What is the best treatment approach for a patient with hypertensive epistaxis, who may be taking anticoagulants and has impaired cardiovascular function?

Treatment of Hypertensive Epistaxis

For hypertensive epistaxis, prioritize immediate local bleeding control with nasal compression and topical vasoconstrictors while avoiding aggressive acute blood pressure reduction, which can cause end-organ ischemia. 1

Immediate Epistaxis Control (First Priority)

The primary goal is to stop the bleeding through local measures, not to lower blood pressure acutely.

• Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 1, 2
• Apply firm sustained compression to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped 1, 2
• Have the patient breathe through their mouth and spit out blood rather than swallowing it 1, 2

If Bleeding Continues After Initial Compression:

• Clear clots from the nose, then apply topical vasoconstrictor (oxymetazoline or phenylephrine spray) - 2 sprays into the bleeding nostril 1, 2
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 2
• This approach resolves 65-75% of epistaxis cases that don't stop with compression alone 1, 2

Advanced Local Measures:

• Consider nasal packing with resorbable material if bleeding continues after 15-30 minutes of proper compression with vasoconstrictors 1, 2
• For patients on anticoagulants or antiplatelet medications, use only resorbable/absorbable packing materials (Nasopore, Surgicel, Floseal) to reduce trauma during removal 2

Blood Pressure Management (Secondary Priority)

Avoid aggressive acute lowering of blood pressure during active epistaxis - this is a critical pitfall that can cause renal, cerebral, or coronary ischemia. 1

• Monitor blood pressure but base control decisions on bleeding severity, inability to control bleeding with local measures, individual comorbidities, and risks of BP reduction 1
• The relationship between epistaxis and hypertension remains controversial, with causality unproven 1
• Patients with epistaxis have significantly higher blood pressure compared to control patients (systolic 161±30 vs 144±22 mmHg), but 79% of those with elevated BP during epistaxis have sustained hypertension requiring long-term management, not acute intervention 3

Long-term Blood Pressure Control (After Bleeding Stops):

For patients with impaired cardiovascular function and heart failure:

• Target BP should be <130/80 mmHg, with consideration for lowering to <120/80 mmHg if tolerated 4
• Use guideline-directed medical therapy: ACE inhibitors (or ARBs), beta-blockers, diuretics, and aldosterone receptor antagonists 4
• Avoid nondihydropyridine calcium channel blockers (diltiazem, verapamil) due to negative inotropic effects 4
• Avoid alpha-blockers (doxazosin) unless other agents are inadequate, as they increase heart failure risk 4

Anticoagulation Management

Do not routinely discontinue anticoagulants or antiplatelet agents unless bleeding cannot be controlled with local measures. 1, 2

• Patients on anticoagulants or antiplatelet therapy represent 39-62% of epistaxis cases requiring ENT referral 5, 6
• Check warfarin INR - most patients with epistaxis on warfarin have INR outside the appropriate therapeutic range 6
• Consider reversal agents only for severe refractory bleeding that is life-threatening 1, 2
• For aspirin in high-risk cardiovascular patients, continue the medication as survival benefits outweigh bleeding risks 2
• Antiplatelet agents (aspirin, clopidogrel) should not be discontinued unless bleeding cannot be controlled with local measures 1, 2

Prevention of Recurrence

Once bleeding stops:

• Apply petroleum jelly or other lubricating agents to the nasal mucosa 1, 2
• Recommend saline nasal sprays to keep mucosa moist 1, 2
• Humidifier use in dry environments can help prevent recurrence 1, 2

Indications for Hospitalization

Consider hospitalization for high-risk features:

• Bleeding not controlled after 15 minutes of continuous pressure 1, 2
• Hemodynamic instability (tachycardia, hypotension) 1, 5
• Severe bleeding (duration >30 minutes over 24 hours) 1
• Posterior bleeding source, which is more common in older hypertensive patients 1, 5
• Age, male sex, hypertension, and anticoagulation therapy are significantly correlated with severe clinical course requiring hospitalization 5

Common Pitfalls to Avoid

• Insufficient compression time - must maintain for full 10-15 minutes without checking 1, 2
• Aggressively lowering BP acutely - can cause end-organ ischemia 1
• Overlooking anticoagulation status - can lead to severe bleeding 1
• Neglecting posterior source evaluation - can lead to uncontrolled bleeding in elderly hypertensive patients 1
• Premature discontinuation of anticoagulants/antiplatelets - most epistaxis resolves with local measures alone 2

Escalation of Treatment

If bleeding persists despite nasal packing:

• Evaluate for surgical arterial ligation (97% success rate) or endovascular embolization (80% success rate) 2
• Both have recurrence rates <10% compared to 50% for nasal packing alone 2
• Endoscopic sphenopalatine artery ligation is the preferred surgical approach 2