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HYPERTENSIVE EMERGENCIES HYPERTENSIVE EMERGENCIES PROF SIR

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									HYPERTENSIVE EMERGENCIES




PROF. SIR J. W. ACHEAMPONG
            Hypertension



Raised Blood Pressure above (140/80)
   Classification of Blood Pressure for
     Adults aged 15 years and older
Category    Systolic Pressure   Diastolic Pressure
Optimal          <120                 <80
Normal           <130                 <85
High normal      130 -139           85 – 89

Hypertension
Stage I (mild)     140 – 159       90 – 99
Stage II(moderate) 160 – 179      100 – 119
Stage III(Severe)  180 – 209      110 – 119
Base on the average of ≥ 2 reading taken at
each of 2 or more visits after an initial
screening.
Source: Joint National Committee on
Prevention, Detection, Evaluation and
Treatment of High Blood Pressure.
       Symptoms of signs

Most patients – No specific symptom
                referable to their blood
                pressure elevation
Symptoms when Present fall into
        3 categories
1. Related to elevated Pressure itself.
2. Related to hypertensive vascular disease
3. Related to the underlying disease (2ndly)
 Related to elevated Pressure itself
1. Headache – localized to the occipital
              region when patient
              awakens in the morning but
              subsides spontaneously
              after several hours.
2.   Dizziness
3.   Palpitations
4.   Early fatiguability
5.   Impotence
          Vascular disease
Epistaxis
Haematuria
Blurring of vision
Weakness or dizziness due to transient
cerebral ischaemia
Angina pectosis
Dyspnea
        Underlying disease
Polyuria & polydipsia
Muscle weakness 2ndly to hypokalaemia
 (Primary Aldosterism).
Weight gain + emotional ability (Cushing’s
 Syndrome). Episodic headaches,
 palpitations, diaphoresis and postural
 dizziness (pheochromocytoma)
   Hypertensive Emergencies
1. Effects on the Heart
   Concentric LVH → function of chamber
   deteriorates →cavity dilates →
   symptoms & signs of Heart failure
2. Angina Pectoris
  – Accelerated coronary arterial disease
  – Increase myocardial oxygen requirement as
    a consequence of increased myocardial
    mass.
                Neurologic effects


           Retinal         CNS
CNS – Cerebral infarction – is secondary to
the increased atherosclerosis
  – Cerebral haemorrhage – result of both
    elevated Arterial pressure and the
    development of Cerebral Vascular
    microaneurysms ( Charcot, Bouchard
    aneurysms).
Hypertensive Encephalopathy
Severe hypertension
Disordered consciouness
Increased intracranial pressure
Retinopahty with papillaedema end
seizures
Transient Ischaemic Attack (TIA)
Focal neurologic signs → 1 transient after
24 hrs.
     Effects on the Kidney
Arteriosclerotic lesions of the afferent &
efferent arteriole & glomerular capillary
tufts are the most common renal vascular
lesions

    decreased glomerular filtration and

            tubular dysfunction

               Renal failure
  Malignant Hypertension
Marked raised BP
Papilloedema
Retinal haemorrhage and excidates
Manifestations of hypertensive
encephalopathy
Severe headache
Vomiting
Visual disturbances (transient blindness)
Transient paralyses
Convulsions, strepor and coma
All due to spasms of cerebral vessels and to
  cerebral oedema.
  Cardiac decompensation
  Rapidly declining renal function
  Hypertensive Emergencies
Physical Examination
 Round face and truncal obesity (Cushing’s
 Syndrome)
 Is muscular development in the upper
 extremities out of proportion to that of
 lower ext.
 Coarctation of Aorta – Delayed femoral
 pulse
 Renal Artery Stenosis + Carotid stenosis –
 bruit
 Acromegaly
Physical Examination cont’d
Palpate enlarged kidney (polycystic)
Weight and height (BMI)
Extremities for oedema ± Evidence of
previous CVA
Examination of ocular fundi is mandatory
(Keith – Wagener-Barker Classification)
Examination of Heart & Lungs (LVF)
Is there left ventricular lift
Are 3rd & 4th heart sounds present
Are there pulmonary rates
 Laboratory Tests for Evaluation of
           Hypertension
Basic Tests for Initial Evaluation
1. Always included
  a)   Urine for protein, blood, and glucose
  b)   Microscopic urinalysis
  c)   Hematocrit
  d)   Serum potassium
  e)   Serum creatinine and/or blood urea nitrogen
  f)   Fasting glucose
  g)   Total cholesterol
  h)   electrocardiogram
 Laboratory Tests for Evaluation of
       Hypertension cont’d
2. Usually included, depending on cost and
   other factors
  a)   Thyroid-stimulating hormone
  b)   White blood cell count
  c)   HDL and LDL cholesterol and triglycerides
  d)   Serum calcium and phosphate
  e)   Chest X-ray; limited echocardiogram
 Laboratory Tests for Evaluation of
       Hypertension cont’d
Special Studies to Screen for Secondary
Hypertension

1. Renovascular disease: angiotensin-
   converting enzyme inhibitor radionuclide
   renal scan, renal duplex Doppler flow
   studies, and MRI angiography
2. Pheochromocytoma: 24-h urine assay for
   creatinine, metanephrines, and
   catecholamines
 Laboratory Tests for Evaluation of
       Hypertension cont’d
3. Cushing’s syndrome: overnight
   dexamethasone suppression test or 24-h
   urine cortisol and creatinine
4. Primary aldosteronism: plasma
   aldosterone: renin activity ratio
Note: HDL, high-density lipoprotein; LDL,
   low-density
     lipoprotein; MRI, magnetic resonance
   imaging
Therapeutic Agents Used to Treat Malignant Hypertension

                                                                 Time Course of Action
                                                                                                 Oral Preparation
Drug            Route            Starting Dose                   Onset    Peak          Duration Available

IMMEDIATE ONSET

Nitroprusside   Continuous IV    0.25μg/kg/min                   <1min       1–2 min     2–5min       No
Nitroglycerin   Continuous IV    5μg/min                         1–5min      2–6 min     3–10min      No
Diazoxide       IV bolus         50mg q 5–10 min up to 600mg     1–5min      2–4 min     4–12 h       No
Fenoldopan      Continuous IV    0.1–0.3μg/kg per min            <5 min      5–10 min     30min       No
Esinolol        Continuous IV    250–500 μg/min x 1 min; then    1–2min      2–3 min      10–20 min   No
                                 50 - 100μg/kg per min x 4min

DELAYED ONSET

Enalaprilat      IV             1.25mg q h                       10–15min     3–4h         6–24h      Yes
Hydralazine      IV, IM          5 – 10 mg q 20 min x 3          10-20 min    20-40 min    4-12 h     Yes
Labetalol        IV             20-80 mg q 10 min up to 300 mg   5 min        20-30 min     3-6 h     Yes
Nicardipine     IV              5-15 mg/h                        5-10 min     20-40 min    1-4 h      Yes
 Drug Therapy for Hypertension
1. Diuretics –
   Thiazides – most frequently used
   Frusemide         heart failure 30%
   Spironolactone reduction in Mortality
2. Anti Adrenergic Agents
a) β-Adrenergic Receptor Blockers (β-
   blockers)
   Propranolol
   Atenolol
   Metoprolol
     Drug Therapy for Hypertension
                cont’d
b) α Adrenergic Receptor blockers
   Phentolamine
   Prozosin
   Doxazosin
c) Central – Adrenergic Agents
   Clonidine
   methyldopa (Also blocking sympathetic Nerves)
d) α/ β – Adrenergic Agents
   Carvedilol
   Labetalol
   Drug Therapy for Hypertension
              cont’d
3. Vasodilators
    Vascular smooth muscle – Hydralazine
                           – Diazoxide
                           – Nitropruscide
4. Angiotension – Converting Enzyme
    inhibitors
   – Captopril
   – Enalapril
   – Ranupril
5. Angiotension Receptor Antagonists
  – Losartan
  – Valsartan
  – Atacand (candesartan)
6. Calcium Channel Antagonists
   Vascular smooth muscle
    Dihydropyridines – Nifedipine
                      – Amlodipine
              - Felodipine
    Benzothiazepines:
              Diatiazem
    Phenylalkylamine:
              Verapamil
THANK YOU

								
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