Emergenze e urgenze ipertensive
Dr. Enrico Haupt
Direttore S.C. Medicina d’Urgenza
Ospedale di Lavagna
Chiavari
Centro Benedetto Acquarone
15/3/2008
Crisi ipertensiva
• Emergenza ipertensiva
• Urgenza ipertensiva
Emergenza ipertensiva
JNC 7
Rialzo severo di PA (>180/120) con
evidenza di iniziale o progressivo
danno d’organo
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ENCEFALOPATIA IPERTENSIVA
EMORRAGIA INTRACEREBRALE
IMA
INSUFF. V. SIN.CON EPA
ANGINA INSTABILE
ECLAMPSIA
ESC
Rialzo pressorio associato a danno
d’organo acuto
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ENCEFALOPATIA IPERTENSIVA
INSUFFICIENZA VENTRICOLARE SIN
INFARTO MIOCARDICO
ANGINA INSTABILE
DISSEZIONE AORTICA
ESA O EVENTO CEREBROVASCOLARE
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CRISI ASSOCIATE A FEOCROMOCITO..
ASSOCIATE AD USO DI COCAINA, LSD,
ANFETAMINE, ECTASY
IPERTENSIONE PERIOPERATORIA
PREECLAMPSIA O ECLAMPSIA
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URGENZA IPERTENSIVA
JNC 7
Le urgenze ipertensive sono
situazioni associate a rilevante
innalzamento della PA senza
disfunzione progressiva degli
organi target :
• Ipertensione stadio II e severa
cefalea
• Fiato corto
• Epistassi
• Ansietà severa
ESC
Aumenti rilevanti della PA
associati a danno d’organo
acuto,come quelli che talora si
rilevano negli anziani con
ipertensione sistolica isolata ,
sono impropriamente definite
emergenze, e dovrebbero essere
trattate con prontezza , ma
nello stesso modo dei rialzi di
pressione cronici
JNC 7
• Hypertensive Emergencies: require
hospitalization and parenteral drug therapy
• Hypertensive Urgencies: usually do not
require hospitalization
Fattori che concorrono a determinare il significato
clinico e prognostico di un rialzo pressorio
• Valori pressori : PAS > 220 mmHg e/o PAD
> 120-130
• La rapidità di insorgenza dei valori pressori
elevati
• La presenza di danno acuto d’organo
• Il sistema nervoso centrale possiede meccanismi di
autoregolazione della circolazione cerebrale, volti a proteggere il
parenchima da variazioni eccessive o repentine della pressione
arteriosa sistemica.
• In caso di riduzione della PA o di aumento delle resistenze
intracraniche, si verifica una progressiva dilatazione delle
piccole arterie di resistenza;
• l’aumento progressivo della PA comporta costrizione arteriolare
con aumento delle resistenze
Ipertensione maligna (accelerata)
• PAD in genere >140
• Emorragie e essudati retinici
• papilledema
Papilledema fase conclamata
TERAPIA
• In caso di emergenza ipertensiva è
sufficiente la riduzione della MAP del 1015% nella prima ora e comunque mai più
del 25% (eccezione per la dissecazione
aortica)
Antihypertensive treatment in patients with
Cerebrovascular Disease (2007 ESCguidelines)
• There is at present no evidence that BP lowering has a
beneficial effect in acute stroke but more research is
under way. Until more evidence is obtained
antihypertensive treatment should start when poststroke clinical conditions are stable, usually several
days after the event. Additional research in this are is
necessary because cognitive dysfunction is present in
about 15% and dementia in 5% of subjects aged ≥65
years
Stroke e PA: fase acuta
SPREAD IV ED.
• PAD >150 nitroglicerina o nitroprussiato
• PAS >220 o PAD 121-140 labetololo ev
• PAS 185-220 o PAD 105-120 rimandare la
terapia (pazienti no RtPa)
• PAS<185 PAD<105 no terapia
Hypertension in pregnancy
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In pre-eclampsia with pulmonary oedema, nitroglycerine
is the drug of choice. Diuretic therapy is inappropriate
because plasma volume is reduced in pre-eclampsia.
Magnesium sulphate is effective in the treatment of
seizures
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Under emergency circumstances, intravenous labetalol,
oral methyldopa and oral nifedipine are indicated.
Intravenous hydralazine is no longer the drug of choice
because of an excess of perinatal adverse effects.
Intravenous infusion of sodium nitroprusside is useful in
hypertensive crises, but prolonged administration should
be avoided (fetal cyanide poisoning)
Is epistaxis evidence of end-organ damage in patients with
hypertension?
Lubianca Neto JF, Fuchs FD, Facco SR, Gus M, Fasolo L, Mafessoni R, Gleissner AL.
Laryngoscope. 1999 Jul;109(7 Pt 1):1111-5.
Absence of association between hypertension and epistaxis: a
population-based study.
Fuchs FD, Moreira LB, Pires CP, Torres FS, Furtado MV, Moraes RS, Wiehe M,
Fuchs SC, Lubianca Neto JF
Blood Press. 2003; 12(3): 145-8
A definite association between blood pressure and
history of adult epistaxis in hypertensive patients was
not found. The evidence for an association of
duration of hypertension and left ventricular
hypertrophy with epistaxis suggests that epistaxis
might be a consequence of long-lasting hypertension.
Active epistaxis at ED presentation is associated with arterial
hypertension.
Herkner H, Havel C, Müllner M, Gamper G, Bur A, Temmel AF, Laggner AN, Hirschl MM
Am J Emerg Med. 2002 Mar ; 20(2): 92-5
Hypertension in patients presenting with epistaxis.
Herkner H, Laggner AN, Müllner M, Formanek M, Bur A, Gamper G, Woisetschläger C, Hirschl
MM
Ann Emerg Med. 2000 Feb ; 35(2): 126-30
Patients with sustained arterial hypertension had significantly
more episodes of epistaxis compared with patients with elevated
blood pressure during epistaxis and no sustained arterial
hypertension
Debate about blood pressure and epistaxis will
continue
Andreas F P Temmel, BMJ 2001;322:1181 ( 12 May )
The evidence for an association of duration of hypertension
and left ventricular hypertrophy with epistaxis suggests that
epistaxis might be a consequence of long term hypertension
http://www.attract
Question:
How common is it for recurrent nose bleeds to be the presenting feature of hypertension?
Answer:
We found very little information with which to answer this question, and the information we did find suggests the association between epistaxis
and hypertension is still controversial (1-4).
We did however find one paper published in 1996 on hypertensive, urgencies and emergencies (5) which discusses the prevalence and clinical
presentation. The authors found that of the most frequent presentations epistaxis accounted for 17%.
1.http://www.hubmed.org/display.cgi?uids=12875475
2.http://www.hubmed.org/display.cgi?uids=11880870
3.http://www.hubmed.org/display.cgi?uids=10650229
4.http://www.hubmed.org/display.cgi?uids=9740920
5.http://hyper.ahajournals.org/cgi/content/abstract/27/1/144
Date Posted : 17/07/2007
Lavagna: il vecchio ospedale