HYPERTENSIVE CRISIS

MOHAMMED R ARAFAHMBBS FACP FRCPC FACC

PROFESSOR OF CARDIOLOGY

Proposed new definition of hypertension

is a progressive cardiovascular syndrome arising from complex and interrelated etiologies.

Early markers of the syndrome are often present before blood-pressure elevation is sustained; therefore, hypertension cannot be classified solely by discreet blood-pressure thresholds.

Progression is strongly associated with function and structural cardiac and vascular abnormalities that damage the heart, kidneys, brain, vasculature and other organs and lead to premature morbidity and death.

ASH Writing Group 2005

Blood Pressure Classification

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension 140–159 or 90–99Stage 2 Hypertension >160 or >100

BP Classification SBP mmHg DBP mmHg

Joint National Committee VII

Hypertensive Urgencies and Emergencies

Patients with marked BP elevations and acute TOD (e.g., encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic dissection) require hospitalization and parenteral drug therapy.

Patients with markedly elevated BP but without acute TOD usually do not require hospitalization, but should receive immediate combination oral antihypertensive therapy.

Joint National Committee VII

GFRProteinuriaAldosterone releaseGlomerular sclerosis

Target Organ DamageTarget Organ Damage

Adapted from Willenheimer R et al Eur Heart J 1999; 20(14): 9971008, Dahlöf B J Hum Hypertens 1995; 9(suppl 5): S37S44, Daugherty A et al J Clin Invest 2000; 105(11): 16051612, Fyhrquist F et al J Hum Hypertens 1995; 9(suppl 5): S19S24, Booz GW, Baker KM Heart Fail Rev 1998; 3: 125130, Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories 1999: 16821704, Anderson S Exp Nephrol 1996; 4(suppl 1): 3440, Fogo AB Am J Kidney Dis 2000; 35(2): 179188

Atherosclerosis*VasoconstrictionVascular hypertrophyEndothelial dysfunction

LV hypertrophyFibrosisRemodelingApoptosis

Stroke

DEATH

*preclinical dataLV = left ventricular; MI = myocardial infarction; GFR = glomerular filtration rate

Hypertension

Heart failureMI

Renal failure

Target Organ DamageTarget Organ Damage

Heart• Left ventricular hypertrophy• Angina or prior myocardial infarction• Prior coronary revascularization• Heart failure

Brain• Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease Retinopathy

Joint National Committee VII

SystolicSystolicdysfunctiodysfunctio

nn

DiastolicDiastolicdysfunctiodysfunctio

nn

HypertensionHypertension

LVHLVH

MIMI

CHCHFF

LV remodellingLV remodellingNormal LV structureNormal LV structureand functionand function

Subclinical LVSubclinical LVddysfunctionysfunction

Overt heartOvert heartfailurefailure

ObesityObesityDiabetesDiabetes

SmokingSmokingDyslipidemiaDyslipidemia

DiabetesDiabetes

Vasan RS et al. Arch Intern Med 1996Vasan RS et al. Arch Intern Med 1996

Progression From Hypertension to CHFProgression From Hypertension to CHF

Increasing Systolic BP Linked to End-Increasing Systolic BP Linked to End-Stage Renal Disease Risk: MRFITStage Renal Disease Risk: MRFIT

1 11.5

2.2

5

0

1

2

3

4

5

6

<117 117-123 124-130 131-140 >140

Klag et al. Klag et al. N Engl J MedN Engl J Med. 1996;334:13-18.. 1996;334:13-18.

PP=.009=.009PP<.001<.001

PP<.001<.001

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just

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Re

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isk

Systolic BP (mm Hg)

MANAGMENTMANAGMENT

In hypertensive urgencies critically In hypertensive urgencies critically elevated BP should be lowered rapidly elevated BP should be lowered rapidly (within 15(within 15--30minutes reduction of MBP 30minutes reduction of MBP by 25%, aim DBP 100-110, SBP 160 mm by 25%, aim DBP 100-110, SBP 160 mm Hg) .Hg) .

Avoid sudden drop of BP which lead to Avoid sudden drop of BP which lead to reduction of perfusion to vital organs reduction of perfusion to vital organs (brain, heart,. etc).(brain, heart,. etc).

In hypertensive emergencies critically elevated In hypertensive emergencies critically elevated BP should be lowered gradually within hours BP should be lowered gradually within hours (aim DBP 100-110 mm Hg, SBP 160 mm Hg).(aim DBP 100-110 mm Hg, SBP 160 mm Hg).

Benefits of Lowering BPBenefits of Lowering BP

Average Percent Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

Joint National Committee VII

Patient EvaluationPatient Evaluation

Evaluation of patients with documented HTN has three objectives:

1. Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment.

2. Reveal identifiable causes of high BP.

3. Assess the presence or absence of target organ damage and CVD.

Joint National Committee VII

CVD Risk FactorsCVD Risk Factors

Hypertension* Cigarette smoking Obesity* (BMI >30 kg/m2) Physical inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD

(men under age 55 or women under age 65)*Components of the metabolic syndrome.

Joint National Committee VII

Identifiable Causes of HypertensionIdentifiable Causes of Hypertension

Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

Joint National Committee VII

Laboratory TestsLaboratory Tests

Routine Tests• Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR,

and calcium• Lipid profile, after 9- to 12-hour fast, that includes high-density and

low-density lipoprotein cholesterol, and triglycerides

Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio

More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

Joint National Committee VII

Goals of TherapyGoals of Therapy

Reduce CVD and renal morbidity and mortality.

Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.

Achieve SBP goal especially in persons >50 years of age.

Joint National Committee VII

Causes of Resistant Hypertension

Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication

• Inadequate doses• Drug actions and interactions (e.g., nonsteroidal anti-inflammatory

drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)• Over-the-counter (OTC) drugs and herbal supplements

Identifiable causes of HTN

Joint National Committee VII

Achieved DBPmm Hg

Risk of a major cardiovascular event reducedRisk of a major cardiovascular event reducedby 30% in the HOT Studyby 30% in the HOT Study

0

5

10

15

20

25

30

105 100 95 90 85 80

% risk reduction

Optimal DBPreduction in theHOT Study

Achieved SBPmm Hg

Risk of a major cardiovascular event reducedRisk of a major cardiovascular event reducedby 22% in the HOT Studyby 22% in the HOT Study

0

5

10

15

20

25

30

170 160 150 140 130

% risk reduction

Optimal SBPreduction in theHOT Study