Published on February 15, 2014
Hypertensive crisis Pratap Sagar Tiwari, MD, Internal Medicine, NGMC
HTN ….global issue Worldwide, noncommunicable diseases (NCDs) surpass CD as causes of death. 1 Nearly 2/3rd of the 57 mill deaths globally in 2008 were due to NCDs. 2 Of the NCD risk factors, the % of deaths attributable to HTN globally is the highest (13%).2 Ref: 1. World Health Organization. Disease and injury regional mortality estimates for 2008. Geneva: WHO, 2011. http://www.who.int/healthinfo/global_burden_disease/estimates_regional/en/index.html - acessed 9th feb 2014. 2. World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO, 2011. S02/21
HTN…Scenario in Nepal 1. In 2008, nearly 50% of total deaths in Nepal were estimated to be due to NCDs, and CVD accounted for 25% of these deaths. 1 Hypertension, one of the major RFs for CVD, was estimated to be present in 26.6/28.6 %(m/f) of Nepalese adults aged 25 yrs and above.1 Ref: World Health Organization. Global health observatory. th feb 2014. http://apps.who.int/gho/data/?theme=main# - accessed 9 S03/21 Geneva.
HTN…Scenario in Nepal Other studies, which were heterogeneous in design, showed variable results, with prevalence estimates ranging from 18.8% to 41.8% .(table) A study comparing the prevalence of hypertension in the same community in 1981 and 2006 reported a threefold increase in prevalence, confirming the trend of a dramatic increase in CVD risk factors in Nepal.1 Ref: 1. Vaidya A, Pathak RP, Pandey MR. Prevalence of hypertension in Nepalese community triples in 25 years: a repeat cross-sectional study in rural Kathmandu. Indian Heart J. 2012;64(2):128– S04/21 131.
References to the Prevalence table (5) Sharma SK, Ghimire A, Radhakrishnan J, Thapa L, Shrestha NR, Paudel N, et al. Prevalence of hypertension, obesity, diabetes, and metabolic syndrome in Nepal. Int J Hypertens. 2011;2011:821971. (6) World Health Organization, Society for Local Integrated Development Nepal, Ministry of Health, Nepal. Bagmati: STEPs noncommunicable disease risk factors survey 2003. Geneva, 2003. (7) Vaidya A, Pokharel PK, Karki P, Nagesh S. Exploring the iceberg of hypertension: a community based study in an eastern Nepal town. Kathmandu Univ Med J. 2007;5(3):349-359. (8) World Health Organization, Society for Local Integrated Development Nepal, Central Bureau of Statistics, Nepal, Government of Nepal. Nepal STEPS noncommunicable disease risk factors survey 2005. Geneva, 2005. (9) Sharma D, Bkc M, Rajbhandari S, Raut R, Baidya SG, Kafle PM. Study of prevalence, awareness,and control of hypertension in a suburban area of Kathmandu, Nepal. Indian Heart J. 2006;58(1):34–37. (10) Shrestha UK, Singh DL, Bhattarai MD. The prevalence of hypertension and diabetes defined by fasting and 2-h plasma glucose criteria in urban Nepal. Diabet Med. 2006;23(10): 1130–1135. (11) Vaidya A, Pathak RP, Pandey MR. Prevalence of hypertension in Nepalese community triples in 25 years: a repeat cross-sectional study in rural Kathmandu. Indian Heart J. 2012;64(2):128–131. (12) World Health Organization, Society for Local Integrated Development Nepal, Ministry of Health and Population, Government of Nepal. Noncommunicable disease risk factors survey 2007/2008: Nepal. Geneva, 2009. http://www.who.int/chp/steps/Nepal_2007_STEPS_Report.pdf - accessed 22 March 2013. (13) Chataut J, Adhikari RK, Sinha NP. The prevalence of and risk factors for hypertension in adults living in central development region of Nepal. Kathmandu Univ Med J. 2011;9(33):13–18. S06/21
HTN…Scenario in Nepal In 19811, only 4.8% of the HTN people were aware of their high BP status while almost 1/3rd (31.8%) of HTN in 20062 and 60 % were aware in 20113 . In 2006, BP was under control in 9.5% of the hypertensives. According to Statistical Fact Sheet 2013 Update from AHA In the United States, 1 out of every 3 adults have high BP and 47.5 % do not have it controlled and almost 50 % of death was attributable to high bp. Ref: 1. 2. 3. Pandey MR and Hypertension Study Group. Hypertension in Nepal—a Scientific Epidemiological Study. Mrigendra Medical Trust: Kathmandu 1983. Sharma D, Bkc M, Rajbhandari S, et al. Study of prevalence, awareness, and control of hypertension in a suburban area of Kathmandu, Nepal. Indian Heart J 2006;58:34–7. Chataut J, Adhikari RK, Sinha NP. The Prevalence of and Risk Factors for Hypertension in Adults Living in Central Development Region of Nepal. Kathmandu Univ Med J 2011;33(1)13-8. S07/21
Scenario A A 50 yrs old obese Male who is a chronic smoker comes to ER with c/o palpitation and headache. There is no H/o HTN in the past. O/E Bp is 210/120 mmhg. Acute severe Hypertension S08/21
Scenario B A 40 yrs old obese F was planned for Cholecystectomy . On PAC, Bp was 190/110 mmhg. Acc to pt, she was diagnosed previously as HTN but she noncompliant to drugs. Uncontrolled Hypertension S09/21
Scenario C A 40 yrs old M with a history of HTN and BPH had a recurrence of head and neck cancer. Two hours after undergoing a modified radical neck dissection and tracheostomy. BP was recorded to be 200/110 mmhg. Acute Postoperative Hypertension S10/21
Scenario D A 55 yrs old Male came to ER complaining of headache and blurring of vision . He is a known c/o HTN since 4 years and has been taking 3 different antihtn drugs that includes a diuretic. His bp was found to be 190/126mmhg. Accelerated hypertension S11/21
Scenario E A 55 yrs old Male went to other center with same compaints of headache and blurring of vision . He is a known c/o HTN since 4 years and has been taking 3 different antihtn drugs that includes a diuretic. His bp was found to be 190/126 mmhg. Pt is confused and hematuria is present. Malignant hypertension S12/21
Acute postop Hypertension Uncontrolled Hypertension Malignant Hypertension Accelerated Hypertension Hypertensive urgency Hypertensive emergency Acute severe Hypertension S13/21
Systolic BP >180 mmhg /or Diastolic BP>120 mmhg Hypertensive crisis End organ damage ???????? S14/21
End organ Damage Neurological Deficit (Htn encephalopathy, cerebral infarction/hemorrhage) Features of Acute LV Heart failure Coronory insufficiency Aortic Dissection Acute Kidney failure S15/21
Hypertensive Crisis >180/120 >180/120 S16/21 E O D Hypertensive Emergency Hypertensive Urgency
Terminologies..continue Malignant hypertension and accelerated hypertension are both hypertensive emergencies, with similar outcomes and therapies. In order to diagnose malignant hypertension, papilledema must be present.1 Note: Preexisting Essential HTN: Essential Malignant hypertension Preexisting Secondary HTN: Secondary Malignant hypertension Ref: 1. Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev. Mar-Apr 2010;18(2):102-7. S17/21
Terminologies..continue Acute elevations in blood pressure (>20 %) in the intraoperative period are typically considered hypertensive emergencies during surgery. 1 Postoperative hypertension is defined as systolic BP≥ 190 mmhg and/or diastolic BP ≥ 100 mmhg on 2 consecutive readings following surgery . 2,3 Ref: 1. GOldberg ME, Larijani Phasrmacotherapy, 18:911-14. 2. Plets C. 1989. Arterial hypertension in neurosurgical emergencies. Am J Cardiol, 63:40C42C. 3. Chonanian AV, Bakris GL, Black HR, et al. 2003b. The Seventh Report of the Joint National COmmittee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA,289:2560-72. S18/21 GE. 1998. Perioperative hypertension.
Terminologies..continue Acute onset, persistent (lasting ≥15 min), severe systolic (≥ 160 mmhg) or severe diastolic hypertension (≥ 110 mmhg) or both in pregnant or postpartum women with preeclampsia constitutes a hypertensive emergency 1,2,3 Major risk factors : H/o HTn for atleast 4 yrs, h/o htn in previous pregnancy and Renal insufficiency Ref: 1. Diagnosis, evaluation and management of the hypertensive disorders of pregnancy. SOGC Clinical Practice Guideline No. 206. Society of Obstetricians and Gynaecologists of Canada. J Obstet Gynaecol Can 2008;30(Suppl 1):S1-S48. 2. COnfidential Enquiries into Maternal Deaths. why mothers die 1997-1999. The fifth report of the COnfidential Enquiries into Maternal Deaths in the United Kingdom. London (UK): RCOG Press;2001. 3. Emergent Therapy for Acute onset, Severe Hypertension with Preeclampsia or Eclampsia. Committee opinion. The American College of Obstetricians and Gynaecologists. December 2011. S19/21
Causes of hypertensive emergencies Essential hypertension Renal disease: Acute GN, Vasculitis, HUS, TTP, RAS Pregnancy: Eclampsia Endocrine: Pheochromocytoma, Cushing’s syndrome Drugs: Cocaine, sympathomimmetics, erythropoietin, cyclos porin, antihypertensive withdrawal, Interactions with monoamine-oxidase inhibitors, amphetamines, lead intoxication Others: Head injury, cerebral S20/21 infarction/hemorrhage, brain tumors
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