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1、Hypertensive Crisis,. 4, Urgency/Emergency evidence ,Hypertensive crisis ,Hypertensive emergency target organ damage coronary ischemia, disordered cerebral function, cerebrovascular events, pulmonary edema renal failure,Hypertensive crisis ,Hypertensive urgency progressive target organ dysfunction h
2、ypertensive crisis ( acute cocaine intoxication), Hypertensive crisis, stage 1, 2 HTN Nonadherence USA 500,000 ( 1%), Hypertensive crisis,Renal disease 1. Parenchymal disease-chronic pyelonephritis-primary glomerulonephritis-vascular/glomerular disease (SLE, systemic sclerosis),Drugs - central actin
3、g alpha2-adrenergic agonist (clonidine, methyldopa) - phyencyclidine, cocaine intoxication -DI: monoamine oxidase inhibitor (tranylcypromine, phenelzine selegilline),Pregnancy Eclampsia/ severe pre-eclampsia,Endocrine - Pheochomocytoma - 1 aldosteronism,CNS disorders - CVA infarction/hemorraghe - He
4、ad injury,Etiology and Pathophysiology, . . SVR hypertensive crisis (triggering) . Endothelium (blood pressure homeostasis),Etiology and Pathophysiology,Endothelium (vascular tone) nitric oxide prostacyclin renin-angiotensin system . compensatory decompensation endothelium ,History & Physical examin
5、ation.extremely important Lab + other test (ECG/ Chest radiographpossible end organ damage),History, ? end organ damage Chest pain MI/ischemia, aortic dissection SOBacute pulmonary edema LVF Back painaortic dissection Neurologic symptoms (headache, blurry vision, N, V )intracerebral or subarachnoid
6、hemorrhage/encephalopathy,History, (sympathomimetic, NSAIDs, herbal product, cocain, methamphetamine) (beta blockers, central sympatholytic agent).rebound hypertension,Physical Examination, 2 20 mmHg SBP aortic dissection BP volume status pressure natriuresis Head&Neck fundoscopic exam grade IIIflam
7、e-shaped hemorrhages, fluffy, white cotton wool spots, yellow white exudategrade IVpapilledema with blurring /hemorrhage/exudate,CVS exam Murmursdiastolic murmur+aortic insuffaortic dissection JVP, S3 gallopCHF Rales at lungspul congestion/edema Smokers renovascular HTN Systolic/diastolic abdominal
8、bruitrenovascular disease Delirium/flapping tremor.encephalopathy,Lab,CBC: peripheral smear schistocyte microangiopathic hemolytic anemia Electrolyte, BUN, Scr renal impairment Hypokalemia metabolic alkalosis intravascular volume depletion secondary hyperaldosteronism,Other tests,ECG myocardial isch
9、emia/infarction LVH chronic hypertension Chest radiograph pulmonary congestion widened mediastinum aortic dissection CT without contrast neurologic symptoms ( mental status, focal neurologic signs cerebrovascular accident/hemorrhage, Urgency/Emergency target organ damage, Hypertensive Urgency, oral
10、antihypertensive agents . hypotension ( peipheral vascular disease, atherosclerotic cardiovascular and intracranial disease) Initial goal: 160/110 mmHg Mean arterial pressure 25% 24 , Mean arterial pressure,MAP = (CO x SVR) + CVP MAP = DP + 1/3(PP) MAP = DP + 1/3( SP-DP) MAP = (2DP+SP)/3, Hypertensive Urgency,ACEI: Captopril onset 15-30 min (max BP drop 30, 90 ) Captopril: 25 mg oral / 50-100mg 90-120 ADR: hypotension, angioedema, renal failure bilateral renal artery stenosis,
