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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