Hypertensive crisis Flashcards
Hypertensive Urgency
SBP > ___ and/or DBP > ___
- no evidence of target organ damage
180
120
Hypertensice Emergency
SBP > ___ and/or DBP> ___
- evidence of target organ damage
180
120
what does target organ damage look like?
- headache
- chest pain
- shortness of breath
- back pain
- numbness/weakness
- change in vision
- difficulty speaking
Risk factors for development of a HTN crisis
- obesity
- ___ gender
- history of CV disease
- higher number of prescibed antihypertensive medications
- ___ with antihypertensive medications
female
non-adherence
Causes of Hypertensive crisis
- ___ HTN
- non-adherence
- medication/substance related
- pregnancy
- ___ disease
- ___ disorders
- chronic
- renal
- endocrine
HTN Urgency - Goals of Therapy and Patient Workup
- reinstitute/intensify antihypertensive drug therapy
- treatment of ___ as applicable
There is NO indication for
- referral to ___
- immediate reduction in ___ (overcorrection may cause harm and offers no benefit)
- hospitalization
- anxiety
- ED
- BP
HTN Emergency - Goals of Therapy and Patient Workup
- Hour 1: reduce BP by max for ___ %
- Hours 2-6: reduce BP < ___ / ___
- Hours 6-48: reduce BP to ___
There is indication for
- referral to ___
- ___ admission
- ___ antihypertensives
Conditions with specific BP goals: stroke, aortic dissection, severe eclampsia/preeclampsia, pheochromocytoma crisis
- 25%
- 160/100-110
- goal
- ED
- hospital
- IV
Why should BP be lowered gradually?
- if you overcorrect and lower too much, it could result in passive ___ and risk tissue ___
collapse, ischemia
Pharmacotherapy
Hypertensive emergency should be treated with ___ medications
Prefer medications with predictable action
- fast onset/offset
- predicatable PK
- minimal AE
Patient-specific factors and type of target organ damage
IV
DHP Calcium Channel Blockers
Nicardipine - ___ IV infusion
- onset: ___ - ___ min
- duration: ___ - ___ min
Pros:
- titratable
- relative lower risk for AE
Cons:
- contraindicated in severe aortic ___
- titrate coutiously with renal/hepatic impairment
- reflex ___
- titratable
- 5-10
- 15-30
- stenosis
- tachycardia
DHP Calcium Channel Blockers
Clevidipine - ___ IV infusion
- onset: ___ - ___ min
- duration: ___ - ___ min
Pros
- lack of accumulation in organ impairment
- titratable
Cons
- contraindicated in severe aortic ___
- lipid formula (contraindicated with ___ / ___ allergy)
- elevates ___
- change ___ lines every ___ hours
- induces ___
- titratable
- 2-4
- 5-15
- stenosis
- soy/egg
- triglycerides
- IV, 12
- AFib
Vasodilators
Nitroglycerin - ___ IV infusion
- onset: ___ - ___ min
- duration ___ - __ min
Pros
- beneficial in coronary ___
- titratable
Cons:
- ___ with prolonged use (Max 24-48 hrs)
- interaction with ___
- ___ limiting
- headache and reflex ___
- caution with high ___
- excessive ___ in hypovolemia
- titratable
- 2-5
- 5-10
- ischemia
- tolerance
- PDE-5i
- dose
- tachycardia
- ICP
- hypotension
ICP = intracranial pressure
Vasodilators
Sodium Nitroprusside - ___ IV infusion
- onset: ___
- duration: ___ - ___ min
Pros:
- titratable
Cons:
- ___ with prolonged use (Max 24-48 hrs)
- interaction with ___
- ___ limiting
- headache and reflex ___
- caution with high ___
- excessive ___ in hypovolemia
- ___ toxicity
titratable
- seconds
- 2-3 min
- tolerance
- PDE-5i
- dose
- tachycardia
- ICP
- hypotension
- cyanide
ICP = intracranial pressure
Vasodilators
Hydralazine - IV ___
- onset: ___ - ___ min
- Duration: ___ - ____ min
Pros:
- may be used on pts with ___
Cons:
- not ___
- less ___ PK
- rebound ___
push
- 10-20
- 60-240
- bradycardia
- titratable
- predicatable
- tachycardia
Beta blockers
Labetalol - IV ___ followed by ____ IV infusion
- onset: ___ - ___ min
- duration: ___ - ___ min
Pros:
- decreases ___ and ___
- can be given as ___ infusion
Cons:
- usually, an IV ___ is more appropriate
- decreases ___
- Contraindication with severe ____, ADHF, and reactive ___ disease
push, titratable
- 5-10
- 180-360
- HR, BP
- titratable
- infusion
- HR
- bradycardia, airway
ADHF = acute decompensated HF
Beta blockers
Esmolol - ___ IV infusion
- onset: ___ - ___ min
- duration: ___ - ___ min
Pros:
- decreases ___
- ___ selective (tolerated in reactive airway disease)
Cons:
- adjunct, not ___ fot BP reduction
- avoid in severe ___ and ADHF
titratable
- 1-2
- 10-20
- HF
- cardioselective
- monotherapy
- bradycardia
Others
Enalaprilat - IV ___
- onset: < ___ min
- duration: ~ ___ hrs
Pros:
- may be beneficial in emergencies related to ___ excess
Cons
- delayed ___ and peak
- contraindicated in ___ , ___kalemia, acute ___ , bilateral ___ artery stenosis, and pregnancy
push
- 15
- 6
- renin
- onset
- AKI, hyperkalemia, MI, renal
Others
Clonidine; taken ___
- onset: ___ - ___ min
- duration: hours; max effect at ___ - ___ hours
Pros:
- ___ option when IV access can not be established
Cons:
- often used inappropriately in hypertensive emergency
- ___ onset
- can cause hypertensive crisis ___
PO
- 30-60 min
- 2-4
- PO
- delayed
- withdrawal
labetalol
clevidipine
hydralazine
Factors that Affect Choice of Treatment
ADHF with pulmonary edema
- avoid ___ and ___
- ___ or ___ appropriate
- ___ and ___ are acceptable alternatives
- BB, non-DHP CCBs
- nitroglycerin, nitroprusside
- nicardipine, clevidipine
Factors that Affect Choice of Treatment
Aortic Dissection
- inititate a ___ then ___ (example: nicardipine, clevidipin, nitroprusside)
- lower BO quickly and prevent reflex ___
(unique BP goals)
- BB, vasodilator
Factors that Affect Choice of Treatment
Acute Coronary Syndromes
- ___ , labetalol, ___ , nicardipine, or ___ can be used
- use caution with ___; avoid ___ in the setting of reduced EF, HR < ___ bpm, SBP < ___ mmHg, 2nd or 3rd degree heart block, or reactive airway disease
- esmolol, nitroglycerin, nitroprusside
- non-DHP CCBs
- BB, 60, 100
Factors that Affect Choice of Treatment
AKI
- most ___ antihypertensives are acceptable
- use caution with ___ ; avoid ___
- IV
- nitroprusside, enalaprilat
Factors that Affect Choice of Treatment
eclampsia/severe preeclampsia
- ___ , ___ , or ___
- contraindicated: ___ and ___
(unique BP goals)
- hydralazine, labetalol, nicardipine
- enalaprilat, nitroprusside
Factors that Affect Choice of Treatment
Stroke (Intracrainial Hemorrhage/Ischemic)
- ___ , ___ , or ___
(unique BP goals)
nicardipine, clevidipine, labetalol
nicardipine 5 mg/hr IV infusion
it is indicated as an adjunct and not a first line agent
