Virtual Doctors Forum: Hypertensive Crises

Information based on BMJ Best Practice Guidance: https://newbp.bmj.com/topics/en-us/27/

Definitions:

Hypertensive Urgency: blood pressure ≥ 180/110 mmHg without acute target-organ damage.

Hypertensive Emergency: severely elevated blood pressure (BP) associated with new or progressive target organ dysfunction.

Although the absolute value of the BP is not as important as the presence of end-organ damage, the systolic BP is usually >180 mmHg and/or the diastolic BP is >120 mmHg.

Q: Why is this a medical emergency?

A: Can lead to irreversible end organ damage

Image from https://www.accp.com/docs/bookstore/ccsap/ccsap2018b1_sample.pdf

Causes:

There are many possible causes of hypertensive emergency.

One very common cause is essential hypertension that is either undiagnosed or inadequately treated.

Another common cause of hypertensive emergency is secondary and resistant hypertension:

  • Renal: most common caused by underlying chronic disease, renal artery stenosis, acute glomerulonephritis, collagen vascular diseases, kidney transplantation.
  • Neurological: head trauma, spinal cord injury, autonomic dysfunction
  • Respiratory: obstructive sleep apnoea
  • Vasculitis
  • Endocrine: multiple causes- but rare and small print! These are also difficult to diagnose without extensive tests and investigations.
  • Pregnancy: pre-eclampsia, HELLP syndrome, and eclampsia are important causes of hypertensive emergency in women. THIS IS OFTEN TREATED DIFFERENTLY
  • Lifestyle factors:
    • excessive dietary salt intake,
    • obesity
    • alcohol consumption
    • smoking
    • drug use

Symptoms:

Neurological:

  • Blurry vision
  • Dizziness
  • Headache
  • Seizures
  • Change in mental status
  • Dysphagia (swallowing difficulty)
  • Numbness
  • Paraesthesia
  • Weakness

Cardiac:

  • Chest pain
  • Shortness of breath
  • Sweating
  • Orthopnoea (breathlessness when lying down)
  • Palpitations
  • Peripheral oedema

Renal:

  • Decreased urine output

Examination:

An appropriately sized cuff should be used for BP readings:

  1. The cuff bladder should encircle at least 80% of the upper arm and the cuff length should be greater than two-thirds the distance between the shoulder and elbow.
  • The arm should be supported at heart level during recordings.
  • Using too large a cuff could result in an underestimation of BP; too small a cuff could lead to overestimation.
  • BP readings should be taken from both arms and readings repeated after 5 minutes to confirm.

If there is a more than 20 mmHg pressure difference between arms, aortic dissection should be considered. This requires urgent transfer to a specialist hospital.

A fundoscopic examination should be performed, looking for the presence of papilloedema retinal haemorrhages, retinal exudates, or engorged retinal veins.

Fundoscopy: Papilloedema
Fundoscopy: Hypertensive Changes

A bedside neurologic exam is also required and should include:

  • testing of cognition
  • examination of the cranial nerves
  • checking gross motor strength and sensation
  • checking the patient’s gait

It is important to listen to the heart sounds to check for any new murmurs or additional sounds. It is also useful to check for artery bruits and whether there is any peripheral oedema present.

Investigations

Depending on clinic facilities, it may not be possible to perform any diagnostic tests, however it is useful to check the following as a minimum if you are able to:

  • FBC- to check for any abnormalities
  • U&E- may show renal impairment
  • Urinalysis- may show blood/protein which can signify end organ kidney damage
  • ECG- may show ischaemia or left ventricular strain pattern

See: https://litfl.com/left-ventricular-hypertrophy-lvh-ecg-library/

Overall the most important thing is to check for evidence of end organ damage as this is what distinguishes hypertensive urgency from hypertensive emergency.

Treatment:

This is according to the British National Formulary and the hyperlinks should link through to the correct doses for each medication.

Hypertensive Urgency (HU):

  • Use of sublingual nifedipine is not recommended.

A systematic review was carried out in the Journal of General Internal Medicine in 2018, which concluded that he optimal choice of antihypertensive agent remains unclear.

The full article can be accessed here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880769/#!po=0.909091

Hypertensive Emergency (HE):

In UK guidelines, oral therapies are generally discouraged as first-line treatment options.

Intravenous treatment options include sodium nitroprusside [unlicensed], nicardipine hydrochloridelabetalol hydrochlorideglyceryl trinitratephentolamine mesilatehydralazine hydrochloride, or esmolol hydrochloride.

The precise choice of drug depends on the past medical history and clinical status of the patient.

It is important to control the patient’s BP, however bringing it down too quickly can also cause renal, cerebral, or coronary ischaemia and should therefore be avoided.

If you do not have access to IV medication, using an oral anti-hypertensive, as per HU guidelines, is likely to do less harm than leaving a patient untreated with grossly abnormal physiology and an increased risk of irreversible end organ damage.

If you are in doubt about how best to manage a case, don’t forget you can contact us at the Virtual Doctors for patient specific advice and guidance.

 

Benign paroxysmal positional vertigo and Epley

BPPV Benign paroxysmal positional vertigo

BPPV is the commonest cause of vertigo. It is Benign as although it can be quite disabling, it is not due to serious disease; Paroxysmal because it occurs in short bursts of up to one minute; Positional as it is provoked specifically by movement to or from certain positions; Vertigo – dizziness defined as an illusion of movement.

Who is affected by BPPV?

BPPV is estimated to affect roughly 50% of all people at some time in their lives and becomes progressively more common with age.

Symptoms of BPPV

The vertigo is generally rotational (like getting off a roundabout) but sometimes sufferers, on lying down, will feel that they are falling through the bottom of the bed or, on getting up, that they are being thrown back onto it. The classic provoking movements to induce BPPV are: lying flat, sitting up from lying flat; turning over in bed; looking up (e.g. hanging washing) or bending down, especially if also looking to the side. The duration of the vertigo is brief; usually five to 30 seconds but very occasionally lasts up to two minutes.

What causes BPPV?

BPPV is caused when loose chalk crystals get into the wrong part of the inner ear. These microscopic crystals should be embedded in a lump of jelly. The crystals weigh the jelly down and make that part of the ear sensitive to gravity. The crystals are constantly being re-absorbed and re-formed and over time fragments come loose. Lying flat can then occasionally cause some of the loose debris to fall into one of the semi-circular canals; the parts of the ear responsible for sensing rotation. Movement in the plane of the affected canal causes the crystals to move along the canal, stimulating it and giving the sensation of rotation.

How is BPPV diagnosed?

During periods when attacks are not occurring, the diagnosis is made from the characteristic history and by the exclusion of other disorders that can cause similar dizzy symptoms. When attacks are occurring, the Hallpike positional test is diagnostic. In the commonest form of BPPV the Hallpike test is positive (i.e. induces vertigo and nystagmus) when the affected ear is down most. Up to 10% of cases may involve both ears.

How is BPPV treated?

At least a half of all cases will get better without treatment though this may take months. As BPPV is basically a mechanical disorder, drugs have no effect and should be avoided. Most cases that do not resolve rapidly can now be relieved by the appropriate Particle Repositioning Manoeuvre; of which the most commonly performed is the Epley manoeuvre which offers instant relief of symptoms in nine out of 10 patients.