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Management of hypertension and hypertensive emergencies
- 1. Management of Hypertension and HypertensiveEmergencies Presenter: Ngabirano Derek MBChB, MakCHS-Uganda
- 2. Definition • Hypertension: Persistentlyhigh resting BP (>140/90 mmHg for at least two measurements five minutes apart with patient seated) on at least 2 or 3 occasions 1 week apart (UCG, 2016).
- 3. Epidemiology of Hypertension •Hypertension is the major cause of premature deaths world wide. • An estimated 1.28 billion adults aged 30-79 years worldwide have hypertension, most (2/3) living in LMICs. • 46% of these are unaware and < 1/2 (42%) are diagnosed and treated. • Approx. 1 in 5 adults (21%) with HTN have it under control (WHO, 2021) • In Uganda, overall prevalence was 26.4%, highest in the central region at 28.5%, followed by the eastern (26.4%), western (26.3%) and northern (23.3%). • Prevalence in urban areas was 28.9%, and 25.8% in rural areas. The differences between regions, and between rural-urban areas were not statistically significant. (David Guwatudde et al, 2015)
- 4. Risk factors Modifiable • Obesity(BMI>=30) • Excess salt intake • Excess Alcohol consumption • Smoking • Stress • Lack of physical activity • Low socio-economic status Non-Modifiable • Age (increases with age) • Gender (More in men in early life, more in women after 60 yrs) • Genetic (Family history) • Ethnicity (increased risk in blacks and Africans)
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- 6. Pathophysiology cont. Source: Adoptedfrom Robbins & Cotran Pathologic basis of Disease , 20th edition (2021)
- 7. Types of hypertension •Primary (Essential) hypertension (80-95%); in which the cause is unknown. May develop as a result of environmental or genetic causes. • Secondary hypertension (5-20%); which has multiple etiologies including renal, vascular, and endocrine causes. Other Types • White coat hypertension; BP that is consistently elevated by office readings but doesn’t meet diagnostic criteria based upon out-of-office readings. • Masked hypertension; BP that is consistently elevated by out-of-office measurements but doesn’t meet the criteria for hypertension based upon office readings. • Isolated systolic hypertension; (systolic ≥140, diastolic <90) most common in elderly patients, due to reduced vascular compliance (Arteriosclerosis)
- 8. Causes of secondaryhypertension Category Causes Renal Parenchymal diseases, renal cysts (including polycystic kidney disease), renal tumors (including renin-secreting tumors), ostructive uropathy Renovascular Arteriosclerosis (elderly), fibromuscular dysplasia (young) Adrenal Primary aldosteronism, Cushing’s syndrome, 17α-hydroxylase deficiency, 11β-hydroxylase deficiency, 11-hydroxysteroid dehydrogenase deficiency (licorice), pheochromocytoma Neurogenic Psychogenic, diencephalic syndrome, familial dysautonomia, polyneuritis (acute porphyria, lead poisoning), acute increased intracranial pressure, acute spinal cord section Miscellaneous Endocrine Hypothyroidism, hyperthyroidism, hypercalcemia, acromegaly Medications High-dose estrogens, adrenal steroids, decongestants, appetite suppressants, cyclosporine, tricyclic antidepressants, monoamine oxidase inhibitors, erythropoietin, nonsteroidal anti-inflammatory agents, cocaine Aortic coarctation causes systolic hypertension in the upper part of the body due to constriction itself Source: Adopted from Harrison’s principles of Internal Medicine 20th edition (2018)
- 9. Stages of hypertension BPCategory Systolic BP (mmHg) Diastolic BP (mmHg) Normal <120 <80 Prehypertension 120 - 139 80 - 89 Stage 1 140 - 159 90 - 99 Stage 2 160 - 179 100 - 109 Stage 3 ≥ 180 ≥ 110
- 10. Approach to thepatient History: • Most patients are asymptomatic. Severe hypertension may lead to headache, dizziness, or blurred vision. • Clues to specific forms of secondary hypertension: – Use of medications (e.g. birth control pills, glucocorticoids, decongestants, erythropoietin, NSAIDs, cyclosporine); – paroxysms of headache, sweating, or tachycardia (Pheochromocytoma); – history of renal disease or abdominal trauma (renal hypertension); – daytime somnolence and snoring (sleep apnea)
- 11. Approach cont. Physical examination: •Measure BP with appropriate-sized cuff (large cuff for large arm). • Measure BP in both arms as well as a leg (to evaluate for aortic coarctation). • Signs of hypertension include retinal arteriolar changes (narrowing/nicking); left ventricular lift, loud A2 • Clues to secondary forms of hypertension include cushingoid appearance, thyromegaly, abdominal bruit (renal artery stenosis), delayed femoral pulses (coarctation of aorta).
- 12. Investigations • Urinalysis forblood, protein and glucose • Blood urea, electrolytes and creatinine • Random Blood Sugar • Serum total and high-density lipoprotein (HDL) cholesterol • Thyroid function tests; TSH • 12-lead ECG (left ventricular hypertrophy, coronary artery disease) • Ambulatory BP recording: to assess borderline or ‘white coat’ hypertension
- 13. Evaluation of secondaryhypertension causes Suspected Dx Clinical clues Diagnostic Testing Primary aldosteronism Drug-resistant hypertension, hypertensive heart disease (left ventricular hypertrophy, atrial fibrillation), hypokalemia, incidentally discovered adrenal mass Plasma renin and serum aldosterone; 24-hour urine aldosterone after oral salt loading; adrenal vein sampling Chronic kidney disease Estimated GFR <60 mL/min/1.73 m2 Urine albumin-to-creatinine ratio ≥30 mg/g, Renal sonography Renovascular disease New elevation in serum creatinine; marked elevation in serum creatinine with ACE inhibitor or ARB; drug-resistant hypertension, flash pulmonary edema, abdominal or flank bruit Renal duplex Doppler sonography; CT or MR angiography; invasive angiography Coarctation of the aorta Arm pulses > leg pulses, arm BP > leg BP, chest bruits, rib notching on chest radiography MR angiography; TEE (transesophageal echo); invasive angiography Cushing syndrome Incidental adrenal mass, truncal obesity, wide and blanching purple striae, muscle weakness 1 mg dexamethasone- suppression test; urinary cortisol after dexamethasone; adrenal CT Pheochromocytoma Incidental adrenal mass; paroxysms of hypertension, palpitations, perspiration, and pallor; diabetes Plasma metanephrines; 24-hour urinary metanephrines and catecholamines; abdominal CT or MR imaging Source: Adopted from Goldman-Cecil Medicine, 26th edition (2020)
- 14. Management Kiruddu National ReferralHospital , Harmonized Guideline, Treatment-Flow Charts (2020)
- 15. Kiruddu National ReferralHospital , Harmonized Guideline, Treatment-Flow Charts (2020)
- 16. Lifestyle modification Diet • Adopta diet that is: – High in vegetables, nuts, fruits, grains, low-fat dairy products, fish, poultry, etc. – Low in sweets, sugar-sweetened beverages, and red meats • Restricting salt intake Physical Activity • Engage in three to four 40-minute sessions of moderate-to-intense aerobic physical activity per week. Others • Reducing alcohol intake • Stopping smoking
- 17. Drug Class Modeof action Side Effects Diuretics Thiazides: Indapamide Chlorthalidone Metolazone Hydrochlorothiazide Block Na+-Cl− cotransporter in the distal convoluted tubule Insulin resistance, hyperglycemia, Hypokalemia, hyponatremia, Hypertriglyceridemia, Hyperuricemia, precipitation of gout, Photosensitivity dermatitis Loop diuretics: Furosemide, Torsemide Block Na+-K+-2Cl− transport in the thick ascending loop of Henle Interstitial nephritis, Hypokalemia, hyperuricemia Potassium-sparing Diuretics: Spironolactone, Eplerenone Prevent circulating Aldosterone from activating the receptor in the distal nephron Hyperkalemia, Spironolactone (gynecomastia, Erectile dysfunction, nonmenstrual bleeding) ACE inhibitors: Captopril, Enalapril, Lisinopril, Benazepril block conversion of the angiotensin I (AT1) to angiotensin 2 (AT2) Cough, Hyperkalemia, Angioedema, Leukopenia, Fetal toxicity, Cholestatic jaundice Source: Adopted from Goldman-Cecil Medicine, 26th edition (2020) Antihypertensive Drugs
- 18. Drug Class Modeof action Side Effects Dihydropyridines CCBs: Amlodipine, Nifedipine Block the opening of voltage-gated (L-type) Ca2+ channels in cardiac myocytes and vascular smooth muscle cells. They lower blood pressure by causing peripheral arterial dilation Headache, Flushing, Ankle edema, Heart failure, Gingival hyperplasia, Esophageal reflux AV block (especially with verapamil), Constipation (often severe with verapamil),Bradycardia, heart failure, Gingival edema or hypertrophy, Esophageal reflux Nondihydropyridine CCBs: Verapamil, Diltiazem ARBs Lorsatan, Valsartan block the action of AT2 on the type 1 angiotensin receptor. Angioedema (very rare) Hyperkalemia , Fetal toxicity β-Adrenergic blockers: Atenolol, bisoprol(β1 selective), Propranolol(non- selective), carvedilol, Labetalol (combined α and β), nebivolol β-blockade involves decreases in cardiac output (β1- receptors), renin release (β1-receptors), and norepinephrine release (prejunctional β2-receptors). Vasodilating β-blockers, Nebivolol stimulates endogenous production of NO New-onset type 2 diabetes (especially in combination with a thiazide), Heart block, acute decompensated heart failure Depression, Bronchospasm nightmares, fatigue, Cold extremities, claudication (β2 effect), SJS, Agranulocytosis Source: Adopted from Goldman-Cecil Medicine, 26th edition (2020)
- 19. Drug Class Modeof Action Side Effects α-Adrenergic blockers: Doxazosin, Prazosin, Terazosin, IV phentolamine (α1 selective) Phenoxybenzamine (α1 & α2) Block the interaction of norepinephrine on vascular α-adrenergic receptors, causing peripheral vasodilation, thereby lowering blood pressure. Orthostatic hypotension, Drug tolerance (in the absence of diuretic therapy), Ankle edema, Heart failure, First-dose effect (acute hypotension) Central sympatholytics: Clonidine, Methyldopa, Reserpine, Guanabenz, Guanfacine Reduce adrenergic drive to the heart and peripheral circulation. Stimulation of postsynaptic α2-receptors and imidazoline receptors in the CNS, and presynaptic α2-receptors Depression, dry mouth, lethargy, Erectile dysfunction (dose dependent), Rebound hypertension with clonidine withdrawal, Coombs test–positive hemolytic anemia and elevated liver enzymes with α-methyldopa Direct vasodilators: Hydralazine, Minoxidil Act by opening vascular ATP-sensitive K+ channels. Reflex tachycardia, Fluid retention, Hirsutism, pericardial effusion with minoxidil, Lupus with hydralazine Source: Adopted from Goldman-Cecil Medicine, 26th edition (2020)
- 20. Pharmacotherapy • First-Line Drugs:Recent practice guidelines recommend initiating drug treatment with one or more of three classes of first-line drugs, which have additive or synergistic effects when used in combination: – (1) calcium-channel blockers, – (2) renin-angiotensin system blockers—either ACE inhibitors or ARBs, – (3) thiazide type diuretics • Combination therapy e.g. Lorsatan / hydrochlorothiazide(HCTZ), Enalapril /HCTZ, Amlodipine/benazepril, Atenolol/chlorthalidone, Bisoprolol/HCTZ
- 21. Source: Adopted fromDavidson’s Principles and Practice of Medicine (2018)
- 22. Hypertensive urgency • Severehypertension (systolic ≥ 180 and diastolic BP≥ 120) but not associated with end organ injury. Hypertensive emergency • Severe hypertension (systolic ≥ 180 and diastolic BP≥ 120) and associated with acute end organ injury.
- 23. End organ Damage •Brain: hypertensive encephalopathy, cerebrovascular accident/ cerebral infarction, intracranial hemorrhage • Eyes: retinopathy, retinal detachment • Heart: Acute coronary syndrome, aortic dissection, acute left ventricular dysfunction • Lungs: Acute Pulmonary edema • Kidney: AKI ( nephropathy) • Liver: HELLP syndrome in the setting Eclampsia/preeclampsia • Placenta: abruptio placenta
- 24. Pathophysiology of hypertensiveemergency • Mechanical stress on the vascular walls is likely to lead to endothelial damage and a proinflammatory response (vasculitis). • This results in increased vascular permeability, platelet and coagulation cascade activation, and fibrin clot deposition leads to hypoperfusion at the level of the target organ. • Encephalopathy is related to failure of autoregulation of cerebral blood flow at the upper pressure limit, resulting in vasodilation and hyperperfusion. • Fibrinoid necrosis has been observed in arterioles of kidney, brain, retina, and other organs.
- 25. Management cont. Kiruddu NationalReferral Hospital , Harmonized Guideline, Treatment-Flow Charts (2020)
- 26. Management cont. Emergency Situation(rare) Kiruddu National Referral Hospital , Harmonized Guideline, Treatment-Flow Charts (2020)
- 27. Recommended Treatment ofhypertensive emergencies Type of Emergency First-Line Therapy Alternative Therapy Hypertensive crisis with retinopathy, microangiopathy, or acute renal insufficiency Labetalol Nitroprusside Nicardipine Urapidil Hypertensive encephalopathy Labetalol Nicardipine, Nitroprusside Acute aortic dissection Nitroprusside plus metoprolol Labetalol Acute pulmonary edema Nitroprusside with loop diuretic Nitroglycerine Urapidil with loop diuretic Acute coronary syndrome Nitroglycerine Labetalol Acute ischemic stroke Labetalol Nicardipine, Nitroprusside Cocaine intoxication Phentolamine (after benzodiazepines) Nitroprusside Pheochromocytoma crisis Phentolamine Nitroprusside, Urapidil Severe preeclampsia /eclampsia Labetalol (plus MgSO4 and oral antihypertensive medication such as nifedipine with or without methyldopa) Ketanserin Nicardipine Source: Adopted from Goldman-Cecil Medicine, 26th edition (2020)
- 28. Prognosis • Prognosis isrelated both to the duration and severity of the blood pressure elevation and the presence of additional cardiovascular risk factors. • Under treatment of hypertension and underuse of combination drug therapy worsen outcomes • Pharmacist-based team management protocols with fixed-dose/once-daily combination pills, proactive follow-up, and access to walk-in blood pressure checks can improve hypertension control rates to 80% or higher. • Patients with drug resistant hypertension should be referred to a hypertension specialist.
- 29. Prevention • Regular physicalexercise • Reduce salt intake • Healthy diet • Stop smoking • Reduce alcohol intake • Periodic screening of BP
- 30. References • Robbins &Cotran Pathologic basis of Disease , 20th edition (2021) • Goldman-Cecil Medicine, 26th edition (2020) • Kiruddu National Referral Hospital , Harmonized Guideline, Treatment- Flow Charts (2020) • Davidson’s Principles and Practice of Medicine, 23rd edition (2018) • Harrison’s principles of Internal Medicine,20th edition (2018) • UpToDate: Hypertension • Medscape: Hypertension • Uganda Clinical Guidelines (2016)