Acute Hypertensive Crisis

Question 1

Hypertensive Emergency vs Urgency

Answer 1

Urgency
-SBP > 180
-DBP > 120

Emergency
-SBP > 180
-DBP > 120
-Acute organ injury (AKI, MI, stroke, encephalopathy)

Question 2

Common Presenting Subjective Symptoms

Answer 2

-SOB
-Pain
-HA
-Altered mental status
-Focal neurological deficit

Question 3

Goals of Therapy

Answer 3

1. Resolve clinical symptoms
2. Prevent end organ damage or worsening of organ damage
3. Achieve specified BP goals

Question 4

Hypertensive Urgency TX

Answer 4

1. Reinstitute/intensify ORAL ant-HTN therapy and arrange follow up
2. Optional: PRN dosing of short acting meds

Question 5

Short-acting Oral Blood Pressure Medications for Optional Urgency TX

Answer 5

Clonidine
-fast, in clinic but brady/sedation

Captopril
-fast, titrate but AKI/hyperkalemia

Labetalol
-vasodilating, but brady/long half life

Minoxidil
-vasodilator, but edema/reflex tachy

MLCC

Question 6

Hypertensive Emergency TX

Answer 6

1. Admit to ICU
2. Aortic dis/preclampsia/pheo?
   *YES = decrease to SBP < 140 in first hour or < 120 if aortic dis
   *NO = decrease by max 25% in first hour then to 160/100-110 over 2-6 hours then normal in 24-48 hours

Question 7

Nitroglycerin (IV)

Answer 7

For emergency (HET)

AE: Headache, Tachyphylaxis

Question 8

Nitroprusside (IV)

Answer 8

For emergency (CEC)

AE: Cyanide toxicity, Coronary steal

Question 9

Hydralazine (IV, PO)

Answer 9

For emergency

AE: Tachycardia

Question 10

Enalaprilat

Answer 10

For emergency

AE: AKI

Question 11

Fenoldopam

Answer 11

For emergency (PIE)

AE: Increased intraocular pressure

Question 12

CCBs for Emergency

Answer 12

DHPs preferred because of vascular selectivity

Nicardipine: reflex tachy/HA (most common)

Clevidipine: soy/egg allergies, ↑ triglycerides

Diltiazem, Verapamil (not really used)

Question 13

Intravenous Beta Blockers (EM)

Answer 13

Esmolol, Labetalol, Metoprolol

-all decrease HR

Question 14

Preferred Agents in EM

Answer 14

LABETALOL preferred IV push unless
*acute HR, bradycardia, or possibly asthma/COPD -BACH

NICARDIPINE preferred IV continuous

Question 15

Acute Myocardial Infarction

Answer 15

nitroglycerin; esmolol, labetalol, metoprolol (M for MELN)

NOT nitroprusside

Question 16

Acute Decompensated Heart Failure

Answer 16

nitroglycerin; nitroprusside

NOT BB/nonDHP

Question 17

Aortic Dissection

Answer 17

nitroprusside or nicardipine + [esmolol or labetalol] (to prevent reflex tachycardia) DAL PEN

NOT hydralazine, minoxidil

Question 18

Acute Kidney Injury

Answer 18

nicardipine, clevidipine, labetalol (P for pines, PAKIL)

NOT diuretics, ACE inhibitors, nitroprusside

Question 19

Hyperadrenergic States

Answer 19

phentolamine, nitroprusside, beta blockers w/ alpha activity (i.e. labetalol) (PPL)

NOT BB w/o alpha

Question 20

Preeclampsia

Answer 20

Magnesium + [labetalol or nicardipine or hydralazine]

NOT diuretics; ACE inhibitors, nitroprusside

Question 21

Hemorrhagic Stroke

Answer 21

SBP < 220
-Mild: Goal 130-150 (NOT lower)
-Sev: Rec 130-150

SBP >=220
-Rec 130-150
-Use IV

Preferred: Nicardipine, Labetalol

Question 22

Ischemic Stroke

Answer 22

Candidate for IV thrombolysis?

YES = lower to < 185/110 before tpa

NO
= BP < 220/110: ix in 2-3d no benefit
= BP >= 220/110: decrease by 15% in 24 hours (target < 220)

Preferred: Nicardipine, Labetalol