HTN Crisis Flashcards
What is a HTN crisis?
> 180/120
What are the risk factors of HTN crisis?
- Female sex
- Age
- Black
- Low income
- Medication non-adherence
What is the patho of HTN crisis?
What is the most common pharmacological causes that could lead to HTN crisis?
Withdrawn of AHTN therapy (b-blockers, clonidine)
Discuss the signs and symptoms of HTN emergency?
What are the steps for HTN emergency treatment?
First hour: Decrease in DBP by 10-15% or MAP by 25% with goal DBP ≥100 mmHg
2-6 hr: SBP 160 and/or DBP 100-110
24-48 hr: Outpatient BP goals
What are the exceptions of HTN emergency treatments?
- Acute aortic dissection
- Stroke
- Pregnancy (severe preeclampsia or eclampsia)
- Pheochromocytoma crisis
What is the dosage form of HTN emergency treatments? Onset? Duration?
IV
Fast
Low DOA → increased titration
Most are titrations and weight based
What is the fastest drug for emergency?
Nitroprusside
What is nitroprusside? MOA? ADRs? CIs? Indications?
MOA: Potent arterial and venous VD that leads to smooth muscle relaxation
Coronary steal and increased ICP
ADR: Acute MI and ICP elevation
CI: Cyanide toxicity with long duration of high doses (72 hr)
Renal and liver failure
Indication: All
Nitroglycerin? MOA? ADR? CI? Indication?
MOA: venous vasodilator with no coronary steal
ADR: Tachyphylaxis (24-48hr) with lacking nitrate-free intervals, flushing, HA, erythema
CI: PDE3is
Indication: MI/ACS and ADF w/ pulmonary edema
Hydralazine? MOA? ADR? CI? Indication?
MOA: Peripheral arterial VD
ADR: Rebound tachycardia, HA, lupuslike syndrome
CI:
Indication: Pregnancy
Nicardipine? MOA? Pros and cons? Indications?
Crosses the BBB → cerebral vasodilation
Metabolized by CYP
Cheaper than clevidipine
Requires large volume adminsitration
Most indications especially strokes
Clividipine? MOA? Pros and cons? Indications?
Inhibits calcium influx in vascular smooth muscle
Lipid emulsion → expire in 12 hr → monitor TAG → caution in soy or egg allergies
Better BP variability profile, less volume administered
Faster BP attainment
What are b1 antagonists used? Indications? MOA?
- Esmolol (rapid onset, short duration, titratable):
- Metoprolol (IV push, slower onset, longer DOA): overaggressive correction:
Aortic dissection
Negative inotropic and chronotropic activity (not VD)
Labetalol? Indication? CI?
1:7 alpha to beta blockade
Infusion or push
Pregnancy, stroke, aortic dissection
Respiratory disease
What is the overall warning of beta blocker?
Avoid with ADHF, heart block, bradycardia
Enalaprilat? Indication? CI?
IV ACEIs not easily titratable
Limited use due to slow onset and DOA
Pregnancy and renal dysfunction
Phentolamine? MOA? Indications? ADRs?
Peripheral alpha 1 and 2 blockier → direct vasodialtion
Pheochromocytoma, catecholamine excess, cocaine, amphetamine induced HTN emergency
Rebound tachycardia
Felodopam? MOA? Indications? ADRs?
Peripheral dopamine 1 agonist → arterial VD
CI: Anaphylaxis with sulfite allergies
ADR: Hypokalemia, flushing, increase IOP
What is the difference between Type A and B aortic dissection?
A: ascending (surgical emergency)
B: aortic arch or descending aorta
What is the treatment goal for aortic dissection?
Control BP and HR
HR <60 ASAP
SBP <120 and/or as low as clinically tolerated
Beta blockers used first, followed by VD if needed
What are the 4 categories of pregnancy HTN?
- Chronic
- Gestational
- Preeclampsia
- Superimposed preeclampsia
What is gestational HTN?
New-onset HTN >20 weeks gestation without proteinuria or other systemic findings
Whaat is preeclampsia
≥140/90 on 2 separate occasions at least 4 hrs apart with proteinuria > 20 weeks gestation or presence of severe features
What is superimposed preeclampsia?
Patient with HTN prior to pregnancy who now has preeclampsia
What severe features are you looking for in pregnancy HTN?
- Thrombocytopenia
- Impaired LFTs
- New renal insufficiency
- Pulmonary edema
- New-onset cerebral or visual disturbances
What is eclampsia?
Seizure onset in a woman with preeclampsia
What is considered severe HTN in pregnancy?
> 160/110
What is pregnancy treatment for HTN?
Delivery is only managed by eclampsia → Magnesium IV added to reduce seizure risk → IV AHTN for BP >160/110, preeclampsia/eclampsia or HTN emergency (Labetalol, hydralazine, CCB) → Goal
What is goal of HTN pregnancy ?
Decrease MAP by 20-25% over minutes to hrs then to ultimate goal SBP<140
When do you treat ischemic HTN?
Only treat BP if: using thrombolytics, other target organ damage present, >220/120
What drugs do you use for Ischemic HTN uemergency?
Labetalol, nicardipine, clevidipine, hydralazin and enalaprilat
What is hemorrhagic HTN emergency? Goal? Drugs?
Elevated BP → hematoma expansion → neurologic worsening
SBP 140-160
Nicardipine or clevidipine
What is pheochromocytoma? Drugs?
Excess release of E and NE due to adrenal tumor
Pure alpha antagonist
Alternatives: phenoxybenzamine or doxzosin
Drugs for cocaine induced HTN emergency?
- Benzos (central effect)
- Phentolamine (2nd line)
- CCB and VD (3rd line)
- Combo of a/b blockers if tachycardia arises
What is the treatment for urgency?
Lower BP slowly using PO med → maintenance med → optimal use of quick onset med
What are the quick onset med? Dose?
- Captopril: 25-50 mg, onset 15-30 min
- Clonidince: 0.2 mg, for HTN rebound with withdrawn
- Labetalol: 200-400 mg
- Hydralazine: 10 mg
Why do we need to correct BP slowly?
- Cerebral ischemia
- Neurological decline
- End organ adjustment to chronic HTN
How should you monitor and follow up with hypertensive emergency?
- ER → ICU
- Follow treatment goals and timelines
- Monitor improvements in end organ damage and side effects of medications
- IV → PO transition
What are we looking for in HTN emergency monitoring?
- Target organ damage
- GIT is functional
- BP is near recommended goal for 2 consecutive readings
How should you monitor and follow up with hypertensive urgency?
