Hypertension Emergencies Therapeutics Flashcards
what numbers are the arbitrary threshold for severe high BP?
180/110mmHg or more
since numbers are arbitrary and can be different for everyone, an elevated BP must be interpreted in the context of what 3 things?
- what is their baseline BP?
- how quickly did the BP increase to the current level?
- are there signs and symptoms of end organ damage?
what characterizes a HTN urgency?
severe BP elevation that is mildly symptomatic or asymptomatic that is not due to an acutely reversible cause (pain, urinary retention) and there is no evidence of target organ damage
what characterizes HTN emergency?
severe BP elevation in the presence of acute symptoms or target organ damage in the brain, eye, heart, or kideny
what is the BP for urgency given by CHEP?
asymptomatic DBP >130mmHg
what is the BP for urgency given by AHA?
SBP >180 or a DBP >120 and no sx or organ dx
what is the BP for urgency given by JNC 7?
SBP >180 or a DBP >120
when a BP is _____mmHg or above, it rarely normalizes without medication
180/110
a HTN urgency requires ___ treatment
urgent
a HTN urgency requires BP lowering within what timeframe and with what types of therapies?
over 24-48 hours with PO medications
t/f a HTN urgency is life-threating
t
a HTN emergency needs BP lowering treatment within what timeframe?
1 hour
what is the 1 year mortality rate for untreated HTN emergency patients?
79%
what is the route of medications given for HTN mergency?
parenteral (IV)
HTN emergency is severe BP elevation in the setting of any of which 9 conditions?
- HTN encephalopathy
- acute aortic dissection
- acute left ventricular failure
- acute coronary syndrome
- acute kidney injury
- intracranial hemorrhage
- acute ischemic stroke
- pre-eclampsia or eclampsia
- cathecholamine-associated HTN
severe headache during a HTN emergency may indicate ____
encephalopathy
agitation, delirium, stupor, seizure in HTN emergency may indicate ___
intracranial process
visual disturbances in HTN emergency may indicate ___
stroke, retinopathy
focal neurological signs during HTN emergency indicate ___
stroke
numbness or weakness during HTN emergency may indicate ___
stroke
dyspnea and chest pain in a HTN emergency may indicate ____
ACS
nausea & vomiting is HTN emergency may indicate ___
elevated intracranial pressure
acute/severe back pain in a HTN emergency may indicate ___
aortic dissection
urinary retention during HTN crisis may indicate ___
acute kidney injury (AKI)
fundoscopy can be used to check for ___
hemorrhages, exudates (cotton wool spots), or papilledema-HTN retinopathy
CBC and liver enzyme testing can be done to check for ___
HELLP syndrome in pregnancy
an ECG can be performed to check for ___
left ventricular hypertrophy, ACS
cardiac enzyme testing can be done to check for ____
ACS
urinalysis and renal function testing can be done to test for ___
proteinuria and AKI
imaging can be performed to check for ___
aortic dissection or suspected stroke
what are 4 potential causes of HTN crisis?
- exogenous substances
- non-adherence to antihypertensives
- renal artery stenosis
- hormonal
what are 5 hormonal conditions that can lead to HTN crisis?
- hyperthyroidism
- hyperparathyroidism
- hyperaldosteronism
- Cushing’s syndrome
- pheochromocytoma
what Rx drugs can increase HTN?
- NSAIDs (including selective Cox-2)
- corticosteroids and anabolic steroids
- OCPs and sex hormones
- vasoconstricting / sympathomimetic decongestants
- calcineurin inhibitors (cyclosporin, tacrolimus)
- erythropoeitin and analogues
- antidepressants: MAOIs, SSRIs, SNRIs
- Midodrine
what are natural substances that can raise BP?
- licorice root
- stimulants like cocanine
- salt
- excessive alcohol intake
stroke volume is affected by what 3 things?
- preload
- afterload
- contractility
how is MAP (mean arterial pressure calculated)?
MAP = (1/3 x SBP) + (2/3 x DBP)
general pathophysiology of how HTN turns into end organ damage
- triggering factors like a vasoconstrictor causes an increase in systemic vascular resistance (big squeeze)
- endothelial injury
- coagulation cascade
- reduced perfusion to organs
- additional vasoactive mediators (RAAS)
- ischemia
in HTN urgency, you want to lower the BP to ___mmHg in 24 hours and then ____mmHg in 48 hours and then to target 140/90mmHg in ___ (timeframe)
180-190/110; 160-100; 140/90
dose of captopril
12.5-25mg SL or PO q6h
onset of captopril
SL: 10-15min
PO: 1-2hr
time for captopril to peak
SL: 1hr
PO: 1-2hr
duration of captopril
4-8hr
captopril should be avoided in what conditions?
pregnancy and renal failure
what is the drug class of clonidine?
alpha 2 agonist
dose of clonidine
0.1-0.2mg PO q8h (max 0.8mg/day)
onset of clonidine
30-60min
time to peak for clonidine
2-4 hrs
duration of action for clonidine
8-12 hours
what are some of the ADRs associated with clonidine?
drowsiness, bradycardia, rebound HTN when stoppedn
what is the drug class of labetolol?
mixed alpha 1 and B1/2 blocker
dosing of labetalol as PO therapy for urgency
100-400mg PO q6h
oral bioavailability of labetolol
25%
onset of labetalol
30-120min
time to peak for labetolol
3-4 hrs
duration for labetolol
6-8hr
what are some ADRs of labetolol?
bradychardia, bronchospasm
can labetolol be used in pregnancy?
yes
what is the drug class for hydralazine?
vasodilator
what is the PO dosing of hydralazine for urgency?
10-25mg PO q6h
what is the PO bioavailability of hydralazine?
50%
onset for PO hydralazine
20-30min
time to peak for PO hydralazine
1-2 hrs
duration for PO hydralazine
8hr
what are some of the ADRs of PO hydralazine?
reflex tachycardia, lupus-like syndrome
PO hydralazine is c/i in what condition?
renal failure
can hydralazine be used in pregnancy?
yes
if a short acting agent is used for initial control, once that control has been reached what type of agent should be used?
a long acting
what are 4 short-acting oral agents that can be used in HTN urgency?
captopril, clonidine, labetolol, hydralazine
in addition to tretment with the oral agents for HTN crisis, what other agents could be used to lower BP gradually in 1-2 days
DHP CCBs, ACE/ARB, thiazide-like diuretics
why is SL (immediate release) nifedipine not given anymore?
causes an uncontrollable rapid drop in BP, peripheral vasodilation resulting in coronary steal phenomena & or reflex tachycardia and have been cases of MI and stroke
genral MOA of CCBs
blocks transmembrane influx of Ca ions into cardiac smooth muscle cells and reduces peripheral vascular resistance by acting directly on vascular smooth muscle
list 3 DHP CCBs used for treatment of HTN urgency
- amlodipine
- nifedipine
- felodipine
which DHP CCB can be used in pregnancy?
Nifedipine XL
dose of amlodipine for urgency
2.5-10mg daily
ADME for amlodipine
A: peak in 6hrs
D: 20L/kg
M: hepatic CYP3A4 & inhibits CYP1A2
E: duration 24hrs
dose of Nifedipine XL for urgency
30-120mg daily
ADME of nifedipine XL
A: peak in 2 hrs
D: highly protein bound
M: hepatic CYP3A4 and CYP1A2
E: duration 24hrs
dose of felodipine XL for urgency
2.5-20mg daily
ADME for felodipine XL
A: peak 2-5hrs
D: highly protein bound
M: hepatic, CYP3A4 and 2C8
E: duration 24hrs
what are some ADRs of DHP CCBs?
peripheral edema, flushing, headache, reflex tachycardia
use caution if using a DHP CCB in patients with what condition?
aortic stenosis
can the nifedipine XL or felodipine XL be chewed or crushed?
no
when should the headache associated with urgency be gone?
within 24hrs
following HTN urgency, when should BP be monitored?
2-3 hours, then 24 hours, 48 hrs, 1 month, then 3 months
following a HTN urgency, when should electrolytes be measured?
3-4 weeks later
when should the patient follow up to ask about peripheral edema?
1 month after
in a hypertensive emergency, you want to decrease the MAP by ___% within what time frame? Then what?
decrease by 20-25% within 1 hour, then to 160/110mmHg after 2-6 hours, then further normalization within the nest 24-48hrs
t//f the choice of agent and blood pressure goals are dependent on the specific HTN emergency
t
list 6 parenteral medications used for HTN emergency?
- enalprilat
- esmolol
- hydralazine
- labetolol
- nitroglycerin
- phentolamine
dose, onset , duration of parenteral enalprilat for HTN E
1.25-5mg IV q6h ; 15-30min, 6-12hrs
dose, onset, and duration of parenteral esmolol for HTN E
bolus 500 mcg/kg IV; continuous 50-300mcg/kg/min; 1-2min, 10-20min
what is the drug category of enalaprilat?
ACEi
what is the typical indiaction for using enalprilat in HTN E?
if patient has acute LV failure
can enalaprilat be used in pregnancy?
no
what is an ADR of enalprilat?
acute renal injury
what is the drug class of esmolol?
cardioselective B blocker
what are some of the ADRs of esmolol?
bronchospasm, heart block, heart failure
in what cases of HTN E is esmolol typically used?
aortic dissection and perioperative
dose, onset and duration of IV hydralazine for HTN E
5-20mg IV q4-6h, may repeat 5mg in 20min; 10-20min, up to 12h
what are some of the ADRs of parenteral hydralazine?
tachycardia, flushing, enpredictable effect
when is hydralazine typically used for HTN E?
pregnancy or if B blockers need to be avoided
dose, onset, and duration for parenterla labetolol for HTN E
20-80mg iv q10min bolus, continuous 0.5-2mg/min IV; 5-10min, 3-6h
what are some of the ADRs of labetolol?
bronchospasm, bradycardia, heart block
when is labetolol used to treat HTN E?
most cases
can labetolol be used in pregnancy?
yes
what drug class is nitroglycerin?
veno/vasodiliator
what is the dose, onset and duration of parenteral nitroglycerin for HTN E?
continuous 5-200mcg/min IV; 2-5min; 5-10 min
what are some of the ADRs of parenteral nitroglycerin?
headache, reflex tachycardia, tachyphylaxis
what are the typical uses for nitroglycern in HTN E?
coronary ischemia, cerebral ischemia
what drug class is phentolamine?
alpha blocker
what is the dose, onset, and duration of parenteral phentolamine for HTN E?
IV bolus 10-15mg q 5-15min prn, continuous 1-40mg/h; 1-2min; 10-30min
what are some of the ADRs of phentolamine?
hypotension, flushing
when is phentolamine typically used in HTN E?
if there is increased catecholamine activity (ex: pheo, tyramine reaction)
which parenteral agent had been used in the past for HTN E, but is not recommended anymore?
Nitroprusside
why is nitroprusside not recommended anymore?
decreased cerebral blood flow and increased intracranial pressure
in what indications should nitroprusside reallyyy be avoided?
hypertensive encephalopathy or following cerebrovascular accident
in patients with CAD, nitroprusside was demonstrated to cause ___
coronary steal
nitroprusside is associated with creating what toxic chemical at recommended rates of infusion?
cyanide
what is the onset and duration of nitroprusside?
less than 1 min, lasts 2 min
what BP signifies acute-onset HTN (HTN E) in pregnancy?
SBP 160+ and or DBP 110+ that lasts 15min or longer
what should be done if a person is diagnosed with acute onset HTN in pregnancy?
immediately should go to the ER
when should you hope to resolve HTN related SOB?
within 4 hours
goal BP and timeframe for acute HTN E in pregnancy
160/110 in 1 hr, then 150/100 by the second hour
goal HR and timeframe for acute HTN E in pregnancy
<100 within 1 hr
what are the complications we are trying to avoid when treating acute HTN E in pregnancy?
stroke, seizures, AKI, fetal distress, premature delivery, initial agressive drop in BP
if the HR >60bpm, what is the recommended therapy for acute HTN E in pregnancy?
labetolol 10-80mg IV q10min (double the dose each time) until goal is achieved or until patient recieves the max of 300mg
if HR is <60bpm, what is the recommendation for acute HTN E in pregnancy?
hydralazine 5-20mg IV q20min until goal achieved or until max dose of 30mg is reached (use caution as hydralazine can have long duration of action & unpredictable BP lowering)
when does BP and HR need to be monitored in acute HTN E in pregnancy?
Q10min until BP is <160mmHg and then Q1hr
if patient has SOB in acute HTN E in pregnancy, when does O2 saturation need to be monitired after starting therapy? When will the lungs need to be ausculatated?
in 1 hour also in 1 hour
for acute HTN E in pregnancy patients, how often do they need to be asked if they are experiencing chest pain, dizziness or light-headedness?
q 30 min
are aortic dissection and aortic aneurysm the same thing?
no
what drugs are typically given for acute aortic dissection?
IV labetolol with or without a vasodilator to decrease pulsatile stress, but you need surgery ASAP
what drug should be avoided in aortic dissection?
hydralazine alone may cause reflex tachycardia
what is the BP goal in aortic dissection?
SBP 100-120mmHg within 20min
what is the HR goal for aortic dissection?
<60bbm within 20min
what is done is a patient is experiencing ischemic stroke and is not eligible for thrombolytic therapy?
treat if SBP>220 or DBP >120; reduce BP by ~15% over the first 24hrs with gradual reduction thereafter
what is done if a patient is experiencing an ischemic stroke and is eligible for thrombolytic therapy?
if high BP (>185/110mmHg) should be treated concurrently before giving thrombolytic drug and maintained for at least 24hrs
what are the 2 drugs of choice for ischemic stroke HTN E?
IV labetolol is the preferred option, but IV hydralazine can also be used (not preferred bc of unpredictable BP changes when you are really needing very carefully controlled BP management)
