!"#$%&$'()*$ ,-$%.

$'/)$(
aLrlcla krlLek Mu, LdM, lCC
AssoclaLe rofessor
ulvlslon of ulmonary and Crlucal Care
unlverslLy of WashlngLon

0)(/12(3%$
l have no nanclal dlsclosures.
456$/7*$(
Aer Lhls course, you wlll be able Lo:
uellneaLe Lhe slgns and sympLoms of a hyperLenslve
emergency
LsLabllsh LreaLmenL goals for hyperLenslve
emergency
rlorluze speclc anu-hyperLenslve medlcauons for
speclc Lypes of hyperLenslve emergencles
LlsL Lhe Loxlclues and slde eecLs of commonly used
anu-hyperLenslve drugs
81)')/91 :%$($'&972'
!"#$%&$'()*$ 8%)()(
- AsympLomauc
- Lower blood pressure over
several hours/days
PyperLenslve
urgency
- Slgns of end organ damage
- Lower blood pressure over
mlnuLes/hours
PyperLenslve
Lmergency
S8 > 180 mmPg or u8 > 110 mmPg
Chobanalan eL al. !"#" 2003: 289:2360
;).'( 9'< ;"-#&2-(
;).'=;"-#&2- :$%/$'&9.$ 2>
:97$'&(
uyspnea 29
ChesL paln 26
Peadache 23
AlLered menLal sLaLus 20
local neurologlc declL 11
MlcroanglopaLhlc hemolysls 27
kaLz eL al. "$ ! &'()* 2009, 136:399
,'< 4%.9' 09-9.$
PyperLenslve
encephalopaLhy
lnLracerebral
hemorrhage
AcuLe
myocardlal
lschemla
ulmonary
edema
ulssecung
aoruc aneurysm
!"#$%&$'()*$ ,'/$#?912#9&?"
lmage from ur. 8.. uelllnger
Peadache
LeLhargy
nausea / vomlung
Selzures
Confuslon! Coma
Papilledema
:2(&$%)2% @$3A2$'/$#?912#9&?"
;"'<%2-$B
Peadache
Selzures
AlLered
menLal
sLaLus
Loss of cerebral
auLo-regulauon
M8l ! symmeLrlc
whlLe mauer
edema
* Also oen referred Lo as 8LS - osLerlor 8everslble LncephalopaLhy Syndrome
C##%29/? &2 D%$9&-$'&
89($ EF
68 year-old female wlLh severe hyperLenslon and
LS8u presenLs Lo Lhe Lu wlLh abdomlnal paln,
weakness and headache. She ran ouL of her anu-
hyperLenslve medlcauons four days ago and
mlssed hemodlalysls earller Lhls week.
Cn Lrlage ln Lhe Lu, her hearL raLe ls 74, blood
pressure ls 240/130 mm Pg, resplraLory raLe 16
and oxygen saLurauon 94 breaLhlng alr.

G?9& H231< 5$ "23% &9%.$& >2% 5122<
#%$((3%$ -9'9.$-$'&I
a) S8 < 140 mm Pg ln nexL 24 hours
b) u8 < 90 mm Pg ln nexL 12 hours
c) u8 < 140 mm Pg ln nexL slx hours
d) S8 < 190 mm Pg ln nexL Lwo hours
e) MA < 90 mm Pg ln nexL hour
J9&$ 2> 0$/%$9($
13-20 decrease
ln rsL mlnuLes/
hours
Coal 160/100
mmPg ln nexL
2-6 hours
normallze over
several days/
weeks
1oo rapld decrease ! organ lschemla
G?9& H231< 5$ &?$ '$K& -2(&
9##%2#%)9&$ )'&$%*$'72' >2% &?$
#97$'& )' &?$ #%$*)23( /9($I
a) AdmlnlsLer oral llslnoprll 40 mg and aLenolol
100mg
b) AdmlnlsLer 20 mg labeLolol lnLravenous bolus
c) AdmlnlsLer enaloprllaLe 3mg lnLravenous bolus
d) lnluaLe a phenLolamlne lnfuslon
e) lnluaLe a nlLroprusslde lnfuslon
J9#)<L2'($&MD)&%9&951$ N'>3()2'(
nlLroprusslde
lenoldopam
nlcardlplne
Lsmolol
nlLroglycerln
O)&%2#%3(()<$
CnseL of
Acuon
uurauon of
Acuon
uosage
ullaLes arLerloles and velns
Cne mlnuLe
1-2 mlnuLes
0.3-3 mcg/kg/
mln
Longer eecL ln renal fallure
O)&%2#%3(()<$
nlprlde on nlprlde o
Marlk and 8lvera. +,)) -./0 ++ 2011, 17:369
O)&%2#%3(()<$ P ,1)-)'972'
nlLroprusslde Cyanlde 1hlocyanaLe
non-enzymauc
converslon
ln Lhe blood
ConverLed ln
Lhe llver
1reaLmenL ! lnLravenous LhlosulfaLe
1oxlclLy ! 1hlocyanaLe >10 g/dl
Q$'21<2#9-
CnseL of
Acuon
uurauon of
Acuon
uosage
uopamlne (u1) recepLor agonlsL
3 mlnuLes Cne hour
0.01-0.3 mcg/
kg/mln
Cood cholce ln renal fallure Cauuon ln glaucoma
Q)%(& @)'$ C.$'&(
nlLroprusslde lenoldopam
LqulvalenL emcacy ln hyperLenslve
emergency
anacek aL al. "1(23 4$ #'2 1993, 2:939.
O)/9%<)#)'$
CnseL of
Acuon
uurauon of
Acuon
uosage
ullaLes arLerloles and llule lmpacL on
cardlac ouLpuL
3-20 mlnuLes Less Lhan 8
hours
3-13 mg/hour
89($ ER
34 year old man wlLh a
hlsLory of coronary
arLery dlsease and
hyperLenslon presenLs
wlLh severe Learlng
chesL and back paln.
Pls blood pressure ls
210/130 and hls hearL
raLe ls 123 beaLs per
mlnuLe.

N' 9<<)72' &2 )-9.)'.M &?$ 5$(&
)'&$%*$'72' H231< 5$S
a) AdmlnlsLer hydralazlne 20 mg lv
b) SLarL an esmolol lnfuslon aL 30 mcg/kg/mln
c) AdmlnlsLer enalaprllaL 3 mg lv
d) SLarL a nlLroglycerln lnfuslon aL 30 mcg/mln
e) AdmlnsLer aLenolol 30 mg orally

ue8akey
SLanford
T9'9.$-$'& U9($< 2' D"#$
- Surglcal emergency
- Cngolng sLudles abouL use
of endovascular sLenLs
1ype A
dlssecuon
- T$<)/91 -9'9.$-$'&
- Lndovascular sLenLs for
Lhose wlLh compllcauons
1ype 8
dlssecuon
:%)'/)#1$( 2> T$<)/91 T9'9.$-$'&
normallze blood pressure + avold Lachycardla
uecrease sLeepness of pulse wave (d/d1)
uecrease Lv conLracullLy
Coal S8 100-110 mmPg and MA 60-70 mmPg
,(-2121
CnseL of
Acuon
uurauon of
Acuon
uosage
8elauve cardloselecuve -blocker
1-2 mlnuLes 10-30 mlnuLes
30-100 mcg/
kg/mln
MeLabollzed ln blood by esLerase
@95$&2121
CnseL of
Acuon
uurauon of
Acuon
uosage
o and blocker
3 mlnuLes 2-18 hours
0.3-2 mg/
mlnuLe
Cen used wlLh nlLroprusslde
!$-2<"'9-)/ ,V$/&( 2> @95$&2121
W <)V$%$'/$
+10
-10
+13
+3
-3
-13
erlpheral vascular
8eslsLance
PearL 8aLe
Cardlac CuLpuL
rlLchard eL al. +5/0 61/ #75 #'2. 1973, 48:973.
@95$&2121 P ;#$/)X/ 82'<)72'(
Acuve coronary
lschemla
heochromocyLoma*
CbsLrucuve lung
dlsease
Congesuve hearL fallure
8radycardla
Cocalne lngesuon*
* - wlLhouL adequaLe lnlual o-blockade
89($ EY
42 year old man wlLh a hlsLory hyperLenslon, dlabeLes
and coronary arLery dlsease s/p percuLaneous
lnLervenuons on 8CA and le clrcumex Lhree years
prlor presenLs wlLh chesL paln and dyspnea. Pls vlLal
slgns are 200/123, hearL raLe 92, S
p
C
2
83 on alr and
resplraLory raLe 32. Pls cardlac exam ls regular wlLhouL
murmurs buL wlLh an S4. Pe has crackles posLerlorly
from Lhe base Lo mld-lung zone. Pls LCC shows S1
depresslons ln Lhe laLeral leads. Pe ls lnLubaLed for
progresslve resplraLory dlsLress.
G?9& )( &?$ '$K& -2(& 9##%2#%)9&$
)'&$%*$'72'I
a) SLarL a nlLroglyerln
lnfuslon aL 30 mcg/mln
b) SLarL a nlcardlplne
lnfuslon aL 3 mg/hour
c) AdmlnlsLer 10 mg oral
capLoprll
d) AdmlnlsLer 20 mg
lnLravenous hydralazlne
e) AdmlnlsLer 13 mg
lnLravenous dlluazem
O)&%2.1"/$%)'
CnseL of
Acuon
uurauon of
Acuon
uosage
ullaLes velns more Lhan arLerloles
2 mlnuLes 3-10 mlnuLes
3-200 mcg/
mlnuLe
ldeal for cardlac lschemla 8lsk of Lolerance aL 24-48 hours
89($ EZ
37 year old woman wlLh pasL medlcal hlsLory of ma[or
depresslon presenLs Lo her prlmary care provlder
reporung headache, palplLauons and sweaung.
Cn Lrlage vlLal slgns, she ls found Lo have a blood
pressure of 240/124 and hearL raLe 132.
Per currenL medlcauons lnclude phenelzlne, serLrallne
and lorazepam as needed for lnLermluenL anxleLy.
She recenLly reLurned from a wlne-Lasung Lrlp Lo lLaly
and drank more Chlanu Lhan usual buL denles any llllclL
subsLance lngesuons.
D?$ 5$(& 9.$'& &2 &%$9& ?$%
?"#$%&$'()2' )(S
a) lnLravenous enalaprllaL boluses
b) lnLravenous pheLolamlne lnfuslon
c) lnLravenous hydralazlne lnfuslon
d) Cral clonldlne
e) 1oplcal nlLroglycerln
89&$/?219-)'$ ,K/$((
MAC
lnhlblLor
1yramlne
PyperLenslve
Crlsls
heo
MeLh-
ampheLa
mlne
Cocalne
:?$'&219-)'$
CnseL of
Acuon
uurauon of
Acuon
uosage
ure o-blocker
1-2 mlnuLes 10-30 mlnuLes
3-13 mg lv
bolus
Cood cholce ln renal fallure Slde eecLs! ushlng, headache
4&?$% C.$'&(
Pydralazlne
- ArLerlolar dllaLor
- 8eex Lachycardla !
avold ln, dlssecuon or
lschemla
- Cen used ln
pregnancy
LnalaprllaL
- lnLravenous ACL-
lnhlblLor
- 8lg A ln hlgh-renln
sLaLes
- Long durauon of
acuon (12-24 hours)
T$<)/972' ;3--9%"
T$<)/972' 4'($& 2> C/72' 03%972' 2> C/72' 02(9.$
Lsmolol 1-2 mlnuLes 10-30 mlnuLes 30-100 mcg/kg/mln
lenoldopam 3 mlnuLes 1 hour 0.01-0.3 mcg/kg/
mln
LabeLolol 3 mlnuLes 2-18 hours 0.3-2 mg/mln or
boluses
nlcardlplne 3-20 mlnuLes < 8 hours 3-13 mg/hr
nlLroglycerln 2 mlnuLes 3-10 mlnuLes 3-200 mcg/mln
nlLroprusslde 1 mlnuLe 1-2 mlnuLes 0.3-3 mcg/kg/mln
henLolamlne 1-2 mlnuLes 10-30 mlnuLes 3-13mg lv bolus
D9A$ !2-$(
lnlual blood pressure lowerlng ! 23
decrease ln rsL mlnuLes/hours
1lLraLable lnfuslons preferred - cllnlcal
scenarlo guldes cholce of agenL
1ype A dlssecuons! surgery
1ype 8 dlssecuons ! medlcal managemenL
CaLecholamlne overload ! phenLolamlne
D!CO[ \4]