Case Presentation

Earlier this block, Laura Rodger (PGY-4 in GIM) led Morning Report. She presented a case of an elderly patient with hypertensive emergency. Thank you to Laura for the content below!

Outline

1. Introduction to Hypertension
2. Hypertensive Emergency vs. Urgency
3. Approach to Hypertensive Emergency
4. Differential Diagnosis, Physical Exam and Investigations in Hypertensive Emergency
5. Management of Hypertensive Emergency
6. CHEP 2018 Hypertension Guidelines
7. Investigations in a New Diagnosis of Hypertension
8. Pharmacologic and Non-pharmacologic Management
9. Treatment of Hypertension in Elderly Patients

Introduction to Hypertension

Hypertensive Urgency vs. Emergency

• Hypertensive emergency: severe hypertension (SBP > 220 AND/OR DBP > 120mmHg) with end organ damage,
  • Pulmonary edema, aortic dissection, myocardial infarction, cerebrovascular hemorrhage, papilledema, fundoscopic hemorrhage, acute renal failure, eclampsia, hypertensive encephalopathy
• Hypertensive urgency: severe hypertension (SBP > 220 AND/OR DBP > 120mmHg) without symptoms or decompensation

Approach to Hypertensive Emergency

• Initially:
  • ABCs
    • Bilateral blood pressure readings
  • Monitoring
  • Oxygen prn
• Concurrently investigate and manage:
  • Focused history, physical exam and investigations, keeping a broad differential diagnosis in mind

Differential Diagnosis

• Vascular: CVA (thrombotic vs ICH), dissection, essential hypertension
• Ischemia: CVA, acute coronary syndrome
• Neoplasia: pheochromocytoma
• Drugs: NMS or serotonin syndrome, NSAIDs, rebound effect
• Infection: – uncommon
• Congenital: – uncommon
• Autoimmune: vasculitis (large or medium vessel >> small), scleroderma
• Toxins: amphetamine or stimulant use, alcohol, withdrawal (See Table S6 below)
• Endocrine: thyroid storm, pheochromocytoma

Physical Exam

• CNS: mental status, focal neurologic deficits
• HEENT: fundoscopy for hypertensive retinopathy, carotid bruits, JVP
• Consider thyroid exam
• CVS: heart sounds, murmurs, precordial exam
• RESP: pulmonary edema
• ABDO: abdominal bruits, palpation of the abdominal aorta
• PERIPHERAL: signs of peripheral vascular disease, peripheral pulses, edema

Investigations

• Bloodwork:
  • CBC+D (do you want a peripheral film?)
  • Electrolytes (including extended lytes + albumin), urea, creatinine
  • Liver enzymes
  • TnT +/- CK
  • TSH
  • “Unstable patient labs”: INR, PTT, lactate +/- ABG
  • ?tox screen
• Imaging:
  • CXR
  • ECG

Management of Hypertensive Emergency

• Initial management:
  • Blood pressure control: no more than 25% reduction in the first 24 hours
  • Medications: in true emergencies intravenous is preferred
  • Nitrates: nitroprusside or nitroglycerin
  • Calcium channel blockers: nicardipine
  • Beta blockers: labetalol, esmolol
  • Other:
    • Enalaprilat
    • Hydralazine
    • Alpha blockers
• Special populations:
  • Stimulant (cocaine associated): avoid beta blockers
  • Pregnant: labetalol, hydralazine
  • Scleroderma renal crisis:ACE inhibitors

Prior to Discharge

• What do you need to consider before discharge?
  • Choice and intensity of antihypertensive treatment
  • Secondary workup
  • Age of patient (in our case she was elderly!)

CHEP 2018 Hypertension Guidelines

• You diagnose hypertension and appropriately manage your patient for their hypertensive emergency… then what?
• Must consider causes and consequences!
• Treat hypertension in terms of pharmacologic therapy and risk factor modification = lifestyle aka “non-pharmacologic” aka “Healthy Behaviour Modification”

Investigations in a New Diagnosis of Hypertension

• Routine labs to order:
  • Urinalysis (and if diabetes, ACR) electrolytes, renal function FBG and HbA1c lipid profile EKG (no routine Echo!)
• Consider work up for secondary causess of hypertension: For further details check out https://wchcmr.org/2019/08/04/case-of-the-week-a-curious-case-of-hypertension/
• Assess global cardiovascular risk (e.g., Framingham)
  • non-modifiable risk factors: age > 55, male, +FHx
  • modifiable risk factors: sedentary, diet, obese, lipids, diabetes, smoking, stress, non-adherence

Pharmacologic Managment

• See https://guidelines.hypertension.ca/prevention-treatment/ for full details:
• Indications for drug therapy for adults with diastolic and/or systolic hypertension
  • Initial therapy should be with either monotherapy or a single pill combination (SPC)
• Recommended monotherapy choices are:
  • a thiazide/thiazide-like diuretic (Grade A), with longer-acting diuretics preferred (Grade B)
  • a β-blocker (in patients younger than 60 years; Grade B),
  • an angiotensin converting enzyme (ACE) inhibitor (in non-black patients; Grade B),
  • an angiotensin receptor blocker (ARB) (Grade B), or
  • a long-acting calcium channel blocker (CCB) (Grade B).

• Recommended SPC choices are those in which an ACE inhibitor is combined with a CCB (Grade A), ARB with a CCB (Grade B), or ACE inhibitor or ARB with a diuretic (Grade B).
• Additional antihypertensive drugs should be used if target BP levels are not achieved with standard-dose monotherapy (Grade B).
• Add-on drugs should be chosen from first-line choices.
• Useful choices include a thiazide/thiazide-like diuretic or CCB with either: ACE inhibitor, ARB or β-blocker (Grade B for the combination of thiazide/thiazide-like diuretic and a dihydropyridine CCB; Grade C for the combination of dihydropyridine CCB and ACE inhibitor; and Grade D for all other combinations).
  • Caution should be exercised in combining a non-dihydropyridine CCB and a β-blocker (Grade D).
  • The combination of an ACE inhibitor and an ARB is not recommended (Grade A)

Non-Pharmacologic Management

• Physical Exercise
  • Prescribe 30-60 minutes of moderate intensity dynamic exercise (e.g., walking, jogging, cycling, or swimming) 4-7 days per week
• Weight Reduction (calculate a BMI!)
  • Maintain a healthy BMI (18.5-24.9) Waist circumference M <102cm F < 88cm
• Alcohol Consumption
  • <2 standard drinks per day and less than 14/week (men) and less than 9/week (women)
• Diet
  • Emphasize fruit, vegetables, low-fat dairy, whole grain, protein from plant sources DASH diet
• Sodium
  • Reduce sodium intake to 2000mg per day
• Potassium intake
  • In patients not at risk of hyperkalemia, increase dietary potassium intake to reduce BP
• Stress management
  • In hypertensive patients in whom stress might be a contributor to high BP, stress management should be considered as an interventionCBT interventions are more effective when relaxation techniques are used

Treatment of Hypertension in Elderly Patients

• CHEP recommends “High Risk” adult patients may be candidates for a SBP target of >120mmHg if they meet one or more of the following
  • Clinical or sub-clinical cardiovascular disease
  • CKD (non-diabetic nephropathy, proteinuria <1g/d, GFR 20-59) Estimated 10 year global cardiovascular risk >15%
  • Age ≥ 75 years old

• Some Key Principles
  • Treat the individual – do not treat a number
  • Consider frailty and comorbidities
  • Always do postural vital signs before up-titrating or initiating new antihypertensives
  • New evidence suggests we may be too aggressive in hospital:
    • Anderson et al. 2018:
    • Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days