7/11/12 - P&P of HT Flashcards
1
Q
Secondary Hypertension Causes
Goal:
Remove causative agent or treat underlying condition
A
Caused by:
- *Comorbid Conditions**
- *Renovascular / SLEEP APNEA / 1* Aldosteronism**
- cushings / pheochromocytoma / thyroid disease / HYPERparathyroidism*
Medications
Amphetamines / Steroids / Decongestants / NSAIDS
Estrogens / Calcineurin inhibitors / Ergot Alkaloids / Erythropoiesis-stimuating agents / Estrogens
- *Food:**
- *Alcohol / Licorice / Sodium**
2
Q
What Determines BP?
(Arterial Blood Pressure)
A
- *ABP** = CO x PR
- *Cardiac Output x Peripheral Resistance**
CO = SV x HR
- *PR determined by:**
- *Vascular Structure/Function**
3
Q
What determines CO = Cardiac Output?
A
BP = CO x PR
CO = SV x HR
Stroke Volume x Heart Rate
↑Preload = ↑Na+ Intake / renal retention
Venous Constriction
↑RAAS stimulation
↑SNS
4
Q
What Determines HEART RATE?
BP = CO x PR
CO = HR x SV
A
ParaSympathetic
Rest / Digest
ACth on heart pacemaker cells –> ↓HR
Sympathetic
Fight/Flight
NE/Epi on pacemaker cells:
–> ↑HR & ↑SV –> vasoconstriction –> ↑PR
5
Q
What Determines STROKE VOLUME?
BP = CO x PR
CO = HR x SV
A
- *Intrinsic Control**
- *HEART RATE** & Contractility
- *Extrinsic Control**
- *NE/Epi** on BETA-adrenergic receptors
- ↑*Force of Contraction–>↑SV
6
Q
What determines PERIPHERAL RESISTANCE = PR?
A
BP = CO x PR
Vascular Constriction** +/- **Vascular HYPERtrophy
↑RAAS
↑SNS over-activity
genetic changes in cell membranes / endothelial factors
7
Q
Normal BP
ACC/AHA Guidelines
A
SBP = <120 mmHg
AND
DBP = <80 mmHg
8
Q
ELEVATED BP
ACC/AHA Guidelines
A
SBP = 120-129 mmHg
AND
DBP = <80 mmHg
9
Q
Stage 1 HyperTension
ACC/AHA Guidelines
A
SBP = 130-139 mmHg
OR
DBP = 80-89 mmHg
10
Q
Stage 2 HyperTension
ACC/AHA Guidelines
A
SBP = _>_140 mmHg
OR
DBP = >90 mmHg
11
Q
SPRINT trial Population
Systolic BP Intevention Trial
A
>50 y/o w/ SBP 130-180
AND
> 1 additional RF for CV disease:
> 75 y/o // Clinical CVD (except stroke) // Subclinical CV disease
ASCVD > 15%
Exclusions:
DM / proteinuria / nursing home residents / symptomatic HF / history of CVA
12
Q
- *SPRINT**
- *Prmary Study outcomes & results**
A
CVD composite - first occurence of:
MI / non-MI Acute Coronary Syndrome/Stroke / HF / Death
- *INTENSIVE TREATMENT** = 2-3 Meds
- *BETTER ALL**:
- *Reducing BP / Primary Outcomes / Mortality / Fraility / Gait**
13
Q
ACCORD BP Results
Action to Control CV risk in DIABETES BP
A
NO BENEFIT in PRIMARY ENDPOINT
composite of non-fatal MI / stroke / CVD death
14
Q
ACC/AHA BP Goals for:
Clinical CVD
or
10 yr ASCVD Risk > 10%
A
< 130/80
BP Threshold:
> 130/80
Same for those with these specific comorbidities:
DM / CKD / CHF / PAD / secondary stroke prevention
Stable ischemic Heart Disease
15
Q
ACC/AHA BP Goals for:
No Clinical CVD
or
10 yr ASCVD Risk < 10%
A
< 130/80
BP Threshold:
> 140/90
16
Q
ACC/AHA BP Goals for:
Older Person > 65y/o
Community Dwelling
A
< 130 SBP
BP Threshold:
> 130 SBP
17
Q
Screening for Secondary HTN / Refractory HTN
A
Abrupt Onset
Onset < 30 yo
Exacerbation of previously controlled HTN
TOD disproportionate to degree of HTN
Malignant HTN
NEW Diastolic HTN > 65 yo
unprovoked / excessive HypoKalemia
18
Q
Diagnosis of HT & New Recommendations
A
> 2-3 properly measured BP readings
@
> 2-3 of visits after initial screening
Home BP monitoring recommended
Daytime average > 130/80
ABPM= Ambulatory BP monitor //HBPM = Home
19
Q
Diagnosis of MASKED HTN
when not on drug therapy
A
Office BP = 120-129 / < 80
after 3months of lifestyle mod & suspected MASKED HTN
Daytime ABPM or HBPM = <130/80mmhg?
- *YES = MASKED HTN**
- -> Lifestyle mods + START ANTI-HT DRUG THERAPY
- *NO = Normal Hypertension**
- -> Lifestyle mods + Annual ABPM or HBPM to detect progression
20
Q
Diagnosis of WHITE COAT HT
when not on drug therapy
A
Office BP > 130/80 but <160/100
after 3months of lifestyle mod & suspected WCHT
Daytime ABPM or HBPM = <130/80mmhg?
- *YES = White Coat Hypertension**
- -> Lifestyle mods + Annual ABPM or HBPM to detect progression
- *NO = Normal Hypertension**
- -> Continue Lifestyle mods + START ANTI-HT DRUG THERAPY
21
Q
When to treat HTN with Pharmacologic Therapy?
(ACC/AHA)
A
- *ABP > 140/90**
- *Primary prevention = no h/o CVD & ASCVD < 10%**
ABP > 130/80 with:
Secondary Prevention = CLINICAL CVD
Primary Prevention: 10yr ASCVD RISK > 10%
Age / Race / Cholesterol Panel / DM risk / BP meds / STATIN / ASA
Smoking
22
Q
BP Thresholds & Recommendations
for Treatment + Follow up
ELEVATED BP = 120-129 / <80
A
Promote optimal lifestyle habits
Non-pharmacologic Therapy
Reassess in:
3-6 MONTHS
23
Q
BP Thresholds & Recommendations
for Treatment + Follow up
Normal BP = <120/80
A
Promote optimal lifestyle habits
Reassess in:
1 YEAR
24
Q
BP Thresholds & Recommendations
for Treatment + Follow up
Stage 1 HTN = 130-139 / 80-89
WITH:
Clinical ASCVDor10yr ASCVD >10%
A
Promote optimal lifestyle habits
+
BP-LOWERING MEDICATION
Reassess in:
1 MONTH
If BP goal is met –> reassess in 3-6 months
if not –> assess adherence / intensify therapy –> 1 month reassessment
25
**BP Thresholds & Recommendations
for Treatment + Follow up**
**_Stage 1 HTN_** = **130-139 / 80-89**
***WITHOUT***:
Clinical ASCVD or 10yr ASCVD \> 10%
**Promote optimal lifestyle habits**
Reassess in:
* *3-6 Months**
* same as Elevated BP*
26
**BP Thresholds & Recommendations
for Treatment + Follow up**
**_Stage 2 HTN**_ = _**\>_** **140/90**
**Promote optimal lifestyle habits
+
_BP-LOWERING MEDS_**
Reassess in:
**_1 YEAR_**
If BP goal is met --\> **reassess in 3-6 months**
*if not --\> assess adherence / intensify therapy --\> 1 month reassessment*
27
**HTN in Older Adults _\>_ 65y/o**
Linear increase in Systolic & Diastolic BP until **~50-60y/o**
**SBP --\> continues to RISE**
**DBP --\> *gradually trends down***
HYVET & SPRINT:
displayed BENEFIT in elderly, *only includes COMMUNITY DWELLING*
Monitor for:
* *Orthostatic Hypotension**
* *caution for Frequent falls / Cognitive imparment / comorbidities**
28
**Best Proven _Nonpharmacological Intervention_
for the
Prevention/Treatment of Hypertension**
**_Weight Loss_**
**_Heat-Healthy Diet_**
DASH / mediterranian
↓**Na Intake** & ↓**Alcohol Intake**
↑**K+ Intake**, *as long as no CI's*
* *↑****Exercise**
* *150 min/wk moderate exercise** // 30 min 5x/wk
29
Which HTN Drug?
Blockade of **sodium reabsorption** @**distal tubule** causing **initial volume loss** mostly in **1st week**
long term **CO & volume** return closer to baselline while **SVR *decreases***
2/2 Vasodilatory effects
ADR:
**Electrolyte abnormalities**: **hypo**-**Na/Mg/K** -- **HYPER-Calemia**
frequent **Urination** / **GOUT** / dehydration / glucose intolerance
* *_THIAZIDE**_ _**DIURETICS_**
* *Hydrochlorothiazide, chlorthalidone, indapamide, metolazone**
**1st Line Drug**
Low dose **chlorathalidone** (**12.5-25mg**) preferred thiazide
**longer t1/2 & proven CVD reduction**
Limitations:
Reduced efficacy with **comorbid renal disease**
30
Which HTN Drug?
BLOCK conversion of **AT1 --\> AT2** = vasodilation / **↓aldosterone**
↓**Bradykinin metabolism** --\> ↑**Bradykinin** --\> **Vasodilation**
ADR:
**HYPERKalemia** / **COUGH**
angioedema / **nephrotoxicity / pancreatitis**
* *_ACE INHIBITORS_**
* *-prils**
**1st Line Drug**
ACC/AHA:
**CKD Stage 1** or **2** **_AND_** **albumin:creatinine ratio \> 300mg/g** or **30-299mg/g creatinine**
Or
**CKD Stage 3 or 4** // **HFrEF** // **CAD**
Limitations:
**COUGH --\> ARB**
31
Which HTN Drug?
Blockade of **sodium reabsorption** @**distal tubule** causing **initial volume loss** mostly in **1st week**
long term **CO & volume** return closer to baselline while **SVR *decreases***
2/2 Vasodilatory effects
ADR:
**Electrolyte abnormalities**: **hypo**-**Na/Mg/K** -- **HYPER-Calemia**
frequent **Urination** / **GOUT** / dehydration / glucose intolerance
* *_THIAZIDE**_ _**DIURETICS_**
* *Hydrochlorothiazide, chlorthalidone, indapamide, metolazone**
**1st Line Drug**
Low dose **chlorathalidone** (**12.5-25mg**) preferred thiazide
**longer t1/2 & proven CVD reduction**
Limitations:
Reduced efficacy with **comorbid renal disease**
32
Which HTN Drug?
Blocks actions of **AT2**
Vasodilation, ↓**aldosterone synthesis**
ADR:
**HYPERKalemia, Nephrotoxicity**
angioedema (very rare)
* *_ARBs_**
* *-sartans**
**1st Line Drug**
typically for **ACE intolerance**
ACC/AHA:
**CKD Stage 1** or **2 _AND_** **albumin:creatinine ratio \> 300mg/g** or **30-299mg/g creatinine**
Or
**CKD Stage 3 or 4** // **HFrEF** // **CAD**
33
Which HTN Drug?
**Vasodilation** of vascular smooth muscle via **calcium antagonism**
ADR:
**Headache / lightheadedness / flushing
dose-dependent peripheral edema**, gingival hyperplasia
--\> ***decrease dose*** or **switch agent** and/or **add RAAS-blocking (ACE/ARB)**
* *_Calcium Channel Blockers - DHP_**
* *Amlodipine, Nifedipine, Felodipine, Nicardipine**
**1st Line Drug**
Biggest role is:
those **w/o "compelling indications"** & **add-on therapy**
34
Which HTN Drug?
↓**CO** via ↓**HR** & ↓**Contractility**
from **inhibition of calcium ion** from entering voltage sensitive areas of **myocardium during depolarization**
ADR:
* *Bradycardia / Heart block**
* *HF Exacerbation (↓CO)**, **dose dependent CONSTIPATION**
* *_NON-DHP - Calcium Channel Blockers_**
* *Diltiazem & Verapamil**
* *ADD-ON THERAPY**
* can be 1st line ACC/AHA*
Biggest role is
**Patients w/ _Comorbid AFIB_**
Patients w/ **_CAD who CANNOT tolerate Beta-Blocker Therapy_**
Limitations:
**CI w/ Beta-blockers (additive) / HFrEF / 2nd-3rd Heart Block**
PK drug interactions: **CYP3a4 substrate/inhibitor**
35
Which HTN Drug?
***Blockade* of B1-receptors** --\> ↓**CO** via ↓**HR** & **↓SV**
Specifically:
**NONselective B1 & B2 adrenergic blocker**
ADR:
**Bradycardia / heart block / Bronchoconstriction**
lethargy / sex dysfunx / reynaud's phenomenon
* *_NON-Selective BETA BLOCKERs_**
* *PROPRANOLOL**
**2nd line / add-on Agent**
Critical role in:
**CAD (ischemic - MI) // HFrEF**
rate control
36
Which HTN Drug?
* **Blockade* of B1-receptors** --\> ↓**CO** via ↓**HR** & **↓SV**
* *CARDIOSELECTIVE**
ADR:
**Bradycardia / heart block / Bronchoconstriction**
lethargy / sex dysfunx / reynaud's phenomenon
* *_Cardioselective BETA BLOCKERs_**
* *Atenolol, Bisoprolol, Metoprolol, Nebivolol**
**2nd line / add-on Agent**
Critical role in:
**CAD (ischemic - MI) // HFrEF**
rate control
37
Which HTN Drug?
***Blockade* of B1-receptors** --\> ↓**CO** via ↓**HR** & **↓SV**
Specifically:
**MIXED** - ***nonselective* Alpha \< Beta adrenergic blockade**
ADR:
**Bradycardia / heart block / Bronchoconstriction**
lethargy / sex dysfunx / reynaud's phenomenon
* *_Mixed BETA BLOCKERs_**
* *Carvedilol / Labetalol**
**2nd line / add-on Agent**
Critical role in:
**CAD (ischemic - MI) // HFrEF**
rate control
38
Which HTN Drug?
***Inhibits* Symphathetically mediated** arterial vasoconstriction
via **blockade of alpha-1 receptors** on vascular smooth muscle
ADR:
**First dose** - **orthosttic effect** / dizziness / fatigue / HA
* *_ALPHA-BLOCKERS_**
* *Doxazosin, Terazosin, Prazosin**
* **Rarely used, ADD-on only***
* ALLHAT trial --\> inferiority to other drugs in CV endpoints*
**BPH d/t Relaxation of Bladder neck**
IF NOT HIGH CV RISK
39
Which HTN Drug?
Production of **false SNS Neurotransmitters**
ADR:
**edema / dizziness / impotence / arrythmia**
* *_Centrally Acting Drugs_**
* *METHYLDOPA**
***RARELY USED***
**_PREGNANCY_**
40
Which HTN Drug?
Binds to **central pre-synaptic Alpha-2 adrenergic receptors**
↓**Sympathetic outflow from CNS**
ADR:
**Bradycardia / Drowsiness
Rebound HTN w/ abrupt DC --\> Taper off**
* *_Centrally Acting Alpha-2 Agonist_**
* *CLONIDINE**
**Add-on Therapy**
only later line **2/2 CNS SE**
Once-Weekly transdermal dosage for non-adherent pts
41
Which HTN Drug?
**Direct Vasodilation of Arterioles**
ADR:
* *edema , drug-induced lupus/vasculitis**
* *reflex tachycardia**
* *_Vasodilator_**
* *HYDRALAZINE**
**Add-on Therapy - 3rd/4th line**
**IV dosage --\> QUICK onset & SHORT duration**
Useful in combination with:
**Nitrates for Pts w/ HFrEF** - esp **AA pts**
42
Which HTN Drug?
**Vasodilation** via **smooth muscle relaxation**
possibly mediated by **cAMP**
ADR:
**Hirsutism, edema, T-wave Changes
Reflex Tachycardia** (always used w/ BB), pericadial effusions
* *_Vasodilator_**
* *MINOXIDIL**
**limited Add-on Therapy - 3rd/4th line**
**Many ADR's & limited efficacy** (organ outcomes)
Significant BP reduction
43
**When to use this HTN drug?**
**_Loop Diuretics_
bumetanide / furosemide / torsemide**
Primarily used as:
* *_DIURETIC_**
when: **CrCl \<30** or **CKD stage 4/5**
Similar e- disturbances to thiazides, except:
* *Calcium Depleting**
* less likely to cause **hypoNatremia***
44
**When to use this HTN drug?**
**_Potassium Sparing Diuretics_
Amiloride / Triamterene**
Primarily used as:
* *_Thiazide + K-sparing combo**_ if _***hypo*Kalemic on thiazide_** -
- BUT caution with **GFR \<45mL/min**
45
**When to use this HTN drug?**
**_Anti-Aldosterone Antagonist_
Eplerenone / Spironolactone**
Primarily used for
**_Primary Aldosteronism_**
&
**_Resistant HYPERTension_**
* *Eplerenone = BID dosing**
* *Spironolactone = Gynecomastia**
**HyperKalemia** --\> caution with **K+ & CKD**
46
**Choosing a BETA BLOCKER**:
## Footnote
**HFrEF**
**Carvedilol**
Mixed A/B
**Metoprolol & Bisoprolol**
cardioselective --\> B1
Proven Mortality Benefit
47
**Choosing a BETA BLOCKER:**
**Asthma / COPD**
**B-1 Selective Agent:
Atenolol / Metoprolol**
Avoid Mixed / nonselective
48
**Choosing a BETA BLOCKER:**
**BPH**
Consider **Alpha-Blockade**
**Carvedilol / Labetalol**
49
**Choosing a BETA BLOCKER:**
**Type 2 DM**
**_CARVEDILOL_** \> Metoprolol
Associated with **lower A1c** & **microalbuminia**
50
**Choosing a BETA BLOCKER:**
**_Migraines_**
Consider **Lipid Solubility = Crosses BBB**
## Footnote
**Propanolol / Carvedilol**
51
* *Exceptions to the rule:
* _Avoid Drugs with SIMILAR TARGETS on BP control_***
* *Ace + Arb + Renin Inhibitor**
* NOT RECOMMENDED*
**_Diuretics_**
**_Non-DHP + DHP CCB_**
52
Choosing Initial Antihypertensive Drug Therapy
**Non-Black** **Population
&
W/ CKD**
**Thiazide** / **ACE / ARB** / **CCB**
**ACE/ARB preferred**
for **CKD**
53
Choosing Initial Antihypertensive Drug Therapy
* *Black Population w/o HF/CKD**
* including those with DM*
* *_THIAZIDES**_ / _**CCBs_**
* preferred over ACE/ARB*
54
Choosing Initial Antihypertensive Drug Therapy
**Black Population with
CKD**+/-**Proteinuria**
* *CKD 1/2** + **Proteinuria** OR **CKD 3/4**:
* *_ACE/ARB_**
55
Choosing Initial Antihypertensive Drug Therapy
**Black Population with
HFrEF**&**CHD s/p MI**
**_Beta Blockers**_ & _**ACEI/ARB_**
56
**What antihypertensive for:
PREGNANT?**
**_MethylDopa_**
Centrally Acting a2-agonist
**_Nifedipine_**
1,4-DHP CCB
**_Labetalol_**
Mixed a/b - blockers
57
What antihypertensive for:
## Footnote
**HFrEF**
**Beta Blocker**
**ACE/ARB**
**Anti-Aldosterone**
58
What antihypertensive for:
## Footnote
**MI**
**Beta Blocker** / **ACE**
59
What antihypertensive for:
**CKD Stage 1 or 2
_AND_
urinary albumin:creatinine ratio \> 300mg/g or 30-299mg/g creatinine**
**OR
CKD Stage 3 or 4**
**ACE/ARB**
60
What AntiHypertensive for:
## Footnote
**DIABETES**
**ACE / ARB**
**CCB - DIURETICS**
if **albuminuria --\> ACE/ARB**
61
What AntiHypertensive for:
## Footnote
**AFIB / Flutter rate Control**
**_NON-DHP CCB_**
Verapamil = PAA / Diltiazem = BTZ
**_Beta Blocker_**
lol's
62
**When to avoid this antihypertensive** **due to contraindications**:
## Footnote
**_THIAZIDES_**
**_GOUT_**
63
**When to avoid this antihypertensive due to contraindications:**
**_CCBs / Vasodilators_**
* *_Venous Insufficiency_**
* avoid CCB & vasodilators*
**_Bradycardia / Heart Block_**
BB's & Non-DHP CCB
* *_HFrEF_**
* caution with Non-DHP CCB*
64
**When to avoid this antihypertensive due to contraindications:**
**_Beta Blockers_**
**_ASTHMA / COPD_**
especialy NON-cardioselective like **propranolol**
**_Bradycardia / Heart Block_**
BB + Non-DHP CCB = negative chronotropes
65
**When to avoid this antihypertensive due to contraindications:**
**_ACE/ARB_**
**_HYPERKalemia_**
ACE/ARB + Spironolactone
**_Pregnancy_**
ACE/ARB + Renin Inhibitors -skirin
66
**_Results of ALLHAT trail_**
**HTN + 1 Additional major CV risk factor**
Primary Endpoint:
**Fatal CHD** or **nonfatal MI**
_In comparison to **Thiazide:**_
**Amlodipine (CCB) / Lisinopril** **(ACE)** = **Very Similar**
* except for:*
* *DOXAZOSIN = Beta Blocker**
* **_INFERIOR TO OTHER THERAPIES_***
But is still recommeneded for initial therapy if patient has:
**CAD/MI or CHF**
1st line for secondary prevention of **MI** & **↓Mortality w/ HFrEF**
67
**When do patients require 2+ HTN Drugs?**
Most patients require 2+ to reach goal BP
Especially when:
**BP \> 20/10 mmHG** (**\>160)**
over goal
**_Stage 2 HTN_** --\> **2x 1st line drugs**
68
**Complementary Combination Therapies**
**_ACE/ARB**_ + _**Thiazide_**
for maintaining **K+ Balance**
**Diuretics can trigger RAAS** --\> ACE can blunt this
* *_ACE/ARB**_ + _**DHP-CCB_**
* lessen **peripheral edema*** from **CCB**
**_Vasodilator + Beta-Blocker + Diuretic_**
BB blunting of **reflex tachycardia**
**Diuretic for Na + H2O retention**
69
**_Resistant HTN_**
## Footnote
**Definition & Risk Factors**
**Not at goal** on **3 BP Meds** (including diuretic)
OR
**Controlled on _\>_ 4 BP meds**
Risk Factors:
**Older Age \>65
Obesity
Black
DM**
70
**Non-Pharmacologic Treatment
Resistant HTN**
Assess/Improve **ADHERENCE**
Consider/Correct **Secondary Causes:
1\* Aldosteronism / OSA / Renal Artery Stenosis**
Target other modifiable caracteristics:
**Obesity / Inactivity / Salt / *low Fiber***
* *D/C Meds that can cause HTN:**
* *_NSAIDS / DECONGESTANTS / AMPHETAMINES_**
71
**Medication Management
Resistant HTN Treatment**
D/C or minimize: NSAIDS / Decongestants / Amphetamines
* *_Maximize DIURETIC_**
* *CHLORTHALIDONE** (preferred diuretic) \> HCTZ
**_+ADD+ Anti-Aldosterone Diuretic_**
PATHWAY RCT, **Spironolactone** \> a/b blockers
* *_+ADD+ agents w/ different MoA_**
* *Loop Diuretics** w/ **CKD** and/or those on **potent vasodilators (minoxidil)**
72
**Major Causes of
SECONDARY HTN**
&
Treatments
**_SLEEP APNEA_**
Spironolactone / CPAP / surgical correction
**_Aldosteronism_**
Spironolactone
**_RenoVascular Disease (Stenosis)_**
Vascular surgery, RAAS blockade w/ **diuretic**
**_HyperThyroid_**
**Renal Parenchymal Disease**
73
**#1 Cause of Secondary Hypertension**
**&**
**TREATMENT**
**_SLEEP APNEA_**
## Footnote
**SPIRONOLACTONE**
**CPAP**
**Surgical Correction**
74
**Monitoring for BP therapy**
_**MONTHLY follow-up** until **BP is controlled**_
Evaluate BP / Adherence / ADRs / Lifestyle Mods
* *Lab Assessment:**
* *dosing RAAS AGENT: BMP** within **2-4 weeks**
* *dosing DIURETIC: BMP** within **1-2 weeks** after changes --\> **q6-12m**
75
**HyperTensive Crisis**
**Definition & Target Organs**
* *Acute** + **Accelerated HTN** that **threatens or damages "end organs"**
* *Brain** --\> stroke/hemorrhage/EC(encephalopathy)
* *Heart**--\> MI/aortic dissection / ventricular dysfxn
* *Kidneys** --\> acute renal failure
* *Eyes** --\> retinal hemorrhage
## Footnote
**URGENCY vs EMERGENCY**
76
**HyperTensive Crisis**
**URGENCY vs EMERGENCY**
**_URGENCY_**
Severe elevations in BP = **\>180/120** mmHg
**_Emergency_**
Severe Elevations in BP
+
**SIGNS OF END ORGAN DMG**
77
**Treatment for**
**_Hypertensive URGENCY_**
severe BP elevation:
**\>180/120 mmHg**
* aggressive treatment does MORE HARM vs GOOD*
* *Abrupt "normalizing"** --\> **organ damage**
* *Organs can be ACCLIMATED to highBP**
Management:
**Investigate S/Sx** of **end-organ damage**
&
**_*reduce BP***_ _**--\> OVER DAYS- WEEKS_**
primarily with PO meds
78
**Treatment for**
**_Hypertensive EMERGENCY_**
severe BP elevation:
**\>180/120 mmHg
&
SIGNS OF END-ORGAN DMG**
***_WITHOUT compelling conditions_**:
Aortic Dissection / Severe Preclamsia / Pheochromocytoma Crisis*
Goal:
↓**BP** by **25%** in **1st hour**
then:
↓BP to **160/100-110** over the next **2-6 hours**
then
**Normalize** over next **24-48 hours**
***_Goal is to NOT normalize BP immediately!_***
exceptions = Aortic Dissection & Severe (pre)eclampsia or Pheochromocytoma criss
79
**Treatment for**
**_Hypertensive EMERGENCY**_ + _**AORTIC DISSECTION_**
severe BP elevation:
**\>180/120 mmHg
&
SIGNS OF END-ORGAN DMG**
Aortic Dissection = Exception
**Reduce SBP \< _120_** during **1st hour**
80
**Treatment for**
**_Hypertensive EMERGENCY_** + _**(Pre)eclamsia** or **Pheochromocytoma**_
severe BP elevation:
**\>180/120 mmHg
&
SIGNS OF END-ORGAN DMG**
Exception
**Reduce SBP** \< **_140_** during **1st hour**
