On line theraputics on Hypertensive crisis

Datuk Dr Sethuraman Nagappan. ASDK;PGDK

MBBS(Madras); MD(Int medicine);MRCP (UK);
FRCP(London); FRCP(Edinburgh)FRCP(Ireland);FAMM:
 SESSION OVERVIEW

• Learning objectives
By completing this session, you will be able to

- Understand the terminology and definition of Hypertensive crises

- Identify the syndromes that comprise Hypertensive crises
- understand the principles underlying controlled BP reduction
- outline an appropriate drug therapy in different clinical situations

Pre requisite

- Have a basic understanding of hypertension and Target organ damage

Duration - 1 Hour

Author - S Nagappan
 Definitions and Terminologies

Hypertension is a chronic condition,resulting in target organ damage over years.However it

is possible for the Blood pressure to rise suddenly and severely to cause acute damage to end
organs.
Hypertensve crisis refers to such sudden critical elevation in BP ,usually with a diastolic BP
above 120 mm of Hg and the presence of ongoing or evolved target organ dysfunction defines
a Hypertensive emergency, whereas the absence of such end organ dysfunction is referred
to as Hypertensive urgency. It is important to recognize that rapidity of rise in BP is more
important than the actual numbers. Accelerated –malignant Hypertension is the term
used to describe severe hypertension with fundal changes of retinal exudates, haemorrhages
and papilloedema. Cerebral, renal and gastrointestinal features are often seen during this
malignant phase .
Chronic uncontrolled severe Hypertension needs to be distinguished from Hypertensive
Urgency wherein the patient may or may not experience severe headache, nose bleeds, or
severe anxiety.The tempo of the rise in BP may also aid in differentiation( sudden or rapid
rise in BP in Hypertensive urgencies).Similarly Hypertensive Emergency requires to be
recognized separately from clinical situations in which patient has elevated BP with target
organ damage that is unrelated to the High BP.
 Hypertension

Uncontrolled Hypertensive Hypertensive Target organ

hypertension damage
urgency emergency unrelated to HTN

Hypertensive
crisis
 Case History

A 45 year old Lady presented to a NGO clinic offering free BP check up at a Sunday market
and her BP was found to be 200/120 mm of Hg. On further questioning by the Doctor
assisting the clinic, the lady was found to be a known hypertensive diagnosed two years ago
and she has stopped taking taking medications for the last six months since she felt well.She
felt that marketting for more than an hour in the busy market that morning could have been
the reason for the high BP.Quick examination of fundus revealed arteriosclerotic changes in
retinal vessels ( Grade 2 KWP )
Q 1) Which of the following statements are true in relation to her condition ?

a) She is suffering from a Hypertensive Urgency

b) She is suffering from Accelerated- malignant hypertension
c) She has only severe uncontrolled Hypertension
d) Her BP reduction needs parentral anti hypertensive medications
e) Her BP can be reduced gradually over a period of days with oral anti hypertensive
medications.
Mark all the correct answers
• Answer; C, E are true

• This Lady simply has a very high BP as a result of discontinuing prior therapy and is not
in distress. Abscence of retinal changes(KWP grade III –IV) differentiates this condition
from Accelerated- Malignant hypertension. Distinguishing Hypertensive Urgency from
this so called Benign chronic uncontrolled Hypertension can be difficult and tempo of the
illness and signs of distress may be helpful.

• She needs observation for a few minutes for the BP to come down and if BP remains
higher than 180/120 mm of Hg ,she should be started on a dose of short acting oral anti
hypertensive drugs (eg an oral dose of captopril with furosemide ),followed by long term
appropriate anti hypertensive therapy.
• Q 2) Which of the following situations constitutes Hypertensive crises ?

a) Perioperative states
b) Pre eclampsia and Eclampsia
c) cocaine and amphetamine substance abuse
d) Steroid therapy in Scleroderma
e) Guillain Barre syndrome

Mark all the correct answers

• Answers ; All are True

• Common clinical situations of Hypertensive emergencies include target organ damage states
like ac coronary syndrome, ac LV failure, ac aortic dissection, Hypertensive encephalopathy, ac
Intracerebral haemorrhage,ac kidney injury and micro angiopathic haemolytic anaemia and
noncompliance to antihypertensive therapy is the usual underlying problem

• However certain special situations warrant recognition;

Perioperative Hyperension has an early onset, usually within 2 hours after surgery and
can lad to complications like Haemorrhagic stroke ,myocardial infarct or bleeding at the vascular
site. Activation of the sympathetic system appears to be the underlying mechanism.
Intracerebral Haemorrhage is a catastrophic complication of pregnancy related hypertension and
aggressive management with attention to details can aviod this. Sympathetic crises can also be
encountered in conditions of substance abuse (cocaine, amphetamine or ecstacy pills),abrupt
withdrawal of Beta blocker therapy or clonidine, and Guillain Barre syndrome.There is also an
association between steriod therapy and scleroderma renal crisis. Interaction of Tyramine
containing foods with MAO inhibitors and Pheochromocytoma are other catecholaminic states
and Phentolamine is often used in these situations.

Beta blockade can potentially aggravate Hypertension with catecholamine excess and
adequate alpha blockade should be achieved before starting Beta blockade.
 Case history

• 55 year old lady ,diagnosed to have hypertension for 5 years,was seen in the AE with 3
day history of nausea,vomitting, headache and dizziness.Her BP was found to be
220/140 mm of Hg.She was drowsy and her fundoscpic examination revealed exudates,
haemorrhages and papilloedema.In the AE she suddenly threw a generalised tonic clonic
seizure.

Q 3) Which of the following are true in relation to her condition ?

a) This patient has intracerbral haemorrhage ( Hypertensive emergency)

b) She is suffering from Hypertensive encephalopathy
c) Focal or lateralising Neurological defecits are common findings.
d) Fragmented red cells should be looked for in the peripheral blood film
e) Ct scan of the brain may show posterior leucoencephalopathy.

Mark all the correct answers.

• Answers; b,d,e are true.

• This condition is Hypertensive encephalopathy and differs from Intracerebral

Haemorrhage by its evolution over a period of days than hours as in ICH.
• Neurological defecits transient or permanent may occur but are infrequent and
their presence should suggest other problems. Sudden lowering of BP may
precipitate neurological defecits.
• Fragmented red cells are seen in haemolytic states and Microangiopathic
Haemolytic anaemia and DIVC are common accompaniements.
• CT Brain often shows classical posterior leucoencephalopathy.

critical elevation in BP leads to failure of autoregulation(vide infra)resulting

in vasodilatation, endothelial damage and breakthrough hyperperfussion of the brain
and the ensuing cerebral oedema defines the clinical syndrome of Hypertensive
encephalopathy. Necrotizing vasculitis, myointimal hypertrophy ,hypertrophic
arteriosclerosis and fibrinoid necrosis are typical pathologic findings. Acute kidney
injury is often present.
 Pressure
Humoral Out of Vasodilat Natriures
vasoconst autoreg ation Endothelial
is
damage
rictors ulation Increased
zone capillary Exudates, Further
haemorrhages Renin-
Premeabi angiotens
vaso
lity Hematuria in constrict
Cerebral ion
Microangiopath Aldostero
oedema ic haemolytic ne
anaemia/DIVC
System
activation
 Malignant
Hypertension

Retina Blood Kidney Brain

Hypertensive Hypertensive
retinopathy encephalopathy
 Q 4) Which of the statements regarding the control of BP in this case are true?

a)Blood pressure should be reduced to normal levels within minutes

b)Reduction of MAP by 25% over 2 to 8 hours is recommended.
c)Gradual reduction of BP over a period of days(1to2) by oral therapy is
sufficient.
d) IV Nitroprusside infusion is safe and is the treatment of choice.
e) Intravenous labetalol ,bolus or infusion, is recommended.

Mark all correct answers

• Answers; b and e are true .
Cerebral autoregulation refers to the ability of blood vessels to maintain a relatively constant
cerebral blood flow (CBF)by constricting or dilating when BP rises or falls respectively.In normal persons,
CBF is constant between mean arterial pressures of 60 and 120 mmof Hg and there is a rightward shift of
autoregulation to mean arterial pressures between to 120 and 180 mm of Hg in chronic hypertensives.
Hypertensive individuals lose autoregulatory ability when the MAP is reduced by more than 25% and are
thus exposed to the hazards of a fall in CBF when the MAP is abruptly reduced by more than 25%, even
though these levels are not truly hypotensive.
IV Nitroprusside; Pure vasodilators like nitroprusside can lead to diversion of blood away from
ischaemic zone(steal phnonomenon).Labetalol with its alpha and beta blocking effect does not lead to
increased intracranial pressure and it can be easily titrated to achieve controlled reduction in BP.
• Q 5) IV Sodium Nitroprusside

a) is an arterial and veno vasodilator

b) increases intracranial pressure
c) Normal renal and liver functions are not necessary
d) Toxicity can result in serious neurologic problems
e) cyanocobalamin is effective in preventing and treating toxicity.
• Answers; a,b,d,e are true.

Sodium nitroprusside is both a arterial and venous dilator. It decreases cerebral blood flow
while increasing the intracranial pressure. Hence it is not the ideal drug for patients with Hyperensive
encephalopathy.
Nitroprusside contains 44%cyanide and cyanide that is released is metabolised in the liver to
thiocyanate which is excreted through Kidney. Therefore normal renal and liver functions are necessary to
prevent cyanide toxicity which is associated with cyto toxicity with cellular respiration failure and
metabolic acidosis. Unexplained cardiac arrest and encephalopathy have been documented.
Cyanocobalamin has been found to be effective in preventing and treating cyanide toxicity. In view of the
severe toxicity , Nitroprusside is used when other alternatives are not available.
 Case history

• 48 year old lady , mother of three children, developed sudden severe headache
while washing clothes and vomitted a few times before collapsing on the bathroom
floor. On arrival at AE, she was stuporous, only responding to painful stimulus. Her
pulse was 94/mt,with a BP of 220/160 mm of Hg. Her respiration was laborious
and noisy and her pupils were unequal with left pupil in mid position and her right
pupil small and reacting to light. Her eyes were deviated to the left side. Paucity of
movements was noted on the right half of the body. History from the husband
revealed that patient was diagnosed to have high BP 2years ago and was not taking
regular treatment. A 12 lead ECG done at AE while waiting for the on call
radiologist to do a CT brain showed deep and symmetrically inverted T waves in
precordial leads;
Q6) Which of the following statements are true in relation to her condition ?

a) She has Hypertensive acute coronary syndrome

b) she had developed Hypertensive intracerebral bleed
c) BP reduction should involve bringing down the MAP by 50% over an hour
by parentral anti hypertensive agents.
d) IV Nitroglycerine can be used safely
e) Nimodipine is the drug of choice
• Answers; b True.
This patient had Hypertensive intra cerebral bleed(later confirmed by CT
scan) as evidenced by tempo of the illness, loss of consciousness, lateralising
neurological signs,and trans tentorial herniation. ECG changes constitute the so
called Cerebral T waves- a sign of organ cross talk, Heart sympathaising for
brain.
High BP can expand the haematoma or cause re bleed, while reducing the BP
can decrease the cerebral blood flow,thereby causing ischaemic
damage.However cautious reduction of MAP by 25% over one to two hours is
recommended.Keep MAP around 130 unless increase in ICP is suspected.In
patients with a ICP monitoring device inserted, Cerebral perfusion pressure
(MAP-ICP ) should be kept above 60 mm 0f Hg.
BP reduction is best achieved with nonvasodilating drugs like nicardipine,
labetalol, and esmolol.Nitroglycerine is a potent vasodilator and can reduce
preload and cardiac output,thereby compromising the cerebral and renal
perfusion.Nimodipine with its added quality of cerebral selectivity is mainly
useful in subarachnoid Haemorrhage.
 Case history

• 64 years old post master woke up from the sleep at 6 AM and noticed that he was
paralysed on his right half of the body.He was aphasic but fully conscious and his BP was
found to be elevated at 190/130 mm of Hg. A CT brain performed at 8.30 AM revealed
massive infarct in the Lt middle cerebral artery territory.

• Q 7) Which of the following statements are true in relation to his condition ?

a) It is advisable to reduce MAP by 25% over 1 to 2 hours with parentral anti

hypertensives
b) It is recommended to reduce BP gradually over a period of 1 to 2 days with oral
antihypertensives
c) BP reduction should not be attempted with in the first Two weeks
d) Thrombolytic therapy should be started immediately
e) Vasodilating anti hypertensive drugs should be used to reduce BP

Mark all correct answers

• Answer; only c is true

Acute rise in BP lasting for days to weeks often accompnies sudden

intracerbral events esp with increased intracranial pressure to maintain
cerebral perfusion (cushing reflex) and there is also impairment of
autoregulation (Rt shift and derangement). Hence aggressive BP reduction
worsens the situation and should be avided.
Current recommendations suggest therapy only for patients with BP above
220/130 mm of Hg and if thrombolytic therapy is planned, then BP should
be reduced to 180/110 mm of Hg and should be maintained at that level
for the next few days.
Thrombolytic therapy is indicated for a period of up to 4.5 hours from the
onset of stroke and in someone with wake up stroke, the time he went to
bed is considered as the time of onset of stroke.
Vasodilating antihypertensives often lead to adverse effects due to steal
phenomenon and reduced cerebral perfusion.Labetalol,Nicardipine and
Esmolol can be used.
52 years old man with Acute coronary syndrome, Acute LV failure
and BP 0f 190/120

• Q 8) Which of the statements are true in the above situation ?

a) Bring down the MAP by 25 % over a short period

b) IV Nitroglycerine drip is a good initial choice.
c) IV enalapril or oral captopril can be used.
d) IV furasemide is indicated.
e) Labetalol is safe and beneficial in patients with ACS and High BP.
• Answers; All are True.

In ac pulmonary oedema, Venodilatation with Nitroglycerine will

decrese the pre load and ACE inhibitors will reduce the afterload. As a
result workload of the heart decreases, while the cardiac output improves.

Labetalol maintains cardiac output and reduces peripheral vascular

resistance without reducing peripheral blood flow.
• Q 9)Which of the statements regarding the use of
antihypertensive drugs in hypertensive emergencies are true?
a)In Aortic dissection, the priority is to reduce the SBP of
<120 mmof Hg and MAP <80 mm oh Hg within 5 to 10 minutes
b)The combination of a Beta blocker and vasodilator is the
preferred approach in aortic dissection
c) Fenoldopam is particularly useful in patients with impaired
renal function
d) Hydralazine is the drug of choice in treating Pregnancy
related Hypertension
e) Sublingual Nifedipine is a safe and effective drug for
controlled BP reduction
• Answers; a,b,c are true
In Aortic Dissection, Besides the elevated BP, the force and velocity of LV ejection plays a
major part in expanding the dissection.Vasodiating antihypertensives will produce reflex
tachycardia and increase aortic ejection velocity thereby increasing the dissecting haematoma.
Combination of a beta blocker and vasodilator is the standard approach. Labetalol, or a
combination of nicardipine and esmolol or combination of nitroprusside and metaprolol are
recommended.
Fenodopam is a selective dopamine agonist and improves creatinine clearence, increases
urine output and facilitates sodium excretion.
Hydralazine has enjoyed considerable popularity in the treatment of Pregnancy related
Hypertension; However its unpredicable hypotensive effect and the long duration of action
may produce adverse effects on the maternal cerebral circulation and uteroplacental
perfusion. Nitroprusside and ACE inhibitors are contraindicated in pregnancy. IV labetalol is
preferred.
Sublingual Nifedipine is not absorbed through buccal mucosa but is rapidly absorbed
through the GI tract.It produces precipitous and severe reductions in BP,leading to
cerebral,renal and myocardial ischaemia. FDA has recommended that this practice of
administering sublingual Nifedipine should be abandoned.
 References

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Chest 20007.131(6) 1949-62
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Post graduat Medicine 1999 May ; 105(3) 119-26
• 3 )Thomas L ; Managing Hypertensive emergencies in the ED
can Fam Physician 2011 oct;57(10)1137-97
• 4 ) 7 th JNC on prevenion, detection,evaluation and treatment of hypertension
2003
• 5) European society of cardiology ; 2007 guidelines for the management of
arterial hypertension
• 6) clinical practice guidelines- management of arterial hypertension 3rd
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