 – Reduce DBP <100 mm Hg vs standard care

»  15% re-bleeds in intervention grp, 33% in control (18% better)

»  43% had ischemic events in intervention grp, 22% in control (21% worse)

2)  2012 American Stroke Association: •  � in SBP to < 160 mm Hg is reasonable

– Not nitroprusside

Patient D – SAH? •  Treatment

– Nimodipine –  Vasospasm 3+ days afterward –  Not your concern unless looking after patient in the ED 3

days later

Patient E Patient E: 51 y o" with a mild headache, concerned about her BP level •  VS: hr 100, BP 209/105, RR 20, temp 36.9oC

–  History •  Hx HTN?

–  Taking meds / compliance? –  EtOH? NSAIDS? –  Med change?

•  N/v, h/a, restlessness/confusion •  Visual changes •  HF sx •  C.P. (AMI / Dissection sx)

Patient E Patient E: 51 y o" with a mild headache, concerned about her BP level

–  Physical exam •  Retina •  Neuro •  Chest •  CVS

–  Asymptomatic v high BP: 1) “Hypertensive urgency” 2) “Severe hypertension” 3) “Grade III hypertension” 4) “Asymptomatic markedly elevated blood pressure” Æ The patient you see most shifts

Patient E •  Diagnostic tests?

•  ECG •  CXR •  Bloodwork (Cr)? •  Urine dip

•  ED treatment •  IV meds? •  PO meds? •  Rx?

Patient E •  Diagnostic tests? •  ACEP HTN Guidelines:

–  Level C recommendations 1)  In ED patients with asymptomatic markedly

elevated BP, routine screening for acute target organ injury (serum Cr, u/a, ECG) is not required.

2)  In select patient populations (eg, poor follow-up), screening for an elevated serum Cr level may identify kidney injury that affects disposition (eg, hospital admission).

Patient E •  ACEP HTN Guidelines:

–  Karras, 2008 •  n=109, 3 EDs, BP ≥180/110 •  Clinically meaningful unanticipated test results •  7 patients (6%)

–  Nishijima, 2010 •  n=167, 2 EDs, DBP ≥ 100 •  12 patients (7.2%)

" Hess 2010, CXR in c.p.: 2.1% Δ, 6% abnormal " Brown 2011, Spec Exam in PV bleed: 6% Δ

Patient E •  ED treatment? •  ACEP HTN Guidelines:

– Level C recommendations 1)  In patients with asymptomatic markedly elevated

blood pressure, routine ED medical intervention is not required.

2)  In select patient populations (eg, poor follow-up), emergency physicians may treat markedly elevated blood pressure in the ED and/or initiate therapy for long-term control.

Patient E •  ED treatment? •  ACEP HTN Guidelines:

–  Grassi, 2008 •  n=549, rest then tx if >180/110 •  No AE within 72 hrs

–  Freis, 1967, JAMA •  n=143 !, DBP 115-130 •  6% (controls) vs 0% (Rx) complications within 4 mo

–  sudden death, ruptured aortic aneurysm/death, ↑↑BUN, & HF

•  39% vs 3% at 20 months, respectively

Patient E •  ED treatment

– My practice… •  IV meds? O •  PO meds? O •  Rx? P

– No comorbidities: HCTZ, CCB (amlodipine), ACE-I or ARB – Comorbidities: LVH, diabetes, RF, afib

"  ACE-I or ARB Exceptions: »  Black persons: CCB or HCTZ »  BB only for post AMI or angina

Patient E •  ED treatment

– Long term goal: •  JNC 8: age > 65 = 150/90 mm Hg, else 140/90 mm

Hg •  CHEP: 140/90 mm Hg, DM 130/90 mm Hg •  ESC: 140-150 mm Hg for elderly

Patient F Patient F: 31 y o", 23 weeks pregnant, concerned about her BP level • VS: hr 90, BP 162/100, RR 20, temp 36.9oC

–  Pre-eclampsia •  GA > 20 weeks •  >140/90 mm Hg or � 30 / 15 mm Hg

–  OLD: 1.  Hypertension 2. Proteinuria (5g/24h) 3. Edema

–  NEW: 1.  Hypertension 2. Proteinuria ≥ 0.3g/24 hr OR Dipstick 1+ ¬  No proteinuria: Platelets < 100,000 Cr double

LFTs twice normal Pulmonary edema Cerebral or visual sx

Patient F Patient F: 31 y o", 23 weeks pregnant, concerned about her BP level

– Pre-eclampsia presentation •  Photophobia, scotomas, cortical blindness •  Headache •  ALOC •  Severe RUQ pain •  Pulmonary edema

– Lab Tests •  U/A, Cr, Glc, lytes, platelets, LFTs

–  U/A + Æ 24 hr protein

Patient F •  All normal in Patient F (gestational HTN) •  HTN Classification in Pregnancy

– Mild •  140-149 / 90-99 mm Hg

– Moderate •  150-159 / 100-109 mm Hg

– Severe •  160+ / 110+ mm Hg

Patient F •  Treatment

•  When to initiate anti-hypertensives? •  SOGC

– New onset SBP > 160 or DBP > 110

•  ACOG –  SBP ≥ 160 or DBP ≥ 105

•  ESC –  SBP ≥ 150 mm or DBP ≥ 95

Æ Target 130-150 / 80-100 mm Hg

Patient F •  Treatment

–  IV •  Labetalol

–  20/40/80/160 (q10min)

•  Hydralazine –  5 mg/1-2 min, q20min repeat 5-10 mg (depending on response) –  Max 20 mg bolus

•  Nitroglycerin (pulmonary edema) –  5 mcg/min, ↑ q3-5min

–  PO •  Methyl-dopa (250 mg bid-tid, ↑q2day)

–  Very mild

•  Labetalol (100 mg bid, ↑q2-3 day) •  Long acting nifedipine (30-90 mg od)

Patient F •  Treatment

– Not in pregnancy – Nitroprusside – ACE-I, ARB, direct renin inhibitors – Short-acting nifedipine – Esmolol, metoprolol, atenolol

Overview Medications - IV 1.  Beta-blockers

1.  Labetalol 2.  Esmolol

2.  Vasodilators 1.  Nitroprusside 2.  Nitroglycerin 3.  Hydralazine 4.  Phentolamine

3.  Non-dihydropyridines •  Diltiazam, Verapamil

Medications (IV) - Unavailable in Canada

1.  Nicardipine •  CCB (2nd gen dihydropyridine) •  Hypertensive encephalopathy •  Dose: 5 mg/hr, increase up to 15 mg/hr

2.  Clevidipine •  CCB (3rd gen dihydropyridine) •  Ultra-short acting •  Dose: 1 mg/hr, increase up to 21 mg/hr

3.  Fenoldopam •  Peripheral dopamine-1-receptor agonist •  Maintains or increases renal perfusion •  Dose: 0.1 mcg/kg/min, ! q15 min

IV Anti-hypertensives Medication   Dosage   Pathophysiology  Labetalol   Bolus: 20 mg IV; may administer 40-80 mg IV

q10 min to a max of 300 mg total Infusion: After 20 mg IV bolus, 0.5-2 mg/min to total dose of 300 mg/24hr  

Selective α1-adrenergic and nonselective β-adrenergic receptor blocker

Esmolol   Load: 250-500 mcg/kg over 1-3 min, then initiate infusion at 25-50 mcg/kg/min. Titrate up to max 300 mcg/kg/min.  

Cardioselective β-adrenergic receptor blocker. Onset 60 seconds, duration 10-20 minutes  

Nitroprusside   Infusion: 0.25-0.5 mcg/kg/min Increase at rate of 0.5 mcg/kg/min to desired effect (after 2 mcg/kg/min risk cyanide poisoning �)  

Arterial & venous vasodilator. Onset in seconds, duration 1-2 minutes  

Nitroglycerin   Infusion: 5-10 mcg/min, increase by 5-10 mcg/min q3-5 min  

Potent, nonselective venodilator. Affects arterial tone at high doses. Onset 2 min, duration 5-10 min  

Phentolamine   Bolus: 5-20 mg IV q5-15min Infusion: 0.2-0.5 mg/min  

α1- & α2-adrenergic blocker  

Hydralazine   Load 5 mg iv over 1-2 min, repeat after 20 min prn, max 30 mg  

Direct arteriol vasodilator  

Questions?