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Hypertension ED Management Update. Todd Berger, MD Program Director, EM Residency Associate Professor, UT Southwestern AusAn

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Hypertension ED Management Update Todd Berger, MD Program Director, EM Residency Associate Professor, UT Southwestern AusAn ObjecAves Explain classificaaon of hypertension according to JNC- 8 Define Hypertensive
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Hypertension ED Management Update Todd Berger, MD Program Director, EM Residency Associate Professor, UT Southwestern AusAn ObjecAves Explain classificaaon of hypertension according to JNC- 8 Define Hypertensive Emergency Discuss end organ damage related to hypertension Discuss treatment of hypertensive emergency Discuss treatment of asymptomaac severe hypertension in the ED Up to 25% of ED Visits 1% of HTN pts will have a HTN Emergency Epidemiology the who gives a slide Prevalence 30% (68M in U.S) 350K Deaths and $131B Health Costs per year 75% of HTN pts know they have HTN 50% are not treated adequately 50% reducaon in CVA mortality when Tx JNC Evidence- Based Guideline for the Management of High Blood Pressure in Adults. Report From the Panel Members Appointed to the Eighth Joint NaFonal CommiHee (JNC 8) JAMA. Dec (epub ahead of print) Sources: ACCORD- BP, HYVET, Syst- Eur, SHEP, JATOS, VALISH, CARDIO- SIS, Delphi, JATOS, MRC, HOT, REIN- 2, AASK, ADVANCE, IPPPSH, LIFE, ALLHAT, ONTARGET, ESH/ESC, CHEP, KDIGO, RENAAL, AHA/ACC JNC 7 The Seventh Report of the Joint NaFonal CommiHee on PrevenFon, DetecFon, EvaluaFon, and Treatment of High Blood Pressure (JNC 7) Hypertension :1206. Sources: ACA/AHA, MERIT HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, valheft, RALES, BHAT, SAVE, Capricorn, EPHESUS, ALLHAT, HOPE, ANBP2, LIFE, CONVINCE, NKF- ADA, UKPDS, Captopril, RENAAL, IDNT, REIN, AASK, PROGRESS Your paaent 67 y.o. referred from their PCP for elevated BP. Told, Go directly to the ED! Pt has no c/o. PMHx: HTN Meds: HCTZ, Lisinopril (out x 3 days) ROS: NegaAve PE: BP 240/120, o/w unremarkable Does this paaent have? o Hypertensive Emergency? o Hypertensive Urgency? o Uncontrolled/Poorly Controlled Hypertension? Your paaent 67 y.o. referred from PCP for elevated BP. Told, Go directly to the ED! Pt is c/o HA, worst of his life, occipital, radiaang to neck. No prior HA. PMHx: HTN Meds: HCTZ, Lisinopril (out x 3 days) ROS: as above, o/w negaave PE: BP 240/120 Neuro: A+Ox3, but becoming more somnolent o/w nonfocal Rest of PE unremarkable Does this paaent have? o Hypertensive Emergency? o Hypertensive Urgency? o Uncontrolled/Poorly Controlled Hypertension? What is Hypertensive Emergency? Elevated BP Acute End Organ Damage What is Hypertensive Emergency? What number??? Hypertensive Emergency? BP 240/120 Worst H/A of life Decreasing MentaAon Hypertensive Emergency? BP 200/100 Crushing Chest Pain RadiaAon to Lep Arm Hypertensive Emergency? BP 160/90 Tearing Chest Pain RadiaAon to Lep Shoulder Unequal Pulses Hypertensive Emergency? BP 120/80 38 weeks pregnant (baseline 90/60) Seizing Rate of Rise What is Hypertensive Urgency? Diastolic above 110 No Sign of Acute End Organ Damage Diastolic BP? 109 111 Elevated BP Acute End Organ Damage No Yes Uncontrolled/ Poorly Controlled Hypertension Hypertensive Emergency Hypertensive Emergency aka Hypertensive Crisis! Malignant Hypertension Accelerated Hypertension Go to the ED Hypertension Hypertensive Emergency A Series of Diseases A Common Symptom Hypertensive Emergency Treatment Specific to that Disease impacts M&M Titratable Goal: ReducAon in BP by 20-25% (minutes to hours) ExcepAons: Pediatrics Pregnancy AorAc Disasters! Hypertensive Emergency Hypertensive Encephalopathy Hypertensive ReAnopathy Hemorrhagic CVA Ischemic CVA Acute Tx lower BP but keep DBP Nitroprusside Fenoldopam, Labetolol, Nicardipine Hypertensive Emergency Hypertensive Encephalopathy autoregulaaon Ischemia Edema Punctate Hemorrhage Sx: H/A, n/v, AMS, visual changes PE: non- anatomic focal deficits papilledema, reanal hemorrhage, covon wool spots Hypertensive Emergency Hemorrhagic CVA Ischemic CVA* Acute Chronic Labetolol DiureAc Nisoldipine ACE Inhibitor Nicardipine Nitroprusside *only if using TPA: 185/110 Hypertensive Emergency Acute MI Unstable Angina Acute Pulmonary Edema Hypertensive Emergency Acute MI Unstable Angina Acute Chronic Nitroglycerin Beta Blocker Beta Blocker NTG ACE I Hypertensive Emergency Acute Pulmonary Edema Acute Chronic Nitroglycerin ACE Inhibitor Enalapril DiureAc Furosemide Beta Blocker Nitroprusside Hypertensive Emergency AorAc DissecAon Ruptured AorAc Aneurysm Hypertensive Emergency AorAc DissecAon Acute Nitroprusside Esmolol Labetolol Goal=SBP 100 if tolerated Hypertensive Emergency Ruptured AorAc Aneurysm Acute O.R. No Meds, even if BP Hypertensive Emergency Acute Renal Failure Acute Fenoldopam, Calcium Ch blocker, Nitroprusside Chronic ACE Inhibitor*, DiureAc, CCI *check for hyperkalemia Hypertensive Emergency Ecclampsia/Preeclampsia Acute Magnesium Labetolol Nicardipine Hydralazine Uncontrolled/Poorly Controlled Hypertension AsymptomaAc or Non- Specific Do I need to work them up? No (if BP 200/110) Do I need to treat them? Not in the ED Refer for Follow Up Clonidine Uncontrolled/Poorly Controlled Hypertension ClassificaFon Systolic Diastolic Treatment Age 60yo, DM, CKD 140* 90 Start Treatment Age 60yo Start Treatment ClassificaFon Non- Black Black CKD Treatment Thiazide, CCB, ACE, ARB Thiazide, (CCB) ACE, ARB HCTZ = first line (can max out and/or add another Rx) ACE Inhibitor = CKD, (DM), Lep Ventricle failure Ca Ch Blocker = elderly with isolated systolic HTN Beta Blocker = Hx of MI with intact LV funcaon, but not protecave against CVA *Class E expert opinion, not c/w Cochrane Study What if? AsymptomaAc Hypertension LVH on ECG Discharge Home Consider ACEI, Beta Blocker What if? AsymptomaAc Hypertension Elevated CreaAnine Check Chart Is this Baseline? Keep for a Repeat CreaAnine (obs, inpt) 90 Pi{alls Pain Anxiety à Observe Improper Cuff Size Secondary Causes of Hypertension Renal Artery Stenosis Pheochromocytoma (Phentolamine, Nitroprusside + Esmolol, Labetolol) GlucocorAcoid Excess Steroid Use ACTH SecreAng Tumors (Pituitary, etc) Adrenal CorAcal Tumors Thyroid (Storm, Hypo) and Parathyroid Disease (Ca,BP ) Sleep Apnea Tyramine in Foods and Drugs (eg MAOI)à Phentolamine Withdrawal from Beta Blocker or Clonidine Alcohol Withdrawal In Summary Hypertensive Emergency = Acute End Organ Damage Treat Titratable Agent (over minutes to hours) Lower BP by 20-25% (except aorta, peds, OB) Choose an agent that lowers M&M for the affected end organ BP 200/110 = Evaluate for Acute End Organ Damage No Acute End Organ Damage = No ED Tx (Refer for f/u) Hypertensive Urgency Final Exam QuesAon What Movie?
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