1、Hypertensive Crisis,. 4, Urgency/Emergency evidence ,Hypertensive crisis ,Hypertensive emergency target organ damage coronary ischemia, disordered cerebral function, cerebrovascular events, pulmonary edema renal failure,Hypertensive crisis ,Hypertensive urgency progressive target organ dysfunction h
2、ypertensive crisis ( acute cocaine intoxication), Hypertensive crisis, stage 1, 2 HTN Nonadherence USA 500,000 ( 1%), Hypertensive crisis,Renal disease 1. Parenchymal disease-chronic pyelonephritis-primary glomerulonephritis-vascular/glomerular disease (SLE, systemic sclerosis),Drugs - central actin
3、g alpha2-adrenergic agonist (clonidine, methyldopa) - phyencyclidine, cocaine intoxication -DI: monoamine oxidase inhibitor (tranylcypromine, phenelzine selegilline),Pregnancy Eclampsia/ severe pre-eclampsia,Endocrine - Pheochomocytoma - 1 aldosteronism,CNS disorders - CVA infarction/hemorraghe - He
4、ad injury,Etiology and Pathophysiology, . . SVR hypertensive crisis (triggering) . Endothelium (blood pressure homeostasis),Etiology and Pathophysiology,Endothelium (vascular tone) nitric oxide prostacyclin renin-angiotensin system . compensatory decompensation endothelium ,History & Physical examin
5、ation.extremely important Lab + other test (ECG/ Chest radiographpossible end organ damage),History, ? end organ damage Chest pain MI/ischemia, aortic dissection SOBacute pulmonary edema LVF Back painaortic dissection Neurologic symptoms (headache, blurry vision, N, V )intracerebral or subarachnoid
6、hemorrhage/encephalopathy,History, (sympathomimetic, NSAIDs, herbal product, cocain, methamphetamine) (beta blockers, central sympatholytic agent).rebound hypertension,Physical Examination, 2 20 mmHg SBP aortic dissection BP volume status pressure natriuresis Head&Neck fundoscopic exam grade IIIflam
7、e-shaped hemorrhages, fluffy, white cotton wool spots, yellow white exudategrade IVpapilledema with blurring /hemorrhage/exudate,CVS exam Murmursdiastolic murmur+aortic insuffaortic dissection JVP, S3 gallopCHF Rales at lungspul congestion/edema Smokers renovascular HTN Systolic/diastolic abdominal
8、bruitrenovascular disease Delirium/flapping tremor.encephalopathy,Lab,CBC: peripheral smear schistocyte microangiopathic hemolytic anemia Electrolyte, BUN, Scr renal impairment Hypokalemia metabolic alkalosis intravascular volume depletion secondary hyperaldosteronism,Other tests,ECG myocardial isch
9、emia/infarction LVH chronic hypertension Chest radiograph pulmonary congestion widened mediastinum aortic dissection CT without contrast neurologic symptoms ( mental status, focal neurologic signs cerebrovascular accident/hemorrhage, Urgency/Emergency target organ damage, Hypertensive Urgency, oral
10、antihypertensive agents . hypotension ( peipheral vascular disease, atherosclerotic cardiovascular and intracranial disease) Initial goal: 160/110 mmHg Mean arterial pressure 25% 24 , Mean arterial pressure,MAP = (CO x SVR) + CVP MAP = DP + 1/3(PP) MAP = DP + 1/3( SP-DP) MAP = (2DP+SP)/3, Hypertensi
11、ve Urgency,ACEI: Captopril onset 15-30 min (max BP drop 30, 90 ) Captopril: 25 mg oral / 50-100mg 90-120 ADR: hypotension, angioedema, renal failure bilateral renal artery stenosis, Hypertensive Urgency,CCB: nicardipine placebo Oral dose 30 mg 8 Onset 0.5-2 ADR palpitation, flushing, headache, dizzi
12、ness, Hypertensive Urgency,CCB: nifedipine Peak effect: 10-20 Short acting FDA stroke 1995 Ad hoc panel National Heart, Lung, and Blood Institute evidence , Hypertensive Urgency,BB: Labetalol Alpha1 and beta adrenergic blockers Onset 1-2 hours randomizations 200 mg oral 3-4 ADR: nausea, dizzness, Hy
13、pertensive Urgency,Clonidine: central acting adrenergic agent (alpha2-receptor agonist) Onset 15-30 Peak 2-4 hours Regimen: 0.1-0.2 mg loading dose 0.05-0.1 mg q hr (max dose: 0.7 mg) ADR: sedation, dry moth, orthostatic hypotension, , Hypertensive Emergency, end-organ damage IV, ICU 1 MAP 10% 2-3 M
14、AP 15% Pressure natriuresis volume depletion hypertensive emergency vasodilator IV saline renin-angiotension-aldosterone system,Neurologic emergency,Hypertensive encephalopathy, intracerebral hemorrhage, acute ischemic stroke Intracerebral hemorrhage: autoregulation systemic perfusion pressure AHA:
15、intracerebral bleed 180/105 mmHg MAP 130 mmHg,Neurologic emergency, Ischemic stroke Perfusion pressure Systemic pressure pre-ischemic blood pressure control cerebral ischemia TIA 1-2 hr MAP 130 mmHg, SBP 220 mmHg MAP 15-20%,Cardiac emergency,Myocardial ischemia, MI, pul edema, aortic dissection MI:
16、Nitrogylcerine myocardial oxygen consumption flow sig HF, betablockers (labetalol, esmolol) Pulmonary edema: IV diuretics ACEI ( enalaprilate) nitroglycerine Na nitroplusside ,Hyperadrenergic state, catecholamine Pheochromocytoma, cocaine amphetamien overdose, momoamine oxidase inhibitor-induced HTN
17、, clonidine withdrawal syndrome Pheochromocytoma: IV Na nitroprusside () IV phentolamine (ganglion-blocking agent) BB block alpha ,Hyperadrenergic state,HTN Clonidine clonidine Cocaine intoxication Benzodiazepine anxiolytic effect ischemia Acute kidney injury Proteinuria, microscopic hematuria, olig
18、uria, anuria IV nitroprusside cyanide/thiocyanide toxicity Fenoldopam mesylate (dopamine1 receptor agonist) , Hypertensive crisis crisis target organ damage cocaine Hypertensive emergency target organ damage Hypertensive urgency target organ damage 160/90-140/90 mmHg uncontrolled HTN. hypertensive u
19、rgency ( slide 7), crisis (.) target organ damage Lab + other test target organ damagec , Hypertensive urgency oral: ACEI captopril 25 mg 160/110 mmHg - MAP 25% Hypertensive emergency IV 1 MAP 10% 2-3 MAP 15%, hypertensive emergency Neurologic: AHA intracerebral bleed 180/105 mmHg MAP 130 mmHg Cardiac: 1-2 hr MAP 130 mmHg, SBP 220 mmHg MAP 15-20% Hyperadrenergic: Pheochromocytoma: IV Na nitroprusside () IV phentolamine (ganglion-blocking agent) HTN Clonidine clonidine ,
