Hypertension 2 Flashcards
How often should follow-up visits be scheduled until BP is at goal?
Every 4-6 weeks
How much of a BP reduction should you see per added agent?
10 mmHg
What are the 2 categories of hypertensive crises?
Hypertensive urgency, hypertensive emergency
What constitutes hypertensive urgency?
BP >180 and/or 120 without evidence of acute target-organ damage typically due to poorly controlled chronic HTN
How is hypertensive urgency assessed?
Rarely emergent therapy/monitoring
Thorough H&P to evaluate for signs/symptoms of organ damage
BMP, UA, EKG
What is the goal of hypertensive urgency treatment?
Reduce BP within hours
Give in office agent if available
What in office agents can be given for hypertensive urgency?
Clonidine, captopril, metoprolol tartrate, hydralazine, nifedipine
What is the action of clonidine?
Central sympatholytic
How fast is the onset of clonidine?
30-60 minutes
How long does clonidine last?
6-8 hours
What are adverse effects of clonidine?
Sedation
What is the mechanism of action of captopril?
ACEI
What is the onset of captopril?
15-30 minutes
How long is the duration of captopril?
4-6 hours
What are adverse effects of captopril?
Excessive hypotension
What is the action of metoprolol tartrate?
Beta blocker
What is the onset of metoprolol tartrate?
20-60 minutes
What is the duration of metoprolol tartrate?
5-6 hours
What are adverse effects of metoprolol tartrate?
Excessive hypotension, bradycardia
What is the action of hydralazine?
Vasodilator
What is the onset of hydralazine?
10-80 minutes
What is the duration of hydralazine?
Up to 12 hours
What are adverse effects of hydralazine?
Tachycardia, headache, GI
Often given with beta blocker due to risk of heart attack
What is the action of nifedipine?
CCB
What is the onset of nifedipine?
15 minutes
what is the duration of nifedipine?
2-6 hours
What are adverse effects of nifedipine?
Excessive hypotension, tachycardia, headache, angina, myocardial infarction, stroke
Severe HTN with signs and/or symptoms of end-organ damage. True medical emergency and must start lowering BP ASAP to preserve function
Hypertensive emergency
What is the typical BP with hypertensive emergency?
220/130
What is the initial evaluation of hypertensive emergency?
Problem-focused H&P (kidneys, heart, stroke, eyes, pulmonary)
CBC, CMP, EKG, CXR, CT head, UA, UDS
What is the goal of treatment for hypertensive emergency?
Use parenteral therapy to lower BP no more than 25% per first 2 hours then goal BP of 160/100 over next 2-6 hours
How do you determine specific goals for managing BP in hypertensive emergency?
Organ involved
What is the BP goal of ischemic CVA in hypertensive emergency? Hemorrhagic?
SBP between 180-200 mmHg with slow reduction
Hemorrhagic- target SBP is <140 mmHg
What is the goal BP for aortic dissection?
SBP <120 mmHg
What is the goal BP for MI?
Need anticoagulation and oxygen; typically use NTG for BP reduction, but no set goal
What calcium channel blockers can be used for hypertensive emergency?
Nicardipine, clevidipine
How fast is the onset of calcium channel blockers used in hypertensive emergency?
Within minutes
What are adverse effects of nicardipine?
Hypotension, tachycardia, headache
What medications are 1st line for african americans?
CCB or thiazide
What medications are first line for non-african americans?
ACEI/ARB, CCB, or thiazide
If a patient has elevated BP, how should they be managed?
Lifestyle changes
Trick question :)
If a patient has stage 2 hypertension, how would you manage them?
nonpharmacologic therapy and BP lowering medication
Follow up in 1 month
What is the only time that you would give a beta blocker or a aldosterone antagonist first line?
Heart failure or post-MI/CAD
How often should an EKG be obtained on a patient with hypertension?
every 2-4 years
What are adverse effects of clevidipine?
headache, nausea, vomiting
what are clevidipine contraindications?
allergy to soy or egg
what are adverse effects of labetalol?
GI, hypotension, bronchospasm, bradycardia, heart block
which patients should you avoid using labetolol in?
Avoid in acute LV systolic dysfunction, asthma
what are the adverse effects of esmolol?
bradycardia, nausea
you should not give esmolol to patients with what?
LV systolic dysfunction, asthma
what are adverse effects of fenoldopam?
reflex tachycardia, hypotension, increased intraocular pressure
what is the mechanism of action of enalprilat?
ACE inhibitor
what are adverse effects of enalaprilat?
excessive hypotension
how is enalaprilat used?
additive with diuretics
What is the mechanism of action of furosemide?
diuretic
what are adverse effects of furosemide?
hypokalemia, hypotension
How is furosemide used?
adjunct to vasodilator
what is nitroglycerin?
vasodilator
what are adverse effects of nitroglycerin?
headache, nausea, hypotension, bradycardia
what do you need to keep in mind with nitroglycerin?
Can develop tolerance
most useful with myocardial ischemia
what is the mechanism of action of nitroprusside?
vasodilator
what are adverse effects of nitroprusside?
GI, CNS, thiocyanate and cyanide toxicity, especially iwth renal and hepatic insufficiency; decreased cerebral blood flow, increased intracranial blood pressure
what are treatment options for hypertensive emergency?
- nicardipine
- clevidipine
- labetolol
- esmolol
- fenoldopam
- enalaprilat (additive with diuretics)
- furosemide (adjunct to vasodilator)
- nitroglycerin
- nitroprusside (no longer first-line agent)
How much is HR expected to change during pregnancy?
increase by 10 bpm during 3rd trimester
How does pregnancy impact BP?
Tends to decrease during 2nd trimester due to decrease in systemic vascular resistance
when is a BP considered abnormal during pregnancy? Why?
> 140/90
associated with increased risk in perinatal morbidity and mortality
what does diagnosis of hypertension during pregnancy require?
2 elevated readings at least 4 hours apart
What are classifications of hypertension during pregnancy?
- Preeclampsia
- Gestational
- Chronic
- Preeclampsia superimposed on chronic hypertension
What is classified as preeclampsia?
New onset HTN (BP >140/90) and proteinuria (24 hr urinary protein >300 mg/24 h or creatinine ratio >.3) after 20 weeks gestation
What is classified as gestational HTN?
HTN (BP 140/90) after 20 weeks gestation without pre-existing HTN or proteinuria
What is considered chronic HTN in a pregnant patient?
HTN before 20 weeks gestation or longer than 12 weeks postpartum
what HTN medications are contraindicated during pregnancy?
ACEI and ARBs
How is acute chronic/gestational HTN treated?
IV labetolol, IV hydralazine, oral immediate-release nifedipine
How is chronic HTN managed during pregnancy?
labetalol, ER nifedipine, or methyldopa
what is the target BP during pregnancy?
130-150/80-100
not recommended to reduce BP by more than 25% over 2 hours
failure to reach BP control in patients who are adherent to full doses of an appropriate 3-drug regimen, including a diuretic
Resistant HTN
What could be an issue leading to resistant HTN?
medication noncompliance
What would you do if a patient has resistant hypertension?
Refer to nephrology or cardiology
to rule out secondary causes
consider switching diuretic to aldosterone receptor blocker
What are causes of resistant HTN?
- Improper blood pressure measurement
- volume overload and pseudotolerance: excess sodium intake, volume retention from kidney disease, inadequate diuretic therapy
- Obesity
- Excess alcohol intake
- Secondary causes of hypertension
What are drug-induced causes of resistant HTN?
- Inadequate doses or inappropriate combinations
- NSAIDs
- Cocaine, amphetamines, other illicit drugs; sympathomimetics
- oral contraceptives
- adrenal steroids
- erythropoietin
- licorice
- selected OTC supplements and medicines (ephedra, ma huang, bitter orange)
