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PHRM 844 > Hypertensive crisis > Flashcards

Hypertensive crisis Flashcards

1
Q

what are the two types of hypertensive crisis

A

urgency and emergency

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2
Q

what is hypertensive urgency

A
  • systolic BP >180 and/or diastolic BP >120
  • no evidence of target organ damage
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3
Q

what is hypertensive emergency

A
  • systolic BP >180 and/or diastolic BP >120
  • evidence of target organ damage (new or worsening)
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4
Q

what are common Sx of target organ damage

A

headache, chest pain, SOB, back pain, numbness/weakness, change in vision, difficulty speaking

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5
Q

what are the risk factors for development of a hypertensive crisis

A
  • obesity, female gender, hx of CV disease
  • higher number of prescribed antihypertensive meds
  • nonadherence w/ antihypertensive meds
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6
Q

common causes of hypertensive crisis

A
  • chronic htn
  • med non-adherence (most common and biggest factor to developing htn emergency)
  • medication/substance related
  • pregnancy
  • renal disease
  • endocrine disorders
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7
Q

goals of therapy for hypertensive urgency

A
  • reinstitute/intensification of antihypertensive drug therapy
  • tx of anxiety as applicable
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8
Q

in a hypertensive urgency, there is no indication for:

A
  • referral to emergency department
  • immediate reduction in BP
  • hospitalization
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9
Q

goals of therapy for hypertensive emergency

A
  • hour 1: reduce BP by a max of 25%
  • hour 2-6: reduce BP <160/100-110
  • hours 6-48: reduce BP to goal
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10
Q

in a hypertensive emergency, there is indication for:

A
  • referral to emergency department
  • hospital admission
  • IV antihypertensives
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11
Q

why should BP be lowered gradually in a hypertensive emergency?

A
  • HTN pts’ bodies adjust to functioning at increased BP
  • if BP is dropped too quickly, there is risk of tissue ischemia
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12
Q

how should hypertensive emergency be treated

A

with IV meds

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13
Q

why are IV meds preferred in a hypertensive emergency

A
  • fast onset/offset
  • predictable PK
  • minimal AEs
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14
Q

DHP CCBs agents for hypertensive emergency

A

Nicardipine
Clevidipine

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15
Q

what is nicardipine dosing

A

2.5-15 mg/hr titratable IV infusion

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16
Q

what is nicardipine onset

A

5-10 min

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17
Q

what is nicardipine duration

A

15-30 min

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18
Q

what are pros of using nicardipine

A
  • titratable
  • relative lower risk of AE
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19
Q

what are cons of using nicardipine

A
  • CI in severe aortic stenosis
  • titrate cautiously w renal/hepatic impairment
  • reflex tachycardia
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20
Q

what is clevidipine dosing

A

1-32 mg/hr titratable IV infusion

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21
Q

what is clevidipine onset

A

2-4 min

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22
Q

what is clevidipine duration

A

5-15 min

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23
Q

what are pros of clevidipine

A
  • titratable
  • lack of accumulation in organ impairment
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24
Q

what are cons of clevidipine

A
  • CI in severe aortic stenosis
  • lipid formula (CI w/ soy/egg allergy; elevates TGs, change IV lines q12h)
  • induces arterial fibrillation
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25
Q

vasodilator agents for hypertensive emergency

A

Nitroglycerin (nitrate)
Sodium nitroprusside (nitrate)
Hydralazine

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26
Q

what is nitroglycerin dosing

A

5-200 mcg/min titratable IV infusion

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27
Q

what is nitroglycerin onset

A

2-5 min

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28
Q

what is nitroglycerin duration

29
Q

what are pros of nitroglycerin

A
  • titratable
  • beneficial in coronary ischemia
30
Q

sodium nitroprusside dosing

A

0.25-10 mcg/kg/min titratable IV infusion

31
Q

sodium nitroprusside onset

32
Q

sodium nitroprusside duration

33
Q

sodium nitroprusside pros

A

-titratable

34
Q

nitroglycerin and sodium nitroprusside cons

A
  • tolerance w/ prolonged use (beyond 24-48 hrs)
  • interacts w/ PDE-5i
  • dose limiting headache and reflex tachycardia
  • excessive hypotension in hypovolemia
35
Q

sodium nitroprusside specific con

A

cyanide toxicity

36
Q

hydralazine dosing

A

10-20 mg IV push q4-6h

37
Q

hydralazine onset

38
Q

hydralazine duration

A

60-240 min

39
Q

hydralazine pros

A

may be used in pts w/ bradycardia

40
Q

hydralazine cons

A
  • not titratable
  • less predictable PK
  • rebound tachycardia
41
Q

B blocker agents for hypertensive emergency

A

Labetalol
Esmolol

42
Q

labetalol dosing

A

10-20 mg IV push followed by 20-80 mg q10min or titratable IV infusion

43
Q

labetalol onset

44
Q

labetalol pros

A
  • decreases HR and BP
  • can be given as titratable infusion
45
Q

labetalol cons

A
  • IV infusion > IV push
  • decreases HR
  • CI w/ severe bradycardia, ADHF, reactive airway disease
46
Q

esmolol dosing

A

titratable IV infusion

47
Q

esmolol onset

48
Q

esmolol duration

49
Q

esmolol pros

A
  • decreases HR
  • cardioselective (tolerated in reactive airway diseases)
50
Q

esmolol cons

A
  • adjunct, not monotherapy for BP reduction
  • avoid in severe bradycardia and ADHF
51
Q

what is a possible problem w/ esmolol

A

only decreases the HR in a pt with hypertensive emergency and doesn’t affect the BP

52
Q

other meds for hypertensive emergency

A

Enalaprilat -> ACEi
Clonidine -> alpha 2 agonist

53
Q

enalaprilat dosing

A

1.25-5 mg IV push q6h

54
Q

enalaprilat onset

55
Q

enalaprilat duration

56
Q

enalaprilat pros

A

maybe be beneficial in emergencies related to renin excess

57
Q

enalaprilat cons

A
  • delayed onset and peak
  • CI in AKI, hyperkalemia, acute MI, bilateral renal artery stenosis, pregnancy
58
Q

clonidine dosing

A

0.1-0.2 mg PO repeat q1h (max of 0.7 mg)

59
Q

clonidine onset

60
Q

clonidine duration

A
  • hours
  • max effect at 2-4h
61
Q

clonidine pros

A

PO option when IV access cannot be established

62
Q

clonidine cons

A
  • often used inappropriately in hypertensive emergency
  • delayed onset
  • can cause hypertensive crisis on withdrawal
63
Q

what meds are 1st line in pts w/ acute decompensated HF with pulmonary edema experiencing a hypertensive emergency

A
  • nitroglycerin or sodium nitroprusside
  • nicardipine and clevidipine are acceptable alternatives
  • avoid B blockers and non-DHP CCBs
64
Q

what meds are 1st line in pts w/ aortic dissection experiencing a hypertensive emergency

A
  • initiate B blocker then vasodilator (e.g. nicardipine, clevidipine, nitroprusside)
  • lower blood pressure quickly and prevent reflex tachycardia
65
Q
  • what meds are 1st line in pts w/ acute coronary syndromes experiencing a hypertensive emergency
A
  • B blockers, nitroglycerin or sodium nitroprusside, or nicardipine
  • use caution w/ non-DHP CCBS
  • avoid B blockers in setting of reduced EF, Hr <60 bpm, SBP <100 mmHg, 2nd or 3rd degree heart block, or reactive airway disease
66
Q

what meds are 1st line in pts w/ AKI experiencing a hypertensive emergency

A
  • most IV antihypertensives are acceptable
  • use caution w/ sodium nitroprusside
  • avoid enalaprilat bc it increases SCr and K
67
Q

what meds are 1st line in pts w/ eclampsia/severe pre-eclampsia experiencing a hypertensive emergency

A
  • hydralazine, lebetalol, or nicardipine
  • CI: enalaprilat and nitroprusside
68
Q

what meds are 1st line in pts w/ stroke (intracranial hemorrhage/ischemic) experiencing a hypertensive emergency

A
  • nicardipine, clevidipine, lebetalol

PHRM 844 (13 decks)

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