HYPERTENSION CRISIS

& SPECIAL CONDITIONS

Dr Stella Palar, SpPD-KGH

HYPERTENSION CRISIS

Definition: Condition with sudden increase of

BP (SBP > 180mmHg, DBP > 120 mmHg)
which need immediate intervention

Classification:
Emergency Hypertension target organ damage,

attempt to decrease BP in minutes/hours

Urgency Hypertension without target organ
damage, attempt to decrease BP in 24-48 hours

HYPERTENSION CRISIS
Clinical Manifestation
Neurology
Headache, blurry vision, seizures, focal neurological

deficit, decrease of consciousness

Ophthalmology
Retinal bleeding, exudates, papillae edema

Cardiovascular
Chest pain, pulmonary edema

Kidney
Azotemia, proteinuria, oliguria

Obstetric
Preeclampsia, eclampsia

HYPERTENSION CRISIS
Management
Ideally treatment be administered in the hospital, however it can be started in
primary health care with oral anti hypertension
Medicine

Route

Pharmacology

Dose

ACE Inhibitor
(Captopril)

Sublingual
Oral

Start: SL: 10-15 min, O:15-30

min
Max effect: SL:60 min, O:1-2 h
Duration: 8 h

6,25-50 mg /x

Central alpha
agonist (Clonidin)

Oral

Start: 30-60 min

Max effect: 2-4 h
Duration:3-12 h

75-150 ug/x/hour
Total 900 ug

Calcium Channel
blocker
(Nifedipine)

Oral

Start: 5-20 min

Max effect: 30-60 min
Duration: 2-6 h

As alternative if
other medicine not
available

HYPERTENSION CRISIS
Management

Target BP for Hypertension Emergency:

First 5-120 minutes reduce MAP 20-25%
Next 2-6 hours reduce to BP 160/100 mmHg
Next 6-24 hours reduce to BP 140/90 mmHg if

no sign of ischemic organ

Drugs

Route

Clonidin
(catapres)

150
mcg/amp

Clonidin 900 mcg in D5% 500 ml given by microdrips

12 drops/min, increase the dosage 4 drops every 15
minutes until target reached observed for 4 hours
switched to oral clonidin

Diltiazem
(Herbesser)

10 mg & 50
mg/amp

Diltiazem 10 mg IV bolus in 1-3 minutes continued with 50

mg/hour for 20 minutes
If BP >20% from initial BP, decrease dose to 30 mg/hour
until target reached
Continue with maintenance 5-10 mg/hour with 4 hour
observation then switched to oral tablet

Nicardipine
(Perdipine)

2 & 10
mg/amp

10-30 mcg /kgBW bolus

When BP stable, continue with 0.5-6 mcg/kgBW/min until
target BP reached

Drugs

Route

Labetalol
(Normodyn)

IV

Labetalol 20-80 mg IV bolus every 10 minutes or can be

given in infusion drips 2 mg/min

Nitroprusside
(Nitropress,
Nipride)

IV

Nitroprusside given by infusion drips dosage 0.25-10

mcg/kg/minutes

HYPERTENSION IN SPECIAL
CONDITIONS

Hypertension in Heart and Vascular Disease

Hypertension in Kidney disorder
Hypertension in Elderly
Hypertension in Neurological Disorder
Hypertension in Diabetes
Hypertension in Pregnancy

Hypertension in Heart & Vascular

Ds

Ischemic Heart Disease

Treatment started with B blokers & ACE-I

then other can be added if needed

Heart Failure
Diuretics, B Blockers, ACE-I

Peripheral Arterial Disease

B blockers, ACE-I

Hypertension in Kidney disorder

Target <130/80 mmHg

If proteinuria choose ACEI / ARB if not
contraindicated
If proteinuria >1g/24h target 125/75 mmHg
Attention to the alteration of renal function
(creatinine should not 20%) & potassium
level in the use of ACEI/ARB

Hypertension in Elderly

Start anti hypertension if:

SBP 160 mmHg if in good condition and

life expectancy
SBP 140 mmHg if DM, smoker, or other
risk factors

Target
65-79 yo
>80 yo

: SBP <140 mmHg

: SBP 140-145 mmHg

Principle: Start low go slow

Hypertension in Neurological Ds

Ischemic stroke
anti hypertension not recommended unless
SBP>220 mmHg DBP>120 mmHg

Hemorrhagic stroke
anti hypertension not recommended unless
SBP >180 mmHg or MAP > 130 mmHg

Hypertension in
Diabetes

Target BP: <130/80 mmHg

Medicine
ACEI
ARB
B blocker
Diuretic
Alfa Blocker
CCB non dihidropyridine

HYPERTENSION IN
PREGNANCY
DEFINITION : SBP 140 mmHg and/or
DBP 90 mmHg
or
rise in SBP 30 mmHg and/or DBP 15
mmHg from preconception

HYPERTENSION IN
PREGNANCY
CLASSIFICATION
1.
2.
3.
4.

Chronic Hypertension
Preeclampsia - Eclampsia
Preeclampsia - Eclampsia Superimposed on
Chronic Hypertension
Gestational Hypertension

1. Chronic Hypertension
Preexisting Hypertension
Definition
Systolic pressure 140 mmHg, diastolic

pressure 90 mmHg, or both.

Presents < 20th week of pregnancy or
persists longer then 12 weeks postpartum.

Causes
Primary = Essential Hypertension
Secondary = Result of other medical

condition (ie: renal disease)

2. PreeclampsiaEclampsia

Definition = New onset of hypertension and

proteinuria > 20 weeks gestation.
Systolic blood pressure 140 mmHg OR diastolic blood

pressure 90 mmHg
Proteinuria of 0.3 g or greater in a 24-hour urine
specimen
Preeclampsia <20 weeks, think MOLAR PREGNANCY!

Categories
Mild Preeclampsia
Severe Preeclampsia

Eclampsia
Occurrence of generalized convulsion and/or coma in

the setting of preeclampsia, with no other neurological

condition.

3. Preeclampsia-Eclampsia
superimposed on Chronic
Hypertension

Affects 10-25% of patients with chronic

hypertension
Preexisting Hypertension with the
following additional signs/symptoms:
New onset proteinuria
Hypertension and proteinuria beginning <20

weeks of gestation.
A sudden increase in blood pressure.
Thrombocytopenia.
Elevated aminotransferases.

4. Gestational
Hypertension
Mild hypertension without proteinuria or other
signs of preeclampsia.
Develops in late pregnancy, > 20 weeks
gestation.
Resolves by 12 weeks postpartum.
Can progress onto preeclampsia.

Often when hypertension develops <30 weeks

gestation.

HYPERTENSION IN
PREGNANCY
Medical Management:
Acute therapy : IV labetalol, IV Hydralazine,

SR Nifedipine
Long term therapy: oral Labetolol,
Methyldopa, Nifedipine
Eclampsia prevention : MgSO4

Contraindicated anti hypertensive drugs:

ACEI (ACE Inhibitors)
ARB (Angiotensin receptor antagonists)

HYPERTENSION IN
PREGNANCY
POST PARTUM MANAGEMENT
Continue to watch for maternal
complication first 3-5 days
Tapper oral anti hypertension over a few
days
Monitor laboratory tests and urinalysis to
ensure all abnormalities resolve after
delivery
Review three months post partum

Drugs for gestational or Chronic

Hypertension in Pregnancy
Drug (FDA Risk)*

Dose

Preferred Agent
Methyldopa (B)

0.5 to 3.0 g/d in 2 divided doses

Concerns or Comments
Drug of choice according to NHBEP safety after
first trimester well documented, including 7
years follow-up

Second line agents

Labetalol (C)
Nifefipine (C)

200 to 1200 mg/d in 2 to 3 divided doses

30 to 120 mg/d of a slow-release preparation

Hydralazine (C)

50to 300 mg/d in 2 to 4 divided doses

Few controlled trials, long experience with few adverse

event document; useful in combination with sympatholitic
agent; my cause neonatal throbocytopenia

Depend on specific agent

May decrease uteroplacental blood flow: may impair fetal

response to hypoxic stress; risk of growth restriction
when started in first or second trimester (atenolol); May
be associated with neonatal hypoglycemia at higher
doses

12.5 to 25.0 mg/d

Majority of controlled studies in normotensive pregnant

women rather then hypertensive patient;can cause
volume contraction and electrolyte disorders; may be
useful in combination with methyldopa and vasodilator to
mitigate compensatory fluid retention

- Receptor blockers (c)

Hydrochlorothiazide (C)

Contraindicated ACE-Is and

angiotensin type 1 receptor
antagonist (D)

May be associated w/ fetal growth restriction

May inhibit labore & have synergistic action w/
magnesium sulfat in BP lowering; little experience w/
other Ca entry blockers

Leads to fetal loss in animal;s; human use associated

with cardiac defect, fetopathy oligohydramnios, growth
rstriction, renal agenesis and neonatal anuric renal
failure, which may be fetal

Drugs for Urgent Control of Severe

Hypertension in Pregnancy
Drug (FDA Risk)*

Dose and Route

Concerns or Comments

Labetalol (C)

10 to 20 mg IV, then 20 to 80 mg every 20 to 30

minutes, maximum of 300 mg; for infusion: 1 to
2 mg/min

Because of a lower incidence of maternal

hypotension and other adverse effect, its use
now supplant that of hydralazine; avoid in
women with asthma or congestive heart failur

Hydralazine (C)

5 mg; IV or IM, then 5 to 19 mg every 20 to 40

minutes; once BP controlled repeat every 3
hours; for infusion: 0.5 to 10.0 mg/h; if no
success with 20 mg IV or 30 mg IM. Consider
another drug

A drug of choice according to NHBEP; long

experience of safety and efficacy

Tablets recommended only: 10 to 30 mg PO,

repeat in 45 minutes if needed

We prefer long-acting preparation; although

obstetric experience with short acting has
been favorible, it is not approved by the FDA
for management of hypertension

30 to 50 mg IV every 5 to 15 minutes
Constant infusion of 0.25 to 5.00g/kg per
minute

Use is waning. My arrest labor, causes

hyperglicemia
Possible cyanide toxicity if used for > 4
hours; agent of last resort

NIfedifine(C)

Diazoxide (c)
Relatively CI
nitropusside (C)

Thank You