E3: HTN Crisis

Question 1

Hypertensive Urgency
Definition
Cause
Symptoms
Treatment
Follow up

Answer 1

Definition: Very high BP (>180/120) without evidence of target organ damage

Cause: Typically from discontinuation of hypertension medications

Symptoms: None or mild, sometimes headache

Treatment: reinstitute or intensify ORAL antihypertensive drug therapy, assess for lifestyle modifications, remove medications/substances that increase BP

Follow up: 1-7 days

Question 2

Hypertensive Emergency
Definition
Symptoms
Treatment
Follow up

Answer 2

Definition: Very high BP (>180/120) with evidence of target organ damage (heart, brain, arteries, retina, kidney)

Symptoms: chest pain, SOB, headache, confusion, FAST, blurry vision, increase Scr

Treatment:
-1hr: BP reduced by 20%
-2-6hr: if STABLE, decrease to 160/100mmHg
-24-48hr: cautiously decrease to 140/90 mmHg
Admit to ICU for continuous monitoring and use parenteral antihypertensive agents (Labetalol and Nicardipine)

Follow up: After discharge, follow up with PCP after 7 to 14 days

Question 3

What 2 disease states are exceptions to the hypertensive emergency BP goals

Answer 3

1. intracranial hemorrhage
2. aortic dissection

Question 4

What agent is preferred over nicardipine or labetalol in acute pulmonary edema and acute myocardial infarction (MI)

Answer 4

Nitroglycerin

Question 5

Hospital course of hypertensive emergency
ED:
ICU:
Floor:

Answer 5

ED:
1. ID target organ damage
2. Start appropriate IV anti-HTN
-20% reduction in BP then go to 160/100

ICU:
1. Cont. IV anti-HTN
2. Maintain BP 160/100 until hr 6, then SLOWLY reduce to 140/90 over 24hr period
3. Cont. monitoring target organ damage

Floor:
1. 24hr after admission
2. Transition to oral anti-HTN when patient is STABLE
3. Cont. monitoring target organ damage

Question 6

Frequency of vitals while titrating medications? Frequency once stable

Answer 6

Take vitals q15min while titrating doses if not sooner

Once stable, q1hr

Question 7

What are the 2 main safety concerns for treating a hypertensive emergency

Answer 7

Hypotension (headache, dizzy, blurry vision, reflex tachycardia)
&
Adverse effects of treatment

Question 8

When should a patient be transitioned to oral anti-hypertensives (3)

Answer 8

1. once target organ damage is no longer worsening
2. med is confirmed appropriate and safe to use in GI tract
3. BP should be consistently near 140/90

Question 9

What things should be considered when transitioning to oral medications? (3)

Answer 9

1. Continue IV therapy while starting oral therapy
2. Resume home medications, may need to intensify doses
3. Start agents which patient can take LONG TERM

Question 10

When a patient is discharge they are placed on an oral regimen, what else is critical to do before their discharge

Answer 10

EDUCATE THEM

Question 11

When a patient is following up with their PCP when should they do it?
What is their BP goal?
What are they monitoring?
What else is important (3)

Answer 11

1. Follow up w/PCP 7 to 14 days after discharge
2. BP goal is <130/80
3. Monitor safety and efficacy
4. Important: Lifestyle modifications, patient education, adherence

Question 12

What 4 things can be done to prevent HTN crisis

Answer 12

1. Discuss w/RPh before starting OTC medications
2. Counsel on adherence
3. Consider non-pharm treatments (lifestyle)
4. Confirming access to meds