Emergent & urgent Hypertension

Reference: Harrison 2012, Chapter 247

به نام خدا

Presented by Dr Sadatinejad, Seyyed Mohsen,student of Medicine from Iran,Kashan 29/6/2015

Definitions:

• Hypertension:• Stage I: 140-159/90-99• Stage II: >160/100

• Hypertensive Urgency:• Systolic BP >180 or Diastolic BP >120 in the absence of

end-organ damage

• Hypertensive Emergencies:• SBP >180 or DBP>120 in the presence of end-organ

damage

Hypertensive Emergencies:

Hypertensive encephalopathyMalignanthypertension StrokeMyocardial infarction/unstable anginaAcute left ventricular failureAortic dissectionAdrenergic crisisPostoperative hypertensionPreeclampsia/eclampsia of pregnancy

Malignant hypertension

Acute ↑ of BP (hypertensive crisis) in a patient with underlying hypertension

or sudden onset of HTN in a previously normotensive individual

with irreversible organ damageSBP >180 or DBP >120

Damage : diffuse necrotizing vasculitis arteriolar thrombi fibrin deposition in arteriolar walls (kidney, brain, retina, and other organs)

Malignant hypertension

Damage : diffuse necrotizing vasculitis arteriolar thrombi fibrin deposition in arteriolar walls (kidney, brain, retina, and

…) Fibrinoid Necrosis progressive retinopathy (arteriolar spasm, hemorrhages,

exudates, and papilledema) renal function with proteinuria microangiopathic hemolytic anemia encephalopathy

Hx: use of MAO inhibitors , OCP,cocaine, amphetamines ,…

Normal

Autoregulation in brain

s

↓ ↓ of BP, under the lower limit of autoregulation = cerebral ischemia (also Renal and Coronary blood flows )

initial Goal

↓ MAP : 25% of HTN (160/100–110 mmHg)in minutes to 2 hIV nitroprusside, labetalol,nicardipine

preeclampsia

5–7% of pregnant women after 20 weeks of gestation

new onset of hypertension (BP>140/90 mmHg) + proteinuria (>300 mg/24 h) (organ damage)

Eclampsia = onset of seizures (convulsions) in a woman with pre-eclampsia

Severe preeclampsia

BP >160/110 mmHgproteinuria >5 g/24 hCNS dysfunction (headaches, blurred vision,

seizures, coma)

Renal dysfunction (oliguria or creatinine > 1.5 mg/dL)

pulmonary edemahepatocellular injury (ALT > 2-fold the upper limits of

normal)

hematologic dysfunction (platelet count < 100,000/L or DIC)

placental dysfunction (oligohydramnios or severe IUGR)

HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)

treatment

Mild preeclampsia Bed restSevere preeclampsia delivery +

labetalol(IV) Nifedipine hydralazine ACEI (-)Magnesium sulfate