Many people think that high blood pressure is the “patent” of the elderly, so even if the blood pressure is found to be a little high during the physical examination, it is not taken too seriously.
Some patients even uphold the principle that medicine is three parts toxic, even if they take antihypertensive drugs, they eat one meal less than the other, and eat irregularly.
But if your own blood pressure is high, and usually not strictly control blood pressure, once stimulated, such as emotions, stay up late, smoking, drinking and other aspects of stimulation, beware of “hypertensive emergencies” to find the door.
Hypertensive patients, please be alert to hypertensive emergencies!
Hypertensive emergencies are sudden and significant increases in blood pressure (generally >180/120mmHg) in patients with primary or secondary hypertension under the effect of certain triggers, accompanied by progressive cardiac, cerebral, renal and other important target organ insufficiency.
They mainly include hypertensive encephalopathy, intracranial hemorrhage (cerebral hemorrhage and subarachnoid hemorrhage), cerebral infarction, acute heart failure, ACS (unstable angina pectoris, acute non-ST-segment elevation myocardial infarction and ST-segment elevation myocardial infarction), aortic coarctation, eclampsia, renal insufficiency, pheochromocytoma crisis and severe perioperative hypertension.
In addition, hypertensive emergencies include the following special cases.
(1) Systolic blood pressure > 220 mmHg and/or diastolic blood pressure > 140 mmHg.
(2) Pregnant women or acute glomerulonephritis, where the blood pressure rise is not obvious but harmful. In a small number of patients, the disease progresses rapidly, with diastolic blood pressure persistently ≥130 mmHg with headache, blurred vision, fundus hemorrhage, exudation and optic disc edema, prominent renal damage, and persistent proteinuria, hematuria with tubuluria, called malignant hypertension.
Bleeding in the fundus
For patients with hypertensive emergencies, it is necessary to rapidly lower the blood pressure, apply appropriate antihypertensive drugs as soon as possible, and clarify the type of drug, route of administration, target level of blood pressure lowering and speed of blood pressure lowering, as well as using effective sedative drugs as appropriate to eliminate the patient’s fear.
Hypertensive emergencies, urgent but not chaotic correct treatment is important!
Hypertensive emergencies are life-threatening and serious illnesses. When a hypertensive emergency is clearly identified, antihypertensive drugs should be applied immediately, usually with continuous intravenous use of antihypertensive drugs, following the principles of individualization, starting with a small dose, adjusting antihypertensive according to the target, and lowering blood pressure rapidly and smoothly in a planned and step-by-step manner to protect target organs.
1, drug antihypertensive: at the same time, according to the different types of hypertensive emergencies to select the best efficacy and minimal adverse effects of antihypertensive drugs to reduce blood pressure to a safe level, based on the pharmacological effects of drugs and clinical experience, commonly have sodium nitroprusside, nitroglycerin, nicardipine, labetalol and so on.
(1) Sodium nitroprusside: mainly given by intravenous infusion, the drug can directly dilate both veins and arteries and reduce the pre and afterload.
Blood pressure should be closely monitored after administration, and the drip rate should be carefully adjusted according to the blood pressure level. The dose can be started at 10 μg/min (min) intravenously and gradually increased to achieve the hypotensive effect, with a maximum dose of 200 μg/min (min) commonly used in clinical practice. After stopping the drip, the effect is only maintained for 3-5 minutes.
Due to improper use of sodium nitroprusside excessive hypotension may occur. Therefore, in the absence of ambulatory blood pressure monitoring conditions, the choice of sodium nitroprusside is not recommended.
(2) Nitroglycerin: Also administered by intravenous drip, starting at a rate of 5-10 μg/min (min). The effect disappears a few minutes after stopping the drug and can be used up to 100-200 μg/min (min).
The drug can dilate veins and selectively dilate coronary arteries and aorta, lowering arterial pressure is not as effective as sodium nitroprusside, but the effect is rapid, and disappears a few minutes after stopping the drug.
However, patients with intracranial hypertension, glaucoma, hypertrophic obstructive cardiomyopathy, cerebral hemorrhage or cranial trauma are prohibited.
(3) Nicardipine: intravenous drip administration, the drug is a dihydropyridine CCB, rapid action, starting with 0.5μg / (kg – min) intravenous drip, can gradually increase the dose to 10μg / (kg – min). It has a short duration and lowers blood pressure while improving cerebral blood flow. Common adverse reactions include tachycardia, facial flushing, etc.
(4) Labetalol: administered intravenously, the drug is an α-β-blocker with rapid onset of action, starting with a slow intravenous injection of 20-100mg, at a rate of 0.5-2mg/min (min) intravenous drip, the total dose does not exceed 300mg. adverse reactions include dizziness, upright hypotension, heart block, etc.
Cardiac monitoring
Close monitoring of ECG, blood pressure and other important indicators is required during drug administration. In addition, since hypertensive emergency patients are often accompanied by anxiety, and anxiety and tension can further increase blood pressure, sedative drugs can be used at the discretion of the doctor’s advice to help quickly and appropriately control the patient’s blood pressure within the target range.
2, antihypertensive goals: For patients with hypertensive emergencies, it is necessary to rapidly lower blood pressure during rescue treatment to prevent or reduce damage to the heart, brain, kidneys and other important organs, but also to control the speed of lowering blood pressure to avoid a significant reduction in blood perfusion to important organs due to rapid lowering of blood pressure.
(1) The first goal of antihypertensive treatment: to lower blood pressure to a safe level within 30-60 minutes. This safe level must be determined on a patient-by-patient basis due to the varying levels of basal blood pressure and the combined target organ damage.
(2) Second goal of antihypertensive therapy: After reaching the first goal, the rate of blood pressure lowering should be slowed down by adding oral antihypertensive drugs and gradually slowing down the intravenous administration to gradually lower the blood pressure to the second goal.
It is recommended that the blood pressure be lowered to 160/100-110 mmHg within 2-6 hours of follow-up, with appropriate adjustments according to the patient’s specific condition.
(3) Third goal of antihypertensive treatment: If the patient’s blood pressure level of the second goal is tolerable and clinically stable, the blood pressure needs to be gradually reduced to normal level in the subsequent 24-48 hours.
The mortality and disability rates of hypertensive emergencies are high, and early, rapid, reasonable, safe and controlled blood pressure lowering is the basis for improving the prognosis. If hypertension is diagnosed, it is important to avoid strict medication and actively prevent such dangerous moments to improve their quality of life.
References
[1]National Health and Family Planning Commission Rational Drug Use Expert Committee,National Association of Physicians Hypertension Professional Committee. Guide to the rational use of medication for hypertension (2nd edition) [J]. Chinese Journal of Frontiers in Medicine,2017,7(9):75-78.