Acute Hypertensive Crisis Flashcards
What are the criteria for Hypertensive urgency?
Hypertensive emergency?
- SBP > 180, DBP > 120
- SBP > 180, DBP > 120, PLUS ACUTE ORGAN INJURY
What are examples of organ injury?
Encephalopathy
AKI
TIA/STROKE
Retinopathy
HF,MI, Angina
Vascular Disease
What are some common etiologies?
-non adherence to antihtn meds
-drug withdrawal (bzd’s , alcohol)
-Anxiety /pain
-Delirium
-Volume overload
-Acute stroke
What are some less common etiologies?
-Pheochromocytoma
* Malignant
hyperthermia
* Neuroleptic malignant
syndrome
* Serotonin syndrome
* Autonomic dysreflexia
* Elevated intracranial
pressure (ICP)
Common presenting Subjective Sx’s ? (5)
SOB, Chest pain, HA, altered mental status, focal neurological deficit
Management of Hypertensive Crisis
- If pt is in hypertensive urgency, what 2 options do u have?
reinstitute or intensify oral anti-HTN therapy and arrange follow up
optional : PRN dosing of short acting meds
Short acting Medications : Pros and cons of each
- Clonidine
- Captopril
- Labetalol
- Minoxidil
- Fast onset In clinic
administration
con : bradycardia and sedation - fast onset + titratable
con : AKI, Hyperkalemia - Vasodilating beta-blocker
Decrease sympathetic nervous system
con : bradycardia, longer half life - potent vasodilator
con : edema, reflex tachycardia
Hypertensive Emergency :
1) Admit them to ICU where they’ll need ___ and ___
2) If conditions are present such as aortic dissection, severe preeclampsia/eclampsia or pheochromocytoma crisis what are BP goals?
- if they dont have these conditions what are ur BP goals?
- arterial line
-continous BP monitoring - decr SBP to < 140 mm Hg during 1st hour or to <120 mmhg if aortic dissection
- decr BP by max of 25% over 1st hr then to 160/100-110 over next 2-6 hrs then to normal over the next 24-48 hrs
What are some hypertensive emergency pharmacotherapy ideal characteristics?
IV
Fast onset
Fast offset
Non renal elim/hepatic metab
minimal side effects
addresses underlying pathology
Direct vasodilators : See chart
See chart
CCB’s : Which ones are usually used? and why is this?
See chart
DHP’s preferred because of vascular selectivity
-Non DHP’s have selectivity for cardiac myocytes (not helpful in this case)
IV BETA Blockers : See Chart
See chart
In general, what’s the preferred IV push agent?
-However this is not preferred in which patients?
What’s the preferred IV continuous agent?
LABETALOL
-unless pt’s have acute HF, bradycardia, or possibly in pt’s with asthma or COPD
Nicardipine
Preferred Agent in ACUTE MI? (4)
Which should u avoid?
Nitroglycerin, esmolol, labetalol, metoprolol
Avoid : Nitroprusside (coronary steal)
Preferred agent in acute decomp HF? (2)
Avoid?
Nitroglycerin ; nitroprusside
beta blockers; non DHP CCBs
Aortic Dissection requires RAPID reduction to SBP of?
Preferred agent in aortic dissection? (4)
Avoid? (2)
<120 in first hr
nitropruss or nicardipine + [Esmolol OR labetalol] to prevent reflex tachycardia
hydralazine, minoxidil
AKI : Preferred? (3)
Avoid? (3)
Nicardipine, clevidipine, labetalol
Diuretics, ACEI’s, nitroprusside
HYPERADRENERGIC STATES : Such as drugs, pheochromocytoma, serotonin syndrome , or abrupt withdrawal?
Preferred ? (3)
Avoid? (1)
Phentolamine, nitropruss, beta blockers with alpha activity such as Labetalol
Beta blockers w/out alpha activity
Pre-eclampsia
Preferred? (4)
Avoid? (3)
Magnesium + [labetalol or nicardipine or hydralazine]
Diuretics, acei’s, nitroprusside
HTN emergency associated with Hemorrhagic and Ischemic Stroke :
If Hemorrhagic Stroke that’s acute (<3hrs) –>
A. if initial SBP >= 220, what BP should u target and what should u use?
B. If Initial SBP is < 220 and pt has mild to mod ICH whats the goal SBP? What should u not lower it to?
-If Severe ICH?
No guideline rec ! but , target SBP 130-150, use IV meds
-Goal SBP 140, dont lower to <130
-No guideline rec but reasonable to target SBP 130-150
If Ischemic stroke that’s acute (<72 hrs from sx onset) and elevated BP –>
A. If pt is candidate for IV thrombolysis whats ur BP goal? (lower and maintain)
B. If pt is NOT a candidate for IV thrombolysis and BP is <220/110 what is witnessed?
C. If pt is NOT a candidate for IV thrombolysis and BP is >=220/110 what should be BP goal?
A. Lower to <185/110 before tPA
-maintain BP <185/110 for 24 hrs s/p tPA
B. Initiating within 48-72 hrs has no benefit
C. DECR BP by 15% during 1st 24 hrs to target BP < 220
What are the preferred agents for Hypertensive emergencies associated with hemorrhagic and ischemic stroke?
What should u avoid?
Nicardipine , labetalol
Nitroprusside
