Acute Hypertensive Crisis Flashcards
Hypertensive Emergency vs Urgency
Urgency
-SBP > 180
-DBP > 120
Emergency
-SBP > 180
-DBP > 120
-Acute organ injury (AKI, MI, stroke, encephalopathy)
Common Presenting Subjective Symptoms
-SOB
-Pain
-HA
-Altered mental status
-Focal neurological deficit
Goals of Therapy
- Resolve clinical symptoms
- Prevent end organ damage or worsening of organ damage
- Achieve specified BP goals
Hypertensive Urgency TX
- Reinstitute/intensify ORAL ant-HTN therapy and arrange follow up
- Optional: PRN dosing of short acting meds
Short-acting Oral Blood Pressure Medications for Optional Urgency TX
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
Hypertensive Emergency TX
- Admit to ICU
- 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
Nitroglycerin (IV)
For emergency (HET)
AE: Headache, Tachyphylaxis
Nitroprusside (IV)
For emergency (CEC)
AE: Cyanide toxicity, Coronary steal
Hydralazine (IV, PO)
For emergency
AE: Tachycardia
Enalaprilat
For emergency
AE: AKI
Fenoldopam
For emergency (PIE)
AE: Increased intraocular pressure
CCBs for Emergency
DHPs preferred because of vascular selectivity
Nicardipine: reflex tachy/HA (most common)
Clevidipine: soy/egg allergies, ↑ triglycerides
Diltiazem, Verapamil (not really used)
Intravenous Beta Blockers (EM)
Esmolol, Labetalol, Metoprolol
-all decrease HR
Preferred Agents in EM
LABETALOL preferred IV push unless
*acute HR, bradycardia, or possibly asthma/COPD -BACH
NICARDIPINE preferred IV continuous
Acute Myocardial Infarction
nitroglycerin; esmolol, labetalol, metoprolol (M for MELN)
NOT nitroprusside
Acute Decompensated Heart Failure
nitroglycerin; nitroprusside
NOT BB/nonDHP
Aortic Dissection
nitroprusside or nicardipine + [esmolol or labetalol] (to prevent reflex tachycardia) DAL PEN
NOT hydralazine, minoxidil
Acute Kidney Injury
nicardipine, clevidipine, labetalol (P for pines, PAKIL)
NOT diuretics, ACE inhibitors, nitroprusside
Hyperadrenergic States
phentolamine, nitroprusside, beta blockers w/ alpha activity (i.e. labetalol) (PPL)
NOT BB w/o alpha
Preeclampsia
Magnesium + [labetalol or nicardipine or hydralazine]
NOT diuretics; ACE inhibitors, nitroprusside
Hemorrhagic Stroke
SBP < 220
-Mild: Goal 130-150 (NOT lower)
-Sev: Rec 130-150
SBP >=220
-Rec 130-150
-Use IV
Preferred: Nicardipine, Labetalol
Ischemic Stroke
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