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HYPERTENSIVE EMERGENCIES:
DECEMBER 2008
volume 3
Dear Colleagues:
Hypertension remains one of the most common disease processes
in patients presenting to the Emergency Department (ED). While
sometimes symptomatic and associated with end organ damage
such as hypertensive encephalopathy, hemorrhagic stroke, acute
coronary syndrome, heart failure, and renal insufficiency, many
patients present without symptoms. Emergency physicians and
hospitalists should understand the appropriate classification
of patients with hypertension, the pathophysiology of this
disease process, and appropriate treatment strategies. In this
EMCREG-International Newsletter, Charles V. Pollack, Jr. MD
and Christopher J. Rees, MD of Pennsylvania Hospital and the
University of Pennsylvania discuss hypertension and parenteral
medications used for treatment of these patients in the ED, including
the Velocity trial. This paper serves as a companion to the
EMCREG-International Hypertension Consensus Panel publication,
a supplement to the March 2008 Annals of Emergency Medicine,
as well as the EMCREG-International Newsletter published earlier
this year by Drs. Judd Hollander and Anna Marie Chang.
Through collaboration with colleagues from a variety of specialties,
patients with hypertension can receive optimal therapy when
presenting to an acute care setting such as the ED. For patients
receiving parenteral therapy, the natural transition of the patient
with hypertensive emergency through the ED to the intensive care
unit or step-down bed involves careful collaboration between the
emergency physician and hospitalist. It is our hope you will find
this EMCREG-International Newsletter helpful in the care of your
patients with hypertension.
Sincerely,
Objectives:
1. Describe the distinctions among hypertensive crisis, urgency,
and emergency
2. Discuss the general approach to acute severe hypertension in the ED
3. Explain the limitations of typically used parenteral
antihypertensive agents in the ED
4. Summarize the potential role of clevidipine in ED management
of hypertensive emergency
Introduction
Hypertension is an extremely common
illness, affecting 50 to 75 million people
in the US, many of whom are unaware that
they even have hypertension.1-3 It is the
most common primary medical diagnosis
in the US.4 Familiarity does not, however,
equate to treatment success; some twothirds of hypertensive patients fail to
achieve adequate control of their blood
pressure (BP).2,3 Poor BP control often
prompts emergency department (ED) visits.
At some point in their lives, 1% of patients
with hypertension will have a hypertensive
emergency, defined as severely elevated
blood pressure associated with target
organ dysfunction.1,2,5
Meanwhile, about 5% of ED patients
have at least one BP reading that is
severely elevated, although most do
Andra L. Blomkalns, MD
Director of CME,
EMCREG-International
W. Brian Gibler, MD
President,
EMCREG-International
About 5% of ED
patients have at least
one blood pressure (BP)
reading that is severely
elevated, although
most do not have a
hypertensive emergency.
Hypertensive Emergencies:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3
Definitions
The JNC 7 describes hypertension using a baseline BP of
115/75 mm Hg, reporting that the risk of cardiovascular
disease (CVD) doubles with each incremental increase
of 20/10 mm Hg. JNC 7 defines blood pressure and
hypertension categories as follows:
Normal:
Pre-hypertension:
Hypertension: Stage 1:
Hypertension: Stage 2:
<120/80 mm Hg
120-139/80-89 mm Hg
140-159/90-99 mm Hg
> 160/100 mm Hg
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and
Education Group
Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research
and
Education Group
Page 3
Hypertensive Emergencies:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3
and
It must be remembered
that hypertensive
emergency is a clinical
diagnosis, and that
the clinical state of the
patient is more important
than the absolute value of
the blood pressure.
Page 4
According to the JNC 7 report, the immediate goal for treating hypertensive emergency
is to reduce the SBP by 10-15%, but by no more than 25%, within the first hour and if
the patient is then stable, to 160/100-110 mm Hg over the ensuing 2-6 hours.4 Aortic
dissection is a special situation which requires reduction of the SBP to at least 120
mm Hg within 20 minutes, with commensurate protection against reflex tachycardia.4
Hypertensive emergency is a clinical diagnosis and the clinical state of the patient is
more important than the absolute value of the BP.
Because of autoregulation, a too rapid reduction in BP can lead to worsening tissue
perfusion with ischemia and possible infarction. There are many agents used for treating
acute severe elevations of BP, and despite having been used for years, most are not ideal
across the broad range of comorbidities seen in an ED population. Parenteral agents
used for the treatment of HE fall into several classes, as shown in Table 2. There are few
clinical trials or comparative studies to help guide the choice among drugs. Instead this
decision is based upon physician and institutional preference and policies, underlying
medical conditions, and target organ involvement.
Education Group
Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research
and
Education Group
Studied in post-operative
hypertension, post-cardiac surgery,
and emergency department
treatment of HE. Potentially
useful for all types of HE syndromes.
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Hypertensive Emergencies:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3
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and
Education Group
Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research
and
Education Group
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Hypertensive Emergencies:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3
Clevidipine has a very rapid onset of action, with a halflife of less than 1 minute. The usual dose is 2 g/kg/min,
with upward doubling titration to effect. Blood pressure
control is often achieved within 5 minutes of starting
an infusion. It is rapidly cleared within 10 minutes.
Clevidipine is metabolized to an inactive metabolite by
esterases in blood and extravascular tissue, independent
of renal or hepatic function. It is logistically simple to
use, being given through a peripheral IV line and with
BP cuff monitoring instead of intra-arterial access. It has
a non-weight-based dosing regimen and no associated
myocardial depression, sino-atrial (SA) node suppression,
or atrio-ventricular (AV) node suppression.
Clevidipine was shown to be safe and effective for the
treatment of acute hypertension during an 18-hour infusion
in a recent clinical trial performed in the ED. VELOCITY
was a Phase-III, open-label, single-arm study to confirm
the safety and efficacy of IV clevidipine for patients with
acute hypertension requiring parenteral treatment for at
least 18 hours. Patients were enrolled in the trial if they
had acute hypertension (SBP >180 mm Hg or DBP >115
mm Hg) on 2 successive occasions 15 minutes apart and
had evidence of acute or chronic end-organ damage,
were 18 years of age or older, and could provide written,
informed consent. Ninety percent (104/117) of patients
reached their target BP within 30 minutes (median for all
patients, 10.9 minutes). No clinical hypotensive events
related to clevidipine were reported throughout the study,
and there was no excessive reflex tachycardia. Transition
to oral therapy was successful in 91.3% of patients.15
ED Bottom Line for clevidipine: Rapid onset and offset
of effect, limited side-effect profile, broadly applicable
without renal or hepatic issues, limited-to-no reflex
tachycardia, easy to administer as requires no central
access or monitoring.
ED Management Strategies
Hypertensive urgencies can and should ordinarily be
managed with oral antihypertensives only. Because the
diagnosis confirms that no end-organ damage is ongoing or
incipient, most patients with hypertensive urgencies have had
their BP control deteriorate over days to weeks to months,
and urgent correction is neither necessary nor advisable.1
Hypertensive emergencies, again by definition with end
organ damage, require parenteral therapy using one or
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and
Conclusion
Treatment of hypertensive emergencies, especially in an
ED, can be challenging and resource-intensive. Many
agents are available, but most are limited by side effects,
pharmacologic and physiologic barriers, or resourcebased barriers. Clevidipine, a new ultrashort-acting
dihydripyridine calcium channel blocker appears to be
an important new addition to the armamentarium of the
clinician. It has been shown to be safe, effective, and
easy to administer in an ED setting. Labetalol continues
to enjoy wide applicability in the ED. Newer, safer, and
easier-to-use agents may begin to replace nitroprusside.
In the case of patients with limited comorbidities,
management in a CDU without formal hospital admission
may be possible, especially in hypertensive urgencies.
Education Group
Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research
and
Education Group
References
1. Aggarwal M, Khan IA. Hypertensive crises: hypertensive
emergencies and urgencies. Cardiology clinics
2006;24:135-46.
2. Marik PE, Varon J. Hypertensive crises: challenges and
management. Chest 2007;131:1949-62.
3. Stewart DL, Feinstein SE, Colgan R. Hypertensive
urgencies and emergencies. Primary Care: Clinics in
Office Practice 2006;33: 613-23.
4. National Heart, Lung, and Blood Institute. Seventh report
of the Joint National Committee on prevention, detection,
evaluation, and treatment of high blood pressure (JNC-7)
2003. Publication No. NIH 03-5233. Bethesda (MD): NIH;
2003.
5. Zampaglione B, Pascale C, Marchisio M, et al.
Hypertensive urgencies and emergencies: prevalence and
clinical presentations. Hypertension 1996;27:144-47.
6. Karras DJ, Ufberg JW, Harrigan RA, et al. Lack of
relationship between hypertension-associated symptoms
and blood pressure in hypertensive ED patients. Am J
Emerg Med 2005;23:106-10.
7. Bennett NM, Shea S. Hypertensive emergency: case
criteria, sociodemographic profile, and previous care of
100 cases. Am J Public Health 1988;78:636-40.
8. Potter JF. Malignant hypertension in the elderly. Q J Med
1995;88:641-47.
9. Lavin P. Management of hypertension in patients with
acute stroke. Arch Int Med 1986;146:66-68.
10. Gilmore RM, Miller SJ, Stead LG. Severe hypertension in
the emergency department patient. Emerg Med Clin N
Am 2005;23:1141-58.
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Hypertensive Emergencies:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3
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and
Education Group
Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research
and
Education Group
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HYPERTENSIVE EMERGENCIES:
Acute Care Evaluation and Management
December 2008, Volume 3
HYPERTENSIVE EMERGENCIES:
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