Hypertensive Crisis Flashcards
What is Hypertensive Crisis?
Hypertensive Urgency
* Systolic BP > 180 and/or Diastolic BP > 120
* No evidence of target organ damage
Hypertensive Emergency
* Systolic BP > 180 and/or Diastolic BP > 120
* Evidence of target organ damage (new or worsening)
Target Organ Damage
Symptoms Patients Report
* Headache
* Chest pain
* Shortness of breath
* Back pain
* Numbness/weakness
* Change in vision
* Difficulty speaking
organs at most risk from acute injury during hypertensive emergency: lungs + heart –> brain –> blood vessels –> kidneys –> eyes
Epidemiology
30% of adults in the United States have hypertension
*1% to 3% of patients with hypertension will have a hypertensive crisis during
their lifetime
Risk factors for development of a hypertensive crisis
* Obesity
* FemaleGender
* History of CV disease
*Higher number of prescribed antihypertensive medications
* Nonadherence with antihypertensive medications
Common causes
- Chronic Hypertension
- Medication Non-Adherence (biggest factor contributing to it/most common cause)
- Medication/Substance Related
- Pregnancy (placenta releases pro-inflammatory cytokines)
- Renal Disease (accumulation of renin)
- Endocrine Disorders
also cocaine, ecstasy, methamphetamine
Goals of Therapy & Patient Workup: hypertensive urgency
Goals
*Reinstitute/Intensification of antihypertensive drug therapy
* Treatment of anxiety as applicable
There is NO indication for
* Referral to emergency department
*Immediate reduction in blood pressure (overcorrection may cause harm and offers no benefit) - no need to be using IV meds
* Hospitalization
Goals of Therapy & Patient Workup: hypertensive emergency
Goals
* Hour 1: Reduce BP by max of 25%
* Hours 2 – 6: Reduce BP < 160/100-110
* Hours 6 – 48: Reduce BP to goal
There is indication for
* Referral to emergency department
* Hospital admission
* IV antihypertensives - need to get BP down fast, don’t use oral
Know that there are conditions with specific BP goals: stroke, aortic dissection, severe eclampsia/preeclampsia, pheochromocytoma crisis
Why BP should be lowered gradually?
if drop BP too quickly, decrease blood flow to brain; chance of tissue ischemia, cut off oxygen supply to organs
Patient Workup
checking to see if organs are affects by the high BP
past medical history:
* History of HTN
* Home medications
* Social & Family History
physical:
* Symptoms
* SBP >180 and/or DBP > 120
* Focal neurologic deficits
* Crackles on lung auscultation
labs:
* CBC
* CMP (electrolytes, SCr, BUN, LFTs, Glucose)
* Toxicology
* Troponin (cardiac damage)
* Pregnancy
other tests:
*EKG
* Head CT
* Chest x-ray
* Eye exam
Pharmacotherapy: factors that affect choice of pharmacologic agents
Hypertensive emergency should be treated with IV medications (unless unable to establish IV access)
Prefer medications with predictable action
* Fast onset/offset
* Predictable pharmacokinetics
* Minimal adverse effects
Patient-specific factors and type of target organ damage should be considered when selecting patient therapy
DHP Calcium Channel Blockers
nicardipine - titratable IV infusion
clevidipine - titratable IV infusion
Nicardipine pros + cons
Pros
* Titratable
* Relative lower risk for AE
Cons
* Contraindicated in severe aortic stenosis
* Titrate cautiously with
renal/hepatic impairment
* Reflex tachycardia
Clevidipine pros + cons
Pros
* Titratable
* Lack of accumulation
in organ impairment
Cons
* Contraindicated in severe aortic stenosis
* Lipid formula (contraindicated with soy/egg allergy; elevates triglycerides, change IV lines Q12hours)
* Induces atrial fibrillation
Vasodilators
nitroglycerin (nitrate) - titratable IV infusion
sodium nitroprusside (nitrate) - titratable IV infusion
hydralazine - IV push
Nitroglycerin pros + cons
Pros
* Titratable
* Beneficial in coronary ischemia (decrease cardiac load)
Cons
* Tolerance with prolonged use (Max 24-48 hours)
* Interact with PDE-5i
* Dose-limiting headache & reflex tachycardia
* Caution with high ICP
* Excessive hypotension in hypovolemia
Sodium nitroprusside pros + cons
Pros
titratable
Cons
* Tolerance with prolonged use (Max 24-48 hours)
* Interact with PDE-5i
* Dose-limiting headache & reflex
tachycardia
* Caution with high ICP
* Excessive hypotension
in hypovolemia
* Nitroprusside only: Cyanide toxicity
Hydralazine pros + cons
Pros
* May be used in patients with bradycardia
Cons
* Not titratable
* Less predictable pharmacokinetics
* Rebound tachycardia
Beta blockers
labetalol - IV push or titratable IV infusion
esmolol - titratable IV infusion (beta selective, doesn’t effect BP, treats HR)
Labetalol pros + cons
Pros
* Decreases HR & BP
* Can be given as a titratable infusion
Cons
* Usually, an IV infusion is more appropriate
* Decreases HR
* CI with severe
bradycardia, ADHF, reactive airway disease
Esmolol pros + cons
Pros
* Decreases HR
* Cardioselective
(tolerated in reactive airway diseases)
Cons
* Adjunct, not monotherapy for BP reduction
* Avoid in severe bradycardia and ADHF
Other medications
enalaprilat (ACEi) - IV push
clonidine (alpha-2 agonist) - PO
Enalaprit pros + cons
Pros
* May be beneficial in emergencies related to renin excess
Cons
* Delayed onset and peak
* CI in AKI, hyperkalemia, acute MI, bilateral renal artery stenosis, pregnancy
Clonidine pros + cons
not for hypertensive emergency
Pros
* PO option when IV access can not be established
Cons
* Often used inappropriately in hypertensive emergency
* Delayed onset
* Can cause
hypertensive crisis on withdrawal
Factors that affect choice of pharmacologic agents
acute decompensated HF with pulmonary edema
aortic dissection
acute coronary syndromes
AKI
eclampsia/severe pre-eclampsia
stroke (intracranial hemorrhage/ischemic)
Acute decompensated HF with pulmonary edema
*Nitroglycerin or sodium nitroprusside (nicardipine and clevidipine are acceptable alternatives)
*Avoid Beta Blockers and non-DHP CCBs
Aortic Dissection
*Initiate Beta blocker then vasodilator (e.g., nicardipine, clevidipine, nitroprusside) - want to decrease BP and HR
*Lower blood pressure quickly and prevent reflex tachycardia
Acute Coronary Syndromes
*Esmolol, labetalol, nitroglycerin, nicardipine, or sodium nitroprusside
*Use caution with non-DHP CCBs; avoid Beta Blockers in the setting of reduced EF, HR < 60 bpm, SBP < 100 mmHg, 2nd or 3rd degree heart block, or reactive airway disease
AKI
- Most IV antihypertensives are acceptable
- Use caution with sodium nitroprusside (due to cyanide toxicity); avoid enalaprilat (don’t want to increase serum creatinine)
Eclampsia/Severe Pre-eclampsia
- Hydralazine, labetalol, or nicardipine
- Contraindicated: enalaprilat and nitroprusside
Stroke (Intracranial Hemorrhage/Ischemic)
- Nicardipine, clevidipine, or labetalol
nitrates not preferred due to increased intracranial pressure
