Hypertensive Emergencies

Jason R. Frank MD MA(Ed) FRCPC

Department of Emergency Medicine

HTN – What’s the Big Deal?

MCC OBJECTIVES – HTN EM

KEY objectives:• Differentiate malignant HTN

from secondary conditions• Conduct initial HTN lowering

treatment

OBJECTIVES:• Differentiate non-localizing

neurologic symptoms• Determine presence of other

hypertensive emergencies• Interpret clinical & lab

findings• Conduct an effective

management plan, including specific Rx

Case 1

• 50 woman sent in by community MD & pharmacist for “HTN emergency”

• Pharmacy BP = 190/90• Extremely worried,

otherwise well• Q: What is the clinical

definition of HTN?

Case 2

• 65 male drove in from cottage• Feeling unwell• Flagged at triage with BP

200/100• Forgot BP meds at home…

missed 3 days

• Q: What is a “hypertensive urgency”?

Case 3

• 72 male with chronic HTN, PAFib, and arthritis.

• Referred to CDU with elev BP “for observation”.

• 180/115 at rest• Progressive SOB over the am.

• Q: What is the definition of a “hypertensive emergency”?

Case 4

• 45 CEO of an IT firm• Presents with cp, SOB,

intense anxiety• Sweating, tacky, BP

200/120• Admits to cocaine

• Q: Management?

Case 5

• 33 F 1 week post-partum• Epigastric pain• Seizure• BP 160/95, P90, T37.2

• Q: Dx? Management?

Case 6

• 60 M presents with tearing RSCP

• Rad to back• Assoc with L headache

and R leg weakness• BP 190/100, P 95

• Q. Management?

This Session: HTN EM

1. Define HTN

2. Classify HTN

3. Provide a DDx for the acutely hypertensive patient, including 2ndary causes

4. Describe the findings of a patient with a HTN emergency

5. Describe high-utility tests for HTN EM

6. Describe the management of each of the categories of HTN

7. Describe at least 2 controversies in the management of HTN EM

HYPERTENSION

Standard Definition• Based on 3 measurements, each 1 wk apart

> 140 systolic> 90 diastolic

Most important #: Diastolic MAP = 1/3 Systolic, 2/3 Diastolic

Define HTN?

Joint National

Commission VIVII 2003

“Pre-HTN”

HTN Defined:

Primary or Secondary

• Majority (90-95%) essential HTN• Of Secondary: ½ have a potentially curable cause

HTN in the Population vs the ED?

HTN in the Population vs the ED?

• Primary HTN– Chronic– “Essential”– >95%– >25% of NA pop’n– 50% adhere to Rx– 75% not optimal– More un-Dx

• Pre-HTN

Thinking about a HTN Definitions:

• Pre-HTN……………........• Primary chronic………….• Transient ………………..• Secondary……………….• “Tertiary” ...………………

• Malignant………….........• Also: accelerated, severe, crisis,

etc

• 130-139/80-89• >140/90• white coat, anxiety, pain, etc• Pathologic organ cause• Iatrogenic, ingestion,

withdrawal, etc • Bad (enceph & retinal)

HTN in the ED – a Taxonomy

• Transient HTN• Chronic HTN• HTN Urgency• HTN Emergency• HTN-associated Crisis

Transient HTN - Examples

• Anxiety• Pain• EtOH-withdrawal• White-coat

HTN “Urgency”

• HTN “threatening” end organ damage• “End organs at risk”

• Various definitions: DBP>110, DBP>115, DBP>120

• Goal: lower BP over hours; rarely requires treatment

• Concern: bogus category, may lead to harm (eg CVAs)-see Gallagher 2003

Malignant Hypertension

Severe HTN

& Evidence of acute end-organ damage

• Diastolic BP usually > 130 mm Hg or MAP > 160• Relative rise much more important than #• Affects 1% of hypertensive patients

MAP is What Matters:

• At normal resting heart rates MAP can be approximated using the more easily measured systolic and diastolic pressures, SP and DP

• or equivalently

• or equivalently

• where PP is the pulse pressure: SP − DP

-Wikipedia

“The Delta Diastolic Threatens Death”

The change in DBP accounts for most of the

change in MAP

“∆ DBP is where it is at”

(for the ED setting)

Hypertensive Emergency?

Volhard & Fahr, 1914

HTN Emergency

Acute elevation in MAP causing end organ damage:• ARF• CHF, ACS• Encephalopathy (>160 MAP)

• CVA, ICH• Hemolysis• Retinal

– All have DBP >120

…Mortality ~90% historically

HTN Emergency – Organ Incidence?

Acute elevation in MAP causing end organ damage:• CVA (24.5%)• CHF (22.5%)• Encephalopathy (16.3%)• ACS (12%)• ICH (4.5%)• ARF (?)• Hemolysis (?)• Retinal (?)

From Zampaglione, 1996

HTN Emergency

Pathophysiology:

• Failure of autoreg• Rapid rise in SVR• Endothelial injury• Arteriolar necrosis• Ischemia• …Cascade

Secondary HTN DDx

Secondary HTN

Increased CO• RF with fluid

overload• Acute renal disease• Hyperaldosteronism• Cushing’s syndrome• Coarctation of the

Aorta

Increased vascular resistance

• Renal Artery Stenosis• Pheochromocytoma• Drugs• Cerebrovascular (CVA,

ICH, SAH)

Renal Artery Stenosis

• most common treatable cause (1-5%)• compromised renal perfusion => activation of RAA • 2 pt groups:

– Elderly with atherosclerotic disease– Young females with fibromuscular dysplasia

• Clinical: abdo bruit (40-80%), retinopathy, HTN resistant to Rx, hypoK

Aldosteronism

• Uncommon but treatable• Na retention, volume expansion, increased CO• Hypernatremia & Hypokalemia typical• Primary: Adrenal adenoma, hyperplasia• Secondary: Cushing’s, CAH, exogenous

mineralcorticoids

Pheochromocytoma

• Tumour, usually in adrenal medulla• Produces xs catecholamines (epi, NE)• Paroxysmal HTN…difficult to recognize• Episodic HTN, HA, palpitations, diaphoresis, anxiety…

not a panic attack!• Easy to diagnose: elevated urinary catecholamines,

metanephrines, vandillylmandelic acid

Coarctation of the Aorta

• Rare but early surgical intervention can improve prognosis

• Clinical triad:1) upper extremity HTN2) systolic murmur over back3) delayed femoral pulses

Drugs

• Cocaine, amphetamines• ETOH withdrawal• Withdrawal from clonidine, beta blocker• MAOI + tyramine containing foods or certain Rx

(meperidine, TCA, ephedrine)– Tyramine causes release of NE– Usually rapidly destroyed by MAO

Secondary HTN• Neuro:– Autonomic dysfunction (eg GBS, cord injuries)– CNS insult (HI, ICH)

• Renal:– Renovascular stenosis– Renal disease (eg GN, Chronic pyelo)

• Endocrine:– Pituitary tumours / ectopic ACTH– Pheochromocytoma; renin tumours; Hyperaldosteronism (egCushings)– Hyper & hypo thyroid & thyroid storm

• Vascular:– Coarctation of the Ao– Vasculitis; Collagen-vascular (eg Scleroderma)– Pre-/Eclampsia

• Sleep apnea

Iatrogenic / Lifestyle HTN (aka “tertiary”)

Too Much:

• Tyramine-MAOI• Glucocorticoids• Thyroxine• Fluid overload• NSAIDS• Sympathomimetics

Too Little:• Clonidine withdrawal• Anti-HTN withdrawal• EtOH withdrawal

HTN – associated Crisis

• HTN is a critical issue relating to an emergency Dx:

• Aortic Dissection• Pre/Eclampsia• ICH• CVA• Cocaine

HTN in the ED – a Taxonomy 2

• Pre-HTN• Chronic HTN• Transient HTN• HTN Emergency• HTN-associated Crisis

• 1’, 2’, 3’

Case 1

• 50 yo woman sent in by community MD & pharmacist for “HTN emergency”

• Pharmacy BP = 190/90

• Extremely worried, otherwise well

Case 2

• 65 male drove in from cottage

• Feeling unwell• Flagged at triage

with BP 200/100• Forgot BP meds at

home…missed 3 days

Case 3

• 72 yo male with chronic HTN, PAFib, and arthritis.

• Referred to CDU with elev BP “for observation”.

• 180/115 at rest• Progressive SOB

over the am.

DDx for the ED Hypertensive Patient

• Transient: pain, anxiety, sympathetic outflow• Chronic essential: poorly controlled• Chronic secondary: renovasc, pyelo, GN, pituitary, thyroid• Iatrogenic: fluid overload, pressors• OD/Ingestion: tyramine-MAOI, cocaine, amphetamines, • HTN-associated crises: Ao dissection, PIH, ICH, CVA, etc• HTN emergencies: CNS, ACS, CHF, retinal, RBCs

Assessment of the ED Hypertensive Pt?

Assessing the HTN Patient in the ED:

• Hx HTN & Tx• Rx use• PMHx• Symptoms of end-

organ damage• Pain

• Confirm BP • Good BP reading• End-organ damage• Heart sounds• Pulses• Fundoscopy

ED HTN Testing?

Testing for ED HTN:

• CBC, 7• EKG• CXR• Urine• CT head prn

r/o HTN emergency

ED HTN Management

HTN Management by Category:

• Pre-HTN………………

• Chronic HTN………….

• Transient HTN………..

• HTN Emergency…......

• HTN-associated Crisis.

• Advise

• Advise, note, po Rx prn

• Assess, observe, benzo prn

• Assess, lower 20% ~1 hour

• Dx-specific tx

Anti-HTN agents in ED: Rosen

Key Agents for Canadian EM Practice:

• Metoprolol• Labetolol• Nitroglycerine

Also:• Nitroprusside• Magnesium• Esmolol• Phentolamine

• Ramipril

• 25-100 po; 5 – 20 IV• 20 mg bolus IV to max 300 mg• 5-100 ug/min

• 0.25-10 ug/kg/min [Lancet, 1949]• 2-6g, then 2g/hr infusion• Load 500ug/kg/ 1min, then 50ug/kg/min, titrate• 5-10 mg/min• 2.5-5 mg po

Therapeutic Goals:

• Do no harm!• End cascade• Ensure perfusion

– Risk further ischemia when BP dropped below >20% preTx

– Maintain CPP

Controversies & Issues

1. Few ED studies for HTN

2. Accuracy of BP

3. Missed Dx

4. HTN “Urgency”

5. Epistaxis

6. Should EP’s treat?

7. Best agents

8. What benefit?

Case 1

• 50 yo woman sent in by community MD & pharmacist for “HTN emergency”

• Pharmacy BP = 190/90• Extremely worried,

otherwise well• Q: What is the clinical

definition of HTN?

Case 2

• 65 male drove in from cottage• Feeling unwell• Flagged at triage with BP

200/100• Forgot BP meds at home…

missed 3 days

• Q: What is a “hypertensive urgency”?

Case 3

• 72 yo male with chronic HTN, PAFib, and arthritis.

• Referred to CDU with elev BP “for observation”.

• 180/115 at rest• Progressive SOB over the am.

• Q: What is the definition of a “hypertensive emergency”?

Case 4

• 45 yo CEO of an IT firm• Presents with cp, SOB,

intense anxiety• Sweating, tacky, BP

200/120• Admits to cocaine

• Q: Management?

Case 5

• 33 F 1 week post-partum• Epigastric pain• Seizure• BP 160/95, P90, T37.2

• Q: Dx? Management?

Case 6

• 60 M presents with tearing RSCP

• Rad to back• Assoc with L headache

and R leg weakness• BP 190/100, P 95

• Q. Management?

This Session: HTN EM

1. Define HTN

2. Classify HTN in the ED setting

3. Provide a DDx for the acutely hypertensive ED patient, including 2ndary causes

4. Describe the findings of a patient with a HTN emergency

5. Describe high-utility tests for HTN in the ED

6. Describe the management of each of the categories of HTN in the ED

7. Describe at least 2 controversies in the management of HTN in the ED

HTN in the ED – a Taxonomy

• Pre-HTN• Chronic HTN• Transient HTN• HTN Emergency• HTN-associated Crisis

• 1’, 2’, 3’

**DO NO HARM**

“Treat patients, not numbers”

HTN – What’s the Big Deal in the ED?

Hypertension in the ED

Jason R. Frank MD MA(Ed) FRCPC

DEM Academic Half Day

December, 2009