CONGRESSO

NAZIONALE ACEMC

2018

7-8-9 NOVEMBRE

AUDITORIUM CNR

AREA DELLA RICERCA DI PISA

EMERGENZE IPERTENSIVE IN PRONTO SOCCORSO.

QUANDO È VERA EMERGENZA E COME TRATTARE

Congresso Nazionale AcEMC 2018 - Pisa

Maria Lorenza Muiesan

Medicina Interna - Medicina di Urgenza

Università di Brescia - Spedali Civili Brescia

- STRATIFICAZIONE SEMPLIFICATA: EMERGENZE IPERTENSIVE

ABBANDONATI I TERMINI CRISI IPERTENSIVE E/O URGENZE IPERTENSIVE

- ITER DIAGNOSTICO TERAPEUTICO BASATO SULLA SINTOMATOLOGIA

DELLE EMERGENZE

- RACCOMANDAZIONI SUL TRATTAMENTO BASATE SU ATTUALE PRATICA

CLINICA E DISPONIBILITÀ DI FARMACI PER VIA ENDOVENOSA

Agenda

Congresso Nazionale AcEMC 2018 - Pisa

van den Born BH et al, Eur Heart J Cardiovasc Pharmacother. 2018

Key target organs : the aorta, heart, brain, retina & kidneys

Asymptomatic uncontrolled hypertension SBP or DBP >180 or >110 mmHg, respectively, in which OD is excluded

van den Born BH et al, Eur Heart J Cardiovasc Pharmacother. 2018

Uncontrolled hypertension (>180/110)

Absence of organ damage Presence of organ damage

Author N CV risk/ year

(approximated)

Vlcek M, 2008 384 6 %

Merlo C, 2012 50 6 %

Patel KK, 2016 58.535 1,8 %

Guiga H, 2017 285 8,9%

Author N CV risk/ year

(approximated)

Keith NM, 1939 200 78%

Guiga H, 2017 385 39%

Stratification of hypertensive emergencies according

to the condition or target organ involved

van den Born BH et al, Eur Heart J Cardiovasc Pharmacother. 2018

Acute and severe increases in BP can be precipitated by pheochromocytoma or by ingestion of sympathomimetics (meta-amphetamine or cocaine.) This can result in a hypertension emergency when there is evidence of acute HMOD

Cerebral edema consequence of an acute hyperperfusion Symptoms : severe hypertension seizures, lethargy, cortical blindness and coma, in the absence of an alternative explanation Histopathological changes : cerebral oedema, microscopic haemorrhages and infarctions Posterior reversible encephalopathy syndrome (PRES)

Hypertensive encephalopathy

10 % patients with malignant hypertension

Malignant hypertension

PAS/PAD usually > 200/ 120 mm Hg

+

advanced retinopathy

(bilateral III-IV K-W grade)

Incidence of malignant hypertension in the Amsterdam multiethnic population

(August 1993- 2005)

2.6 (+/- 0.9) /100,000 patients/year

The annual incidence of all-cause mortality is 2.6 per 100 patient-years compared with normotensive (0.2) and hypertensive (0.5) controls (both P<.01) Amraoui et al J Clin Hypertension 2014

Van den Born J Hypertens 2006

Predictors of mortality in malignant hypertension patients

Journal of Hypertension 2017, 35:2310–2314

351 patients who had at least 5-year history of malignant hypertension from the West Birmingham Malignant Hypertension Registry

Shah M et al. Am J Hypertens. 2016

Trends in hospitalization for hypertensive emergency

2002–2012 nationwide inpatient sample database to identify patients with HTNE 129,914 admissions, 630 (0.48%) patients died during their hospital stay

Presence of acute cardiorespiratory failure, stroke/TIA, chest pain, and aortic dissection were most predictive of higher hospital mortality.

Prospective analysis

77154 patients admitted to ED

University Hospital Brescia

during the year 2010

1728 (2.2%)

patients with hypertensive

emergencies or urgencies

1551 (90%)

20%

80%

Emergencies

Urgencies

Age 70 ± 14 yrs,

range 18-102

M 44 %; females 56 %

Clinica Medica Università di Brescia & ED Spedali Civili di Brescia, Muiesan ML et al abst ESH 2011

Clinica Medica University of Brescia & ED Spedali Civili Brescia,

Cardiovascular events*

Follow up (days)

Log Rank (Mantel-Cox) p<0.001

Emergencies

Urgencies

Emergencies

Urgencies

Log Rank (Mantel-Cox) p<0.0001

* Acute coronary syndromes, cerebrovascular events or hospitalizations for heart failure

0

4

8

12

16

20

Urgencies Emergencies

Events/100 patients/years

Muiesan et al, J Hypertens 2011 (abst)

diagnostic studies in patients with suspected hypertensive emergency

For all

On indication

In a patient admitted to the emergency department for acute hypertension, a funduscopic

examination may particularly helpful in identifying the presence of exudates, haemorrages

and/or papilledema.

The detection of these retinal changes indicates the presence of acute organ damage and

allows the diagnosis of hypertensive emergency and of malignant hypertension

Patient evaluation

Katz JN et al Am Heart J 2009

STAT registry (Studying The Treatment

of Acute hyperTension)

1,588 patients from 25 sites

Median age 58 years

49% women

56% African-American

Traditional ophtalmoscope Smartphone small optical device (D-Eye, Si14 S.p.A.)

Muiesan Ml et al J Hypertens 2017

2 observers (1 trained not expert, 1 expert ophtalmologist )

16 patients (31%) had III-IV grade KW 2 patients had hemorrhages and 6 exudates 9 patients grade 2–4 papilledema

Mydriatic adult Papiledema

Muiesan ML et al J Hypertens 2017

The optimum therapy, treatment is dictated by consensus on the basis of: - particular presentation of the clinical situation - end-organ complications

-not on the absolute value of blood pressure

BP lowering target/timing in hypertensive emergency

European Society of Hypertension & European Society of Cardiology , 2013

• Reduce blood pressure by <25% during ‘‘first hours’’ and then subsequent cautious reduction.

• Intravenous agents most usually employed: labetalol, sodium nitroprusside, nicardipine, nitrates, and furosemide.

AHA/ACC , 2017

• For adults with a compelling condition (i.e., aortic dissection, severe

preeclampsia or eclampsia, or pheochromocytoma crisis), SBP should be reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection.

• For adults without a compelling condition, SBP should be reduced by

no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours.

• In adults with a hypertensive emergency, admission to an intensive care unit is recommended for continuous monitoring of BP and target organ damage and for parenteral administration of an appropriate agent

van den Born BH et al, Eur Heart J Cardiovasc Pharmacother. 2018

van den Born BH et al, Eur Heart J Cardiovasc Pharmacother. 2018

Target BP

mmHg

Timeline for BP

reduction

Baseline BP

Acute aortic dissection SBP < 120 ( lower if

tolerated)

+ HR < 60bpm

Minutes >150

Acute pulmonary

edema

SBP < 140 Minutes >160

Coronary ischemia

(ACS)

SBP < 140 Minutes- slow >160

Hypertensive

encephalopathy

< 180

MAP 20-25 %

Minutes >220 /120

Ischemic stroke 15 % MAP 1 hour >220/120

Ischemic stroke +

Thrombolysis

SBP< 185 first 24 hours

SBP< 180 after

thrombolysis

1 hour >185

Acute hemorrhagic

stroke

SBP< 180 to < 140 Minutes

>180

Malignant hypertension SBP < 180

MAP 20-25 %

Hours >220

Severe pre-

eclampsia/HELLP

SBP / DBP < 160/105 Minutes/hours >160/105

ESH/ESC guidelines 2018

Drug of choice Alternative

Acute aortic dissection Nitroprusside/NTG + esmolol Labetalol, Metoprolol

Verapamil or diltiazem

Acute pulmonary edema Furosemide

NTG/nitroprusside / CPAP

Urapidil

Clevidipine

Coronary ischemia (ACS) NTG

Labetalol

Clevidipine

Urapidil

Hypertensive

encephalopathy

Labetalol

Nicardipine

Nitroprusside

Ischemic stroke Labetalol

Nicardipine

Nitroprusside

Ischemic stroke +

Thrombolysis

Labetalol

Nicardipine

Nitroprusside

Acute hemorrhagic

stroke

Labetalol

Nicardipine

Urapidil

Malignant hypertension

with or without ARF

Labetalol

Nicardipine

Nitroprusside, Urapidil,

fenoldopam , clevidipine

Severe pre-

eclampsia/HELLP

Labetalol

Nicardipine + Magnesium sulphate

Consider delivery

ESH/ESC guidelines 2018

•ESH/ESC guidelines 2018 and ESC/ESH position paper Eur Heart J Cardiovasc Pharmacother. 2018

ULTIMA DIAPOSITIVA

Congresso Nazionale AcEMC 2018 - Pisa

Treatment aspects of hypertensive emergencies and urgencies vary widely according to a patient’s clinical conditions and are largely based on consensus from clinical experience , observations and comparisons of intermediate outcomes

Further research is needed to assess the impact of acute hypertension-mediated organ damage on future cardiovascular risk and its therapeutic consequences in these patients

Park SK et al, J Hypertens 2017;35:1474-1480

CLINICAL EFFICACY OF RESTING VS ANTI-HYPERTENSIVE

TREATMENT IN HYPERTENSIVE URGENCIES

N.138 patients with hypertensive urgency randomized to resting vs resting + telmisartan 80 mg

Flow chart for acute BP elevation

[

]

Muiesan ML et al ESH Manual of Hypertension 2018