Crysis Hypertension - Urgency VS Emergency Hypertension

Hypertensive Crisis - Urgency VS Emergency

Introduction

Hypertensive Crisis is typically defined as Systolic Blood Pressure (SBP) > 220 mm Hg or Diastolic BP > 125 mm Hg. Basically, it was devided into 2 types :

• Hypertensive Urgencies
  
• Hypertensive Emergencies
  

Hypertensive Urgency

Hypertensive Urgency are situations in which Blood Pressure must be reduced within a few hours (<> 220 mmHg or DBP > 125 mmHg that persists after a period of observation) and without evidence of acute end-organ damage.

Hypertensive Emergency

Hypertensive Emergency are situations in which SBP > 220 mmHg or DBP > 125 mmHg and require substantial reduction of blood pressure within 1 hour to avoid the risk of serious morbidity or death.

Clinical Manifestation of Hypertensive Emergency :

• Eyes: Retinal hemorrhages and exudates, papilledema.
• CNS: Intracranial hemorrhage, lacunar infarcts, stroke, or hypertensive encephalopathy. The latter is characterized by the insidious onset of headache (often occipital and worse in the morning), nausea, and vomiting, followed by alterations in mental status, lethargy, and restlessness/agitation. Can progress to seizures and coma if untreated. Generally characterized by the lack of localizing neurologic signs.
• CV: Pulmonary edema, unstable angina/myocardial infarction, acute aortic dissection.
• Renal: Malignant nephrosclerosis, leading to acute renal failure, hematuria, and proteinuria. Activation of the renin-angiotensin system can further exacerbate the HTN.
• Hematologic: Hemolytic anemia can occur with severe HTN.

Others Type Of Hypertensive Emergency :

• Malignant Hypertension - In order to diagnose Malignant Hypertension, papilledema must be present
• Accelerated Hypertension - Defined as a recent significant increase over baseline blood pressure that is associated with target organ damage. This is usually vascular damage on funduscopic examination, such as flame-shaped hemorrhages or soft exudates, but without papilledema.
  

Treatment

Hypertensive Urgency

• Goal : To relieve symptoms and bring BP to reasonable level within 24–48 hours, aiming for gradual attainment of optimal control over several weeks
• Medication : Clonidine, Captopril, Metoprolol, and Hydralazine are effective oral agents.
• Precautions : Avoid B-Blockers if cocaine use, Avoid angiotensin-converting enzyme (ACE) inhibitors if renal artery stenosis suspected, Avoid short-acting dihydropyridine calcium channel blockers because BP reduction is often precipitous
  

Hypertensive Emergency

• Goal : To reduce mean arterial pressure by 25% in 1–2 h; then to reduce BP to 160/100 mm Hg over next 6–12 h
  
• Medication : Nitroprusside, labetalol, and nitroglycerin are most commonly used intravenously. Fenoldopam, a peripheral dopamine agonist, is also effective
• Precautions : If with ischemic stroke, only treat if BP exceeds 220/120 mm Hg; aim to reduce by only 10–15%, If thrombolytic agents are to be used to treat ischemic stroke, target BP is <>
• ACE inhibitors are specifically indicated in scleroderma crisis

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Mean Arterial Pressure (MAP)

Mean Arterial Pressure (MAP)

Definition

Mean arterial pressure is a term to describe a notional average blood pressure in an individual. It is defined as the average arterial pressure during a single cardiac cycle.

The blood pressure in our body is always changing and it is part of the human physiology. It is very rare that someone's blood pressure is always the same. Because we are always active and we are always doing different things like eating, sitting, standing, walking, breathing, moving around and doing so many other things throughout a day.

Formula

As blood is pumped out of the left ventricle into the arteries, pressure is generated. The mean arterial pressure (MAP) is determined by the Cardiac Output (CO), Systemic Vascular Resistance (SVR), and Central Venous Pressure (CVP) according to the following relationship, which is based upon the relationship between Flow, Pressure and Resistance :

MAP = (CO × SVR) + CVP

Because CVP is usually at or near 0 mmHg, this relationship is often simplified to:

MAP Approx = CO × SVR

Therefore, changes in either CO or SVR will affect MAP. If CO and SVR change reciprocally and proportionately, then MAP will not change. For example, if CO doubles and SVR decreases by one-half, MAP does not change (if CVP = 0). It is important to note that variables found in are all interdependent. This means that changing one variable changes all of the others.

In practice, MAP is not determined by knowing the CO and SVR, but rather by direct or indirect measurements of arterial pressure. From the aortic pressure trace over time, the shape of the pressure trace yields a mean pressure value (geometric mean) that is less than the arithmetic average of the systolic and diastolic pressures as shown to the right.

Why Measuring The MAP?

There are different reasons that mean arterial pressure is taken and recorded. Not all are related to health. The mean arterial pressure is known as part of a couple biological processes that do not show any health problems. When an arterial blood flow goes through the body it is going somewhere that it has in mind. Usually the blood is pumped through the arteries and left in the beds of capillaries that will run across the surface of different organs and give them the nutritional substances that are needed to operate properly.

Perfusion Pressure is Thought to Actually be The Mean Arterial Pressure.
MAP = Perfusion Pressure

For the mean arterial pressure to allow an organ to operate the way that it should, it must be at around 60 mmHg. This is enough for an organ of the average size person as long as it is remains at this spot. If the value falls below the average, it means that there is not enough blood pumping into the organ and this will cause the organ to become ischemic. The result will be tissue damage to the organ. The mean arterial pressure should be checked and calculated on a regular basis. Some health officials check the value of a person's arterial pressure when they check a person's blood pressure. It is just one of the many calculations that have to be made about blood pressure.

Simplyfied Mean Arterial Pressure (MAP) Equation

MAP = [(2 x Diastolic)+Systolic] / 3

Interpretation

• MAP around 70 - 110 : Normal

• MAP of about 60 : Necessary to Perfuse Coronary Arteries, Brain, Kidneys

• MAP less than 60 : Low Perfusion - Will Cause Ischemic Organ and Tissue Damage

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Prothrombin Time (PT) & International Normalize Ration (INR)

Prothrombin Time (PT) & International Normalize Ratio (INR)

Introduction

An INR is useful in monitoring the impact of anticoagulant (“blood thinning”) medicines, such as Warfarin(Coumadin). Patients with atrial fibrillation often take anticoagulant medications to protect against clots that can cause strokes. While taking Warfarin, patients have regular blood tests to monitor their INR. Just as patients know their blood pressure numbers, they also should know their Warfarin (Coumadin) dosage and their INR.

This standarization system was introduced by World Health Organization (WHO) in 1983 to provide a common basis for the interpretation of the PT result independent of the sensivity of the thromboplastin reagen which tends to vary from one manufacturer to another

Normal Result Of Prothombin Time

Although there is some variation depending on the source of the thromboplastin used in the test. (For this reason, laboratories report a normal control value along with patient results.) A prothrombin time within this range indicates that the patient has normal amounts of clotting factors VII and X.

The Normal Prothrombin Time (PT) is 11-15 seconds

Abnormal Results Of Prothombin Time

A prolonged PT time is considered abnormal. The prothrombin time will be prolonged if the concentration of any of the tested factors is 10% or more below normal plasma values. A prolonged prothrombin time indicates a deficiency in any of factors VII, X, V, prothrombin, or fibrinogen.

It may mean that the patient has a vitamin K deficiency, a liver disease, or disseminated intravascular coagulation (DIC). The prothrombin time of patients receiving warfarin therapy will also be prolonged-usually in the range of one and one half to two times the normal PT time. A PT time that exceeds approximately two and a half times the control value (usually 30 seconds or longer) is grounds for concern, as abnormal bleeding may occur.

Formula

INR = Patient PT / Mean Of Normal Patient Range

Interpretation (INR)

• 1.0 : For Healthy People,
• 2.0 - 3.0 : For patients on anticoagulants, or patients with atrial fibrillation,
• 3.0 - 4.0 : For patients with mechanical heart valves.
• > 4.0 : Indicate that blood is clotting too slowly (High Risk For Uncontrolled Bleeding)

The Ideal INR must be individualized for each patient

While the INR reporting format may improve the management of anti-coagulanted patient, the INR inapproriate in three subsets, such as :

1. The System was designed for patient who are stabilized on oral anticoagulant therapy and is not appropriate for those patient who have recently begun their treatment.
2. Patient with liver disease should not be monitored by the INR since they frequently lack circulating factors
3. Patient who are being routinely screened for clotting factors deficiencies.

Food & Drug Effects

Do not take any prescription or nonprescription medicines without first talking to the doctor who tracks your INR test results. Foods high in vitamin K, a natural blood-clotting factor, can alter an INR. Broccoli, lettuce, spinach and liver are all high in vitamin K. Doctors usually encourage patients to include these nutritious foods in a healthy diet. It is important, however, to consume a consistent amount of these foods and not drastically change eating habits. It is important to have follow up blood tests as scheduled by your doctor and to know your Warfarin (Coumadin) dosage and INR.

Many Food & Drugs Can Change The INR such as :
Aspirin, Ibuprofen, Antibiotics, Vitamin K, Brocolli, Lettuce, Spinach, and Birth Control Pills/Progesterone-Estrogen Combination Pills.

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