Hypertensive crisis resident survival guide
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]; Rim Halaby, M.D. [3]
Overview
Hypertensive crisis is usually a term that is used to describe a severe elevation in the blood pressures that may or may not present with end-organ damage.[1] It includes both hypertensive emergency and hypertensive urgency. Noncompliance with antihypertensive medications is the most common cause of hypertensive crisis.[2]
Classification
Hypertensive crisis can be further classified as hypertensive urgency and hypertensive emergency based on either the absence or presence of acute end-organ damage.[1]
Hypertensive Urgency
Hypertensive urgency is the severe elevation in the blood pressure without any evidence of acute end-organ damage.
Hypertensive Emergency
Hypertensive emergency mostly falls into stage 2 of hypertension. It is usually the severe elevation in the blood pressure (systolic blood pressure >180 mm Hg, or diastolic blood pressure >120 mm Hg) complicated by acute end-organ dysfunction, such as hypertensive encephalopathy, eclampsia, dissecting aortic aneurysm, acute left ventricular failure with pulmonary edema, acute myocardial infarction, acute renal failure, or symptomatic microangiopathic hemolytic anemia.[3]
Causes
Life Threatening Causes
Hypertensive crisis is a life-threatening condition and must be treated as such irrespective of the cause.
Common Causes
- Antihypertensive medications withdrawal ( beta blockers, clonidine)
- Noncompliance with antihypertensive medications[2]
- Pheochromocytoma
- Side effects of monoamine oxidase inhibitors
- Stimulants (cocaine, methamphetamine, phencyclidine)
Management
Characterize the symptoms: ❑ CNS: severe headache, dizziness, confusion, weakness/numbness, dysphagia, altered level of consciousness Obtain a detailed history: ❑ Use of medications (prescription or over the counter) ❑ Compliance to anti-hypertensive medications if applicable ❑ Recreational drug use (methamphetamine, cocaine, phencyclidine) | ||||||||||||||||||||||||||||||
Examine the patient: ❑ Blood pressure ♦ Measured by the physician ♦ Both arms ♦ Appropriate cuff size ❑ Fundoscopic exam (looking for papilledema, exudates, hemorrhages) ❑ Complete neurological and mental status exam ❑ Cardiopulmonary signs of pulmonary edema, murmurs, gallops ❑ Abdomen (looking for pulsatile masses, tenderness, bruits) ❑ Peripheral pulses | ||||||||||||||||||||||||||||||
Order Labs: ❑ CBC ❑ Electrolytes
| ||||||||||||||||||||||||||||||
Evidence of end organ damage? | ||||||||||||||||||||||||||||||
YES | NO | |||||||||||||||||||||||||||||
Hypertensive emergency | Hypertensive urgency | |||||||||||||||||||||||||||||
❑ Admit to ICU[5] | ❑ Treat as outpatient or admit for observation | |||||||||||||||||||||||||||||
❑ Monitor the blood pressure closely
❑ Assess volume status
❑ Commence continuous infusion of short acting IV antihypertensives based on patient's end organ damage | ❑ Administer Oral antihypertensives ❑ Monitor the patient clinically within the first few hours of commencing medications NB - Gradual blood pressure reduction over 24 - 48 hours | |||||||||||||||||||||||||||||
Failure to control the blood pressure ❑ Consider a combination of antihypertensive medications | Good control of the blood pressure ❑ Review old or start new medications ❑ Modify risk factors ❑ Schedule a follow up | |||||||||||||||||||||||||||||
Intravenous Antihypertensive Drugs
Shown below is a table of the IV antihypertensive drugs and their appropriate doses.[3]
Drug | Dose |
---|---|
Clevidipine | 1 to 2 mg/h as IV infusion, max 16 mg/h |
Enalaprilat | 1.25–5 mg every 6 hrs IV |
Fenoldopam | 0.1–0.3 µg/kg per min IV infusion |
Hydralazine | 10–20 mg IV |
Nicardipine | 5–15 mg/h IV |
Nitroglycerin | 5–100 µg/min as IV infusion |
Nitroprusside | 0.25–10 µg/kg/min as IV infusion |
Esmolol | 250–500 µg/kg/min IV bolus, then 50–100 µg/kg/min by infusion May repeat bolus after 5 min or increase infusion to 300 µg/min |
Labetalol | 20–80 mg IV bolus every 10 min 0.5–2.0 mg/min IV infusion |
Phentolamine | 5–15 mg IV bolus |
Oral Antihypertensive Drugs
Shown below is a table of the oral antihypertensive drugs and their appropriate doses.[3]
Drug | Dose |
---|---|
Captopril | 12.5 to 25 mg PO or SL, repeat as needed. max dose - 50 mg PO |
Clonidine | 0.1-0.2 mg PO x 1, then 0.05 to 0.1 mg/1-2 hrs. Max dose - 0.6 to 0.7 mg |
Labetalol | 200 mg PO, then 200 mg/hr until desired effect. Max dose - 1200 mg |
- Other agents to consider include:
- PO frusemide 20mg (repeat as necessary)
- PO nifedipine SR 30mg, single dose
- PO felodipine 5 mg, single dose
Management of Specific Hypertensive Emergencies
Hypertensive emergencies | Preferred agents |
---|---|
Aortic dissection | Labetalol, or nicardipine + esmolol, or nitroprusside + esmolol or nitroprusside + IV metoprolol Note: Administer beta blocker to control the heart rate before initiating a vasodilator e.g. nitroprusside
|
Acute pulmonary edema / systolic dysfunction | Nitroglycerin + (Nicardipine or, fenoldopam, or nitroprusside) + loop diuretic |
Acute pulmonary edema / diastolic dysfunction | Low-dose Nitroglycerin + (esmolol, metoprolol, labetalol, or verapamil) + loop diuretic |
Acute coronary syndrome | Nitroglycerin + (labetalol or esmolol) |
Hypertensive emergency with acute or chronic renal failure | Nicardipine or fenoldopam |
Hypertensive encephalopathy | Nicardipine, labetalol, fenoldopam Note: the blood pressure should not be lowered by more than 25% |
Pre-eclampsia / eclampsia | Labetalol or nicardipine |
Sympathetic crisis / cocaine overdose | Benzodiazepine + (verapamil, diltiazem, or nicardipine) Note: Beta blockers should NOT be administered alone to prevent un-opposed alpha-adrenergic stimulation |
Cerebrovascular accident | Nicardipine, labetalol, fenoldopam, or clevidipine Note: An expert's judgement is required to determine if the blood pressure should be lowered. |
Withdrawal of antihypertensive therapy e.g. clonidine or propanolol | Re-administer the discontinued drug; phentolamine, nitroprusside, or labetalol, if necessary |
Dos
- Hypertensive emergencies are best managed with a continuous infusion of short-acting titratable antihypertensive agents.
- Avoid sublingual and intramuscular routes of drug administration due to their unpredictable pharmacodynamics.
- Assess the patient' volume status before initiating intravenous vasodilators to prevent or minimize a substancial fall in blood pressure.[7]
Don'ts
- Don't consider nifedipine, nitroglycerin and hydralazine as first-line therapies in the management of hypertensive crises due to their potential toxicities and adverse effects.[5]
- Don't use intramuscular or sublingual antihypertensive medications in the case of hypertensive emergency.
- Don't use rapid acting antihypertensive if the patient is not in an ICU setting.
References
- ↑ 1.0 1.1 "The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V)". Arch Intern Med. 153 (2): 154–83. 1993. PMID 8422206. Unknown parameter
|month=
ignored (help) - ↑ 2.0 2.1 Stewart, DL.; Feinstein, SE.; Colgan, R. (2006). "Hypertensive urgencies and emergencies". Prim Care. 33 (3): 613–23, v. doi:10.1016/j.pop.2006.06.001. PMID 17088151. Unknown parameter
|month=
ignored (help) - ↑ 3.0 3.1 3.2 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289 (19): 2560–72. doi:10.1001/jama.289.19.2560. PMID 12748199.
- ↑ Varon J, Marik PE (2003). "Clinical review: the management of hypertensive crises". Crit Care. 7 (5): 374–84. doi:10.1186/cc2351. PMC 270718. PMID 12974970.
- ↑ 5.0 5.1 Varon, J. (2008). "Treatment of acute severe hypertension: current and newer agents". Drugs. 68 (3): 283–97. PMID 18257607.
- ↑ Chobanian, AV.; Bakris, GL.; Black, HR.; Cushman, WC.; Green, LA.; Izzo, JL.; Jones, DW.; Materson, BJ.; Oparil, S. (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289 (19): 2560–72. doi:10.1001/jama.289.19.2560. PMID 12748199. Unknown parameter
|month=
ignored (help) - ↑ Marik, PE.; Varon, J. (2007). "Hypertensive crises: challenges and management". Chest. 131 (6): 1949–62. doi:10.1378/chest.06-2490. PMID 17565029. Unknown parameter
|month=
ignored (help)