CURRENT TREATMENT OF

HYPERTENSIVE EMERGENCIES
DEFINITION :
 HYPERTENSIVE CRISIS
A severe elevation in BP, generally a SBP > 220 mm Hg and / or
DBP > 120 mm Hg. (JNC-VI, 1997)
 HYPERTENSIVE EMERGENCIES
Severe elevation in BP complicated by acute target organ
dysfunction, such as coronary ischemia, stroke, intracerebral
hemorrhage, pulmonary edema, or acute renal failure.
 HYPERTENSIVE URGENCIES
Severe elevations in BP without evidence of target organ
deterioration.

Colhum DA. Oparil S, New Engl. J. Med, 323 : 1177, 1990

 HYPERTENSIVE CRISIS
DBP >120 mmHg

URGENCY EMERGENCY
 BP within hours < 24 hours  BP within minutes < 1 hours
(PARENTERAL / ORAL) (PARENTERAL)

- Accelerated malignant hypertension

- Hypertensive encephalopathy
- Intracerebral/Subarachnoid hemorrhage
- Acute aortic dissection
- Acute left ventricular failure
- Acute myocardial infarction
- Acute glomerulonephritis
- Eclampsia
- Severe epistaxis
KAPLAN NM . Lancet 344:1335,1994
- Perioperative hypertension, etc
End-Organ Damage Associated Hypertensive Emergencies

End-Organ Damage Type No of Cases (%)

Cerebral Infarction 26 (24.5)
Intracerebral or sub-arachnoid
5 (4.5)
hemorrhage
Hypertensive encephalopathy 18 (16.3)
Acute pulmonary edema 24 (22.5)
Acute congestive heart failure 15 (14.3)
Acute myocardial infarction or unstable
13 (12.0)
angina pectoris
Eclampsia 5 (4.5)
Aortic dissection 2 (2.0)

Zampaglione, et al. AHA ; 27 (1) : 144

Circumstances Requiring Rapid
Treatment of Hypertension (DBP > 120 mmHg)
Accelerated-malignant hypertension with papilloedema
Cerebrovascular
• Hypertensive encephalopathy
• Atherothrombotic brain infarction with severe hypertension.
• Intracerebral hemorrhage, subarachnoid hemorrhage.

Cardiac
• Acute aortic dissection
• Acute left ventricular failure
• Acute or impending myocardial infarction
• After coronary bypass surgery

Renal
• Acute glumerulonephritis
• Renal crisis from collagen-vascular diseases.
• Severe hypertension after kidney transplantation
Circumstances Requiring Rapid
Treatment of Hypertension (cont…)

Excessive circulating – cathecolamines

• Pheochromocytoma crisis
• Food and drug interactions with monoamine oxidase inhibitor
• Sympathomimetic drug use (cocaine)
• Rebound hypertension after suddent cessation of antihypertensive drugs.

Eclampsia, Surgical

• Severe hypertension in patients requiring immediated surgery.

• Post-operative hypertension
• Post-operative bleeding from vascular suturelines

Severe body burns, Severe epistaxis.

Kaplan NM : Management Hypertension Emergencies, LANCET, 344, 1994 : 1335

Treatment

1. The goal of therapy is to reduce systemic vascular

resistance.
2. The approach is to initially reduce mean arterial pressure
by about 25 % with further reductions accomplished more
gradually.
3. In general the initial reduction should be achieved over a
period of 1 to 2 hours with less rapid reduction over the
ensuring 6 hours to a DBP of + 100 mm Hg.
4. With the exception of patients with aortic dissection, the
BP should not be reduce to normotensive and especially
hypotensive levels, as target organ hypoperfusion may
results.
 Current Recommendation of
the AHA :
• Hypertension in the setting of acute ischemic
stroke should only be treated rarely and
cautiously .
• Treat : DBP > 120-130 mmHg , objective
reduction 20 % in the first 24 hours.
• Abandon oral nifedipine.
• Short
actingIV.(labetalol,nicardipine,fenoldopam )
• SNP increase ICP,cyanide poisoning
 Intracerebral Hematoma
• Hypertension serve to protect CBF in
the setting of high ICP.
• Treat if : systolic blood pressure > 200
mmHg or DBP > 110 mmHg.
• The rate of decline in blood pressure
was independently associated with
increased mortality.
MANAGEMENT OF HYPERTENSIVE EMERGENCIES
JNC-VI RECOMMENDATION

• Reduce Mean Arterial BP no More than 25 %

over 2 hours then Reduce to 160 / 100 mm Hg
within 2-6 hours.

• Avoid excessive falls in Blood Pressure

• Titrate with Intravenous antihypertensives.

• Guideline of treatment based on concensus
expert.
 End-Organ Complication of
Hypertensive Emergencies
END- COMPLICATIONS THERAPEUTIC CONSIDERATIONS
ORGAN
Aortic Aortic dissection -BLOCKADE, labetolol (decrease dp/dt), SODIUM
NITROPRUSSIDE with -BLOCKADE, avoid isolated
use of pure vasodilators.

Brain Hypertensive encepha- Avoid centrally acting antihypertensive drugs such

lopathy as CLONIDINE.
Cerebral infarction or Avoid centrally acting agents : avoid rapid
Haemorrhage decreases in blood pressure

Heart Myocardial ischaemia Intravenous GLYCERYL TRINITRATE, -BLOCKADE.

Myocardial infarction
Heart failure DIURETICs & ACE inhibitors useful, -BLOCKERS
with caution.

Kidney Renal insufficiency DIURETICs with cautions, CALCIUM Antagonists

useful.

Placenta Eclampsia HYDRALAZINE, LABETOLOL, CALCIUM Antagonists

useful; avoid sodium nitroprusside.

dp/dt = change in pressure / change in time LANCET 2000; 356 : 411-417

Autoregulation of Cerebral Blood Flow

Lancet 2000; 356: 411–17

 Autoregulation
• Difficulty in balancing between organ :
• Brain , heart and kidney.
• Different organ depending on the
preexisting lesion has a different
threshold of perfusion pressure.
Intravenous Drugs
for Hypertensive Emergency

DRUGS DOSAGE ONSET of ACTION

Nitropruside 0.25 – 10 g/kg/min as IV Infusion Instantaneous
Nitroglycerin 5 – 100 g/min as IV Infusion 2 – 5 min
Nicardipine 5 – 15 mg/hours IV 5 – 10 min
Hydralazine 10 – 20 mg IV 10 – 20 min
10 – 50 mg IM 20 – 30 min
Enalapril 1.25 – 5 mg q 6 hours 15 min
Fenoldopam 0.1 – 0.3 g/kg/min < 5 min
Phentolamine 5 – 15 mg IV 1 – 2 min
500 g/kg/min for 4 min, then 150 –
Esmolol 1 – 2 min
300 g/kg/min IV
20 – 80 mg IV bolus every 10 min
Labetolol 5 – 10 min
2 mg/min IV Infusion

Braunwald , 2001
Intravenous Drugs for Hypertensive
Emergencies Available in Indonesia

Vasodilators
• Clonidine
• Nitroglicerin
• Sodium Nitropruside
Ca-Antagonist
• Diltiazem Hydrochloride
 COMMONLY USED DRUG IN
HYPERTENSIVE EMERGENCY

DILTIAZEM I.V. (HERBESSER)

 Useful for hypertensive emergency and urgency.
 Acts as calcium slow-channel blockers.
 Dose-dependent :
• Predictable onset of action
• Rapidly reduced BP.
• No rebound on withdrawn
 Adverse effect : bradycardia, hypotension, headache, flushing.
 Has antiischemic and antiarrhythmic effect (class-IV)
Organ Target HER CLON NTG NIFE
Cardioprotective
Heart rate
Ischemic

Dilate: coroner ++ - ++ +
Anti-

collateral ++ - - -
Antiarrhytmic + - - -
Antivasospasm ++ - - +
Renoprotective
Afferent + - - +
RBF - -
Efferent + - - -
CGP - -
Cerebroprotective
CBF
Epstein M, 1991, Bakris GL, 1993, Mancia G, 1996, Messerly FH, 1996
Conclusion :
1. Hypertensive emergencies require immediate BP reduction.
This is most safely accomplished in the intensive care
setting with use of an Intravenous agent.
2. With the advent of better tolerated, long-acting anti
hypertensive agents, hypertensive crisis become less
common, with an estimated prevalence rate of 1% among
hypertensive patients.
3. Diltiazem IV is scalable and predictable effective to lower
BP faster in avoiding complications of hypertensive
emergency.
4. In hypertensive urgencies BP should be reduced more
gradually with an fast-acting agents per os in an out
patient setting.