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Systemic and Pulmonary Hypertension

Systemic and Pulmonary Hypertension. Tintinalli Chap. 61. Classification of Hypertension. Systolic BP Normal: < 120 Prehypertension: 120-139 Stage 1: 140-159 Stage 2: >160. Diastolic BP Normal: <80 Prehypertension: 80-89 Stage 1: 90-99 Stage 2: >100. Hypertensive Emergency.

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Systemic and Pulmonary Hypertension

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  1. Systemic and Pulmonary Hypertension Tintinalli Chap. 61

  2. Classification of Hypertension • Systolic BP • Normal: < 120 • Prehypertension: 120-139 • Stage 1: 140-159 • Stage 2: >160 • Diastolic BP • Normal: <80 • Prehypertension: 80-89 • Stage 1: 90-99 • Stage 2: >100

  3. Hypertensive Emergency • Acute elevation of blood pressure associated with end-organ damage (>180/120 mmHg) • Acute aortic dissection • Acute pulmonary edema • Acute myocardial infarction • Acute coronary syndrome • Acute renal failure • Severe preeclampsia, HELLP syndrome, eclampsia • Hypertensive retinopathy • Hypertensive encephalopathy • Subarachnoid hemorrhage • Intracranial hemorrhage • Acute ischemic stroke • Acute postoperative hypertension • Sympathetic crisis

  4. Hypertensive Urgency • Severe elevation in blood pressure without progressive target organ dysfunction

  5. Symptoms • Chest pain •  Acute Coronary Syndrome •  Aortic Dissection • Neurologic symptoms (Headache, focal deficit, AMS, seizures, visual disturbance) • Hypertensive encephalopathy • Intracranial hemorrhage •  Stroke • Peripheral edema • New-onset renal failure • Preeclampsia/HELLP syndrome

  6. Other Common Symptoms • Headache • Dyspnea • Visual changes • Dizziness • Epistaxis

  7. Diagnostics • BMP--Creatinine • CXR • EKG • UA

  8. Treatment of Hypertensive Emergencies • Labetalol—alpha1, beta adrengeric, much mores BETA • Esmolol—beta 1 adrenergic, VERY SHORT, often with nitroprusside to block tachy • Metoprolol • Nicardipine—CCB, Dec peripheral resistance, dec cerebral vasospasm (good stroke) • Clevidipine • Nifedipine • Nitroglycerin—Venous>>>artery • Nitroprusside—vasodilator/arteriolar • Phentolamine—Pure Alpha blocker • Fenoldopam—dopamine 1 receptor antagonist (acutely improves renal function) • Enalaprilat • Clonidine

  9. Special Circumstances • Acute MI  Nitro, metoprolol • Sympathetic crisis  Avoid beta blockers • Preeclampsia/Eclampsia No ACE inhibitors • Pulmonary edema  Nitro, diuretics

  10. Treatment of Hypertensive Urgencies • Nitroglycerin • Labetalol • Clonidine • Captopril/Lisinopril • Nifedipine • Losartan

  11. Dispo and Follow-up • Arrange follow up for BP check • If >180 SBP or >110 DBP • Consider initiating therapy • If >200 SBP or >120 DBP • Begin antihypertensive therapy • HCTZ • Lisinopril

  12. Pulmonary Hypertension • Elevation of pulmonary vascular pressure which compromises right ventricular function • Median pulmonary artery pressure > 25 mmHg at rest or > 30 mmHg during effort • Classified into five groups based on cause

  13. Incidence • Sleep apnea – 25-20% • CREST syndrome – 60% • Hemoglobinopathies – 10-30%

  14. Symptoms • Dyspnea • Fatigue • Syncope • Chest pain • Peripheral edema

  15. Clinical Findings • Increased pulmonary component (P2) of second heart sound • Murmur of tricuspid regurgitation • Graham Steell murmur of pulmonary insufficiency • Prominent sternal impulse • JVD • Ascites

  16. EKG • Right axis deviation • R/S ratio of >1 in V1 • S wave > 7mm in V5/V6 • Incomplete RBBB

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