Morning Report 9/28/15 – Hypertensive Urgency/Emergency

Teaching Pearls:

  • Distinguish whether elevated blood pressure is secondary to other etiologies, including brain bleed, aortic dissection, drug use, etc
  • Hypertensive emergency/urgency is a diagnosis of exclusion. Defined as very high blood pressure with active end organ damage. End-organ damage includes:
    • Acute encephalopathy
    • Pulmonary edema
    • Aortic dissection
  • Cushing’s Reflex: Hypertension, Bradycardia, and Respiratory variation.
  • In LVH, you can commonly see T wave inversions along lateral leads due to repolarization abnormalities.
  • Hypokalemia, Metabolic Alkalosis, Hypertension –> consider hyperaldosteronism, bilateral renal artery stenosis, or Cushing’s syndrome. Check Renin and Aldosterone levels:
    • Elevated Renin/Elevated Aldosterone –> bilateral renal artery stenosis
    • Low Renin, Elevated Aldosterone –> Conn’s syndrome
    • Low Renin, Low Aldosterone –> Consider Cushing’s syndrome as corticosteroids can still bind to mineralocorticoid receptors.
  • Treatment for Hypertensive emergency: Decrease of blood pressure 10-20% within the first hour. Then 5-15% for the next 23 hours. No more than 25% within the first 24 hours to prevent hypoperfusion.
  • Two exceptions are acute CVA and aortic dissection.
    • Acute CVA – no need to treat unless BP>185/110 with consideration of tPA, or BP>220/120
    • Aortic Dissection – Important to treat aggressively to goal SBP 100-120. Use beta blockers.
  •  Medications For Treatment
    • Nitroglycerin gtt, Nitroprusside (fast onset, short half life, risk factors for cyanide toxicity include AKI, increased infusion rate)
    • Beta Blockers – Labetalol or esmolol
    • Calcium Channel Blockers – Nicardipine

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