Scenario: an 85 year old lady has been sent to your ED for a blood pressure of 210/120 from the GP.
1. Distinguish between hypertensive crisis and hypertensive urgency.
Hypertensive crisis is defined as high BP with End organ damage. Hypertensive Urgency is defined as high BP without end organ damage.
End Organ Damage assessment
1.CNS - rule out symptoms of hypertensive encephalopathy :
impaired judgement and memory, confusion, somnolence
Visual vield defects, colour blindness
Rule out symptoms of ischaemic stroke or haemorrhagic stroke.
2.Cardiorespiratory - rule out symptoms of APO left ventricular dysfunction, ischaemia, dissecting aneurysm
3.Renal - acute renal failure
Rule out conditions associated with malignant hypertension
Coarctation of the aorta.
- remember that an excessive hypotensive response is potentially dangerous in that it may induce ischemic complications: stroke, AMI or blindness.
- The general goal is to achieve a 10-20% reduction in systolic BP in the first hour, and an additional 5-15% reduction in BP in the first 24 hours.
General Management Exceptions:
Acute Ischemic stroke blood pressure is usually not lowered unless it is ≥185/110 mmHg in patients eligible for alteplase or ≥220/120 mmHg in patients not eligible for alteplase.
Acute aortic dissection the systolic blood pressure is rapidly lowered to a target of 100 to 120 mmHg within 20 minutes.
- Alteplase eligble: IV labetalol or nicardipine to achieve a BP <185/110
- Alteplase not eligble: IV labetalol or nicardipine to achieve BP <220/120
BP treatment is a balancing act between the risk of reducing cerebral perfusion and the benefit of reduced bleeding.
Hypertension is usually treated in the situation when cerebral perfusion pressure is >120 mmHg + the intracranial pressure is >20 mmHg using IV mannitol.
Acute heart failure
Use IV loop diuretics and nitroglycerine.
Avoid hydralazine - increases cardiac work
and beta-blockers - decreases cardiac contractility
Acute coronary syndrome
Use IV nitroglycerin, nicardipine, or esmolol:
reduce the underlying coronary ischemia and/or increased myocardial oxygen consumption.
Acute aortic dissection
Target of 100 to 120 mmHg within 20 minutes. Use IV nitroprusside or clevidipine.