Severe Hypertension

Urgencies and Emergencies

Definition
BP >180/110 mmHg
(persistently elevated after 30
minutes bed rest)

Presentation
Asymptomatic
Non-specific: dizziness, headache etc.
Symptoms and sign of acute target organ
damage: acute coronary syndrome, acute heart
failure, stroke, acute renal failure, hypertensive
encephalopathy, dissecting aneurysm

Causes
MOST COMMON: Long standing poorly
controlled hypertension
Other causes:
Renal parenchymal disease
Systemic disease with renal involvement
Renovascular disease
Endocrine
Pre-eclampsia and Eclampsia
Drugs
Coarctation of Aorta

Our Role?
History (HTN and other causes)
Physical examination
Pulse: Rate, rhythm, delays
BP
Precordium: Location and character of apex beat,
Auscultate for heart sounds, breath sounds (bibasal
crepitation)
Abdomen: Palpation, auscultation for renal bruit
Fundoscopy
Others

Urgent investigations: depending on situation RBS,

ECG, urine dipstick etc.

Then, patients can be classified:

Asymptomatic severe hypertension

Hypertensive urgencies
Hypertensive emergencies

Hypertensive Urgencies
Grade III or IV retinal changes,
proteinuria +2 but no overt organ

failure

Management
May be admitted
Measurement of BP after 30 minutes of bed
rest
Aim of therapy: 25% of reduction of BP but no
less than 160/90 mm Hg in 24 hours
Mode of therapy: ORAL (usually
combination)

Oral treatment for HTN urgencies

Drug

Dose (mg)

Onset of
action
(hour)

Duration
(hour)

Frequency
(prn)

Captopril

25

0.5

1 2 hours

Nifedipine

10 20

0.5

35

1 2 hours

Labetalol

200 400

4 hours

Hypertensive Emergencies
Any patient with complications of severe
hypertension i.e. acute target organ
damage even if BP is less than 180/110 mm
Hg (BP risen rapidly).

Management
MUST BE ADMITTED
Aim of therapy: 25% of reduction of BP
depending on scenario but no less than 160/90
mm Hg in 3 12 hours
TAILORED THERAPY TO CAUSE
Mode of therapy: PARENTERAL

Treatment Options for HTN

Emergencies
Drug

Dose (mg)

Onset of
action

Duration

Remarks

Sodium
Nitroprusside

0.25 10
g/kg/min

Seconds

1 5 minutes

Caution in
renal failure

Labetalol

IV bolus 50
mg (over at
least 1
minute)
repeating if
necessary at 5
minute
intervals to a
max of 2
mg/min

< 5 minutes

3 6 hours

In pregnancy,
200 mg in 50
ml NS and
infusion at
4 ml/ hour.
Caution in
heart failure

Treatment Options for HTN

Emergencies (contd.)
Drug

Dose (mg)

Onset of
action

Duration

Remarks

Nitrates

5 100 g/
min

2 5 minutes

3 5 minutes

Preferred in
acute
coronary
syndromes
and acute
pulmonary
oedema

Treatment Options for HTN

Emergencies (contd.)
Drug
Hydralazine

Dose (mg)
IV 5 10 mg
maybe
repeated after
20 30
minutes
200-300
mcg/min
initially.
Maintenance
50 150
mcg/min

Onset of
action
10 20
minutes

Duration
3 8 hours

Remarks
Initial dose in
pregnancy is
25g/min IV
infusion (25 mg
in 500 ml NS at
30 ml/hour).
Caution in
acute coronary
syndromes,
CVA and
dissecting
aneurysm

Treatment Options for HTN

Emergencies (contd.)
Drug

Dose (mg)

Onset of
action

Nicardipine

IV bolus 10-30
mcg/kg
over 1 minute
210
mcg/kg/min

5 10 minutes

Esmolol

IV bolus 1 2
minutes
250500
mcg/kg over
1 minute
50200
mcg/kg/min for
4 minutes. May
repeat sequence

3 10 minutes

Duration
1 4 hours

Remarks
Caution in
acute heart
failure and
coronary
ischemia
Used in perioperative
situations and
tachyarrhytmia

Summary