10 Hypertensive Emergencies, part 1

Question 1

BP cutoff for hypertensive crisis

Answer 1

SBP >180 mmHg, and/or
DBP >120 mmHg

Question 2

Remarks on hypertensive urgency

Answer 2

There is no clinical benefit of rapid pharmacological intervention (usually parenteral) to reduce blood pressure.
Also, precipitous drops in blood pressure can be harmful.

Current recommendations for patients with hypertensive urgency are reinstitution or intensification of oral antihypertensive therapy and prompt outpatient follow up
Gradual blood pressure reduction should occur over days to weeks

Question 3

Remarks on differentiating aortic dissection from ACS

Answer 3

It is imperative to differentiate because BP goals are different and anticoagulation can prove catastrophic in acute aortic dissection

Question 4

therapeutic goal in acute aortic dissection

Answer 4

reduce shear forces by:
SBP 100 - 120 mmHg
*HR ≤60 bpm
ideally within the first hour of presentation

also, pain control with opioids helps decrease sympathetic tone

*Current AHA recommend HR target of 60-80 bpm

Question 5

therapeutic agents for acute aortic dissection

Answer 5

Esmolol or Labetalol,
+/- Nicardipine or Nitroprusside

Always use beta blockers prior to vasodialtors

Question 6

Therapeutic goal for acute hypertensive pulmonary edema

Answer 6

reduce BP by 20-30%
diuresis through vasodilation
symptomatic relief

Question 7

preferred agent for acute hypertensive pulmonary edema

Answer 7

nitroglycerin
“Interventions that improve forward flow, via afterload reduction, tend to work better than diuresis.”

Question 8

how to administer nitroglycerin?

Answer 8

SL: 0.4 mg
IV: start at 5 mcg/min, increase by 5 mcg/min every 3-5 mins to 20 mcg/min;
if no response at 20 mcg/min, increase by 10 mcg/min every 3-5 mins , up to 200 mcg/min
(note: many clinicians initiate with a higher infusion rate)

Question 9

precautions for nitroglycerin

Answer 9

Avoid in cases of compromised cerebral (because it would dilate cerebral arteries) and renal perfusion.
Avoid concurrent use (within past 24-48 h) with phosphodiesterase-5 inhibitors (sildenafil)

Question 10

Remarks on hypertensive encephalopathy

Answer 10

Hypertensive encephalopathy is a clinical diagnosis made after excluding focal ischemia or bleeding

Question 11

clinical presentation of hypertensive encephalopathy

Answer 11

altered mental status,
headache,
vomiting,
seizures, or
visual disturbances

most patients will have papilledema

Question 12

therapeutic goal for hypertensive encephalopathy

Answer 12

Decrease MAP by 20%-25% in the first hour of presentation
(after excluding stroke)
more aggressive lowering may lead to ischemic infarction

Question 13

MRI finding of reversible edema that’s predominantly posterior (occipital) suggests

Answer 13

posterior reversible encephalopathy syndrome (PRES)
which carries a poor prognosis

Question 14

Therapeutic goals for ICH

Answer 14

if SBP >220 mm Hg, consider aggressive management with IV infusion
If SBP 150-220 mm Hg, IV boluses of antihypertensive medicaiotns should be used to acutely lower SBP to 140 mm Hg

Question 15

Therapeutic goal for SAH

Answer 15

SBP <160 mm Hg to prevent rebleeding.
(140-160 mm Hg)

Question 16

In SAH, this lowers BP and reduces vasospasm, reduces subsequent infarction rates, and decreases mortality

Answer 16

Oral Nimodipine 60 mg PO every 4 hours within 4 days (96 hours) of onset

Question 17

Therapeutic goal for acute ischemic stroke

Answer 17

if thrombolysis is planned: ≤185/110 mmHg

if thrombolysis is not planned:
<220/120
- BP should be reduced by ≤15% in the first 24 hours

Treat more aggressively or correspondingly if with other concomitant hypertensive emergency (e.g., ACS, aortic dissection, preeclapsia/eclampsia)

Question 18

preferred therapeutic agents for acute myocardial infarcdtion

Answer 18

nitroglycerin, esmolol

Question 19

How to administer esmolol

Answer 19

Loading dose: 250-500 mcg/kg infused over 1-3 mins IV, follow with:
Maintenance infusion:
- 50 mcg/kg/min IV over 4 mins;
- if adequate effect not observed, repeat loading dose and increase infusing rate in increments of 50 mcg/kg/min IV for 4 mins
- this regimen can be repeated for 4 bolus doses and to an infusion rate of 300 mcg/kg/min