Management of severe asymptomatic hypertension

(hypertensive urgencies)

Shiva Seyrafian IKRC- IUMS 16-10-2014 __ 24-7-93



Definition:

systolic

and/or blood pressure

diastolic ≥180

mmHg blood pressure

≥120

mmHg)  Can produce a variety of acute, life threatening complications(

hypertensive emergencies

).

 Relatively asymptomatic (other than perhaps headache) and have no acute signs of end organ damage (

hypertensive urgency

).

Accelerated-malignant hypertension with papilloedema Cerebrovascular Hypertensive encephalopathy Atherothrombotic brain infarction with severe hypertension Intracerebral hemorrhage Renal Acute glomerulonephritis Renal crises from collagen vascular diseases Severe hypertension after kidney transplantation Subarachnoid hemorrhage Cardiac Acute aortic dissection Acute left ventricular failure Acute or impending myocardial infarction After coronary bypass surgery

Excessive circulating catecholamines Pheochromocytoma crisis Food or drug interactions with monoamine-oxidase inhibitors Sympathomimetic drug use (cocaine) Rebound hypertension after sudden cessation of antihypertensive drugs Eclampsia Surgical Severe hypertension in patients requiring immediate surgery Postoperative hypertension Postoperative bleeding from vascular suture lines Severe body burns Severe epistaxis

Most commonly in patients who are: 1.

Nonadherent with their chronic antihypertensive regimen or those who are nonadherent with a low sodium diet.

2.

Medication-adherent patients following ingestion of large quantities of salt.

 Quickly confirmed with a repeat measurement

Blood pressure reduction goals:

 In the absence of symptoms, a more gradual reduction in pressure.



Sublingual nifedipine is now contraindicated

 Blood pressure may decline spontaneously simply with rest in a quiet room.

 Cerebral or myocardial ischemia or infarction can be induced by aggressive antihypertensive therapy.

 In the

absence of

signs of

acute end-organ damage

, the goal of management is to reduce the blood pressure to

≤160/100

mmHg over

several hours to days.

  An

elderly

patient may be at particularly

high risk for cerebral or myocardial ischemia

from excessively

rapid reduction

of blood pressure.

This patient who often have a

high pulse pressure

(eg, diastolic blood pressure <90 mmHg with systolic blood pressure ≥180 mmHg), the initial goal blood pressure of ≤160/100 mHg, achieved even slower.

 All patients should be provided a

quiet room

to rest, fall in BP of 10 to 20 mmHg or more.

If treated previously:

 Increase the dose of existing antihypertensive medications, or add another agent.

 Reinstitution of medications in non-adherent patients.

 Addition of a diuretic, and reinforcement of dietary sodium restriction , in patients who have worsening hypertension due to high sodium intake.

If Untreated hypertension:

  Relatively rapid initial blood pressure reduction ( over several hours ):

oral furosemide oral clonidine oral captopril

(if the patient is not volume depleted) at a dose of 20 mg (or higher if the renal function is not normal), a small dose of (0.2 mg); or a small dose of (6.25 or 12.5 mg).

A low dose of a calcium channel blocker, beta blocker or ACE inhibitor, but not a diuretic alone . Oral nifedipine XL 30 mg once daily (of the long-acting preparation), oral metoprolol XL 50 mg daily, or ramipril 10 mg once daily.

Monitoring and follow-up:

 managed in the emergency room, since exclusion of acute end-organ damage   laboratory testing, may require administration of medications      several hours of observation.

in the physician's office

if the evaluation and management can be carried out.

observed for a few hours, sent home with close follow-up over the subsequent days evaluation for symptoms hypertension or hypotension.

related to

 Monitoring and close phone follow-up.

 does not have a physician, follow-up may need to be in the emergency room.

 Over the course of weeks to months, the dose and selection of medications is modified to achieve desired goals usually with longer acting agents.

 Hypertension accounts for an estimated 54 percent of all strokes and 47 percent of all ischemic heart disease events globally.

 Hypertension: the most important risk factor for premature cardiovascular disease,  More common than cigarette smoking, dyslipidemia, and diabetes.

Major risk factors Target organ damage Hypertension Cigarette smoking Obesity (BMI ≥30 kg/m2) Physical inactivity Dyslipidemia Diabetes mellitus Heart disease Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Stroke or transient ischemic attack Chronic kidney disease Microalbuminuria or estimated GFR <60 mL/min Age >55 years for men, >65 years in women Family history of premature coronary disease Men - <55 years Peripheral arterial disease Retinopathy Women - <65 years

The JNC 7 report. JAMA 2003; 289:2560.

Shiva Seyrafian IKRC- IUMS 16-10-2014 __ 24-7-93

    Reduction of sodium intake, Moderation of alcohol, weight loss in the overweight or obese, Diet rich in fruits, vegetables, legumes,  Low-fat dairy products and low in snacks, sweets, meat, and saturated fat.

Individual dietary factors:

  Increased intakes of potassium, calcium, fish oil, fiber.

Milk-based and vegetable-based protein, folate, flavonoids (cocoa, tea).

 Cessation of smoking  Institution of an aerobic exercise regimen.

 In prehypertension or stage 1 hypertension, lifestyle changes may control the blood pressure adequately.

 In higher BP or additional risk (eg, diabetes or chronic kidney disease), drug therapies should first be used to more quickly and effectively control the blood pressure.

 Once blood pressure is well controlled , lifestyle changes should be strongly If these are successfully achieved, reduction of medications may be possible.

advised.

DASH trial (Dietary Approaches to Stop Hypertension ):  A combination diet

fat rich in fruits, vegetables, legumes, and low-fat dairy products and low in snacks, sweets, meats, and saturated and total

(this combination diet is called the

“DASH

diet”

).

 The DASH diet is comprised of four-five servings of fruit, four-five servings of vegetables, two three servings of low-fat dairy per day, and <25 percent fat.

lower risk of developing hypertension (14 years F/U):  Body mass index of less than 25kg/m2,   A daily mean of 30 minutes of vigorous exercise, Adherence to the DASH diet,   Modest alcohol intake, Infrequent use of nonnarcotic analgesics,  Intake of 400microg/d or more of folate . The presence of all six factors: a marked decrease in the risk for hypertension.

Perioperative management of hypertension

SHIVA SEYRAFIAN IUMS, IKRC

PERIOPERATIVE MANAGEMENT OF HYPERTENSION

 Of 76 patients who died of a cardiovascular cause within 30 days of elective surgery, a preoperative history of hypertension was four times more likely than among 76 matched controls.

 Induction of anesthesia: systolic blood pressure can increase by 90 mmHg and heart rate by 40 beats per minute.

 period of anesthesia: The mean arterial pressure tends to fall, intraoperative hypotension.

 Immediate postoperative: Blood pressure and heart rate slowly increase.

 Diastolic dysfunction from left ventricular hypertrophy, systolic dysfunction leading to congestive heart failure, renal impairment , and cerebrovascular and coronary occlusive disease .

 Mild to moderate hypertension: (diastolic pressure less than 110 mmHg) do not appear to be at increased operative risk

Six independent predictors of major cardiac complications High-risk type of surgery (examples include vascular surgery and any open intraperitoneal or intrathoracic procedures) History of ischemic heart disease (history of MI or a positive exercise test, current complaint of chest pain considered to be secondary to myocardial ischemia, use of nitrate therapy, or ECG with pathological Q waves; do not count prior coronary revascularization procedure unless one of the other criteria for ischemic heart disease is present) History of HF History of cerebrovascular disease Diabetes mellitus requiring treatment with insulin Preoperative serum creatinine >2.0 mg/dL (177 µmol/L)

 Abruptly discontinuing some medications (eg, beta blockers, clonidine ) may be associated with significant rebound hypertension .

 Most antihypertensive agents can be continued until the time of surgery, taken with small sips of water on the morning of surgery.

 ACEI,ARB: withhold them on the morning of surgery in patients who are taking them for congestive heart failure in whom the baseline blood pressure is low , OR in renal failure patients to avoid significant hypotension during the induction of anesthesia.



Calcium channel blockers :

aggregation, increased incidence of postoperative bleeding, probably due to inhibition of platelet 

Withdrawal syndromes:

clonidine, methyldopa, guanfacine and the beta blockers are associated with acute withdrawal syndromes that can lead to adverse perioperative events. These drugs should

not

be abruptly stopped perioperatively.



Centrally acting sympatholytic drugs:

Rebound hypertension usually occurs after abrupt cessation of fairly large oral doses (eg, greater than 0.8 mg/day), but has also been noted with transdermal clonidine.



Beta blockers:

be reduce intraoperative myocardial ischemia, recommended that patients with one or more risk factor for CHD given beta blockers perioperatively .

Hypertension usually begins within approximately two hours.

30 minutes of the completion of surgery and lasts  History of hypertension preoperatively  Pain  Excitement on emergence from anesthesia  Hypercarbia  Type of surgery

    A marked rise in blood pressure following surgery should be treated immediately .

Remedial causes: bladder distention pain, agitation, hypercarbia, hypoxia, hypervolemia, and Chronic antihypertensive therapy should resume with their usual medications .

Therapy should be considered for patients with a sustained systolic blood pressure above 180 mmHg or diastolic blood pressure greater than 110 mmHg, once remedial causes have been excluded or treated.

 Patients taking diuretics may be given parenteralfurosemide or bumetanide .

 Patients taking beta blockers may be given parenteral propranolol , labetalol , or esmolol .

 Patients taking an ACE inhibitor may be given parenteral enalaprilat .

 Patients taking centrally acting agents can be given a clonidine patch.

 Patients taking calcium channel blockers can be given intravenous nicardipine .

Uptodate ® Oct 2013

 The ideal circumstance is to normalize blood pressure (eg, to less than 140/90 mmHg) for several months prior to elective surgery.

 It is not necessary to postpone elective procedures in patients with a blood pressure below 170/110 mmHg.

 Elective surgery should be postponed in patients with blood pressures above 170/110 mmHg.  Such patients who require urgent surgery should be treated with a parenteral drug acutely.

 Patients who are taking chronic antihypertensive time of surgery.

medications should continue taking their medication until the  The drug can be administered with a sip of water on the morning of surgery and resumed postoperatively as needed.

 Alternative parenteral resume oral medications.

agents can be prescribed for patients who are unable to

 In particular, beta blockers acting agents such as and centrally clonidine should not be stopped acutely.

If necessary,  Intravenous propranolol or labetalol can be administered to patients taking beta blockers  Or transdermal clonidine can be administered to patients taking clonidine.

 Remedial causes of postoperative hypertension such as hypercarbia, hypoxia, hypervolemia, and bladder distention pain, agitation, should be excluded or treated .

 Once this has been done, be considered for therapy patients should with a persistent systolic 180 mmHg or a blood pressure diastolic above blood pressure above 110 mmHg .

  1.

2.

3.

Before age 50, women have a lower prevalence of hypertension than men, but after age 55, they have a higher prevalence.

The prevalence rises with age, approaching 80 to 90 percent in women over the age of 70.

Incidence of coronary heart disease(1/2).

Left ventricular hypertrophy is less common.

At equal degrees of hypertension, women were at lower risk than men in all age groups from 40 to 70.

 Body mass index of less than 25 kg/m 2  A daily mean of 30 minutes of vigorous exercise  Adherence to the DASH diet, modest alcohol intake  Infrequent use of nonnarcotic analgesics  Folate intake of 400 microg/day or more

    Women and men respond similarly to antihypertensive therapy .

All women should follow a health lifestyle and periodically monitored for rises in blood pressure and end-organ damage .

Other cardiovascular risk factors important determinant of antihypertensive medications .

(smoking, hypercholesterolemia, and diabetes mellitus): an the need for ( The presence LVH ) by of left ventricular hypertrophy echocardiography carries an increased risk of cardiac events in women that is equivalent to that in men.