Hypertensive Crisis Flashcards by Corey Brend

What is hypertensive urgency?

-Systolic BP > 180 and/or diastolic BP > 120
-No evidence of target organ damage

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What is hypertensive emergency?

-Systolic BP >180 and/or diastolic BP >120
-Evidence of target organ damage (new or worsening)

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Symptoms of hypertensive crisis

-Headache
-Chest pain
-Shortness of breath
-Back pain
-Numbness/weakness
-Change in vision
-Difficulty speaking

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Risk factors for the development of a hypertensive crisis

-Obesity
-Female gender
-History of CV disease
-Higher number of prescribed antihypertensive medications
-Nonadherence with antihypertensive medications

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Common causes of a hypertensive crisis

-Chronic hypertension
-Medication non-adherence
-Medication/substance related
-Pregnancy
-Renal disease
-Endocrine disorders

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Goals of therapy for hypertensive urgency

-Reinstitute/intensification of antihypertensive drug therapy
-Treatment of anxiety as applicable

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Goals of therapy for a hypertensive emergency

-Hour 1: reduce BP by max of 25%
-Hours 2 - 6: reduce BP <160/100-110
-Hours 6 - 48: reduce BP to goal

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What past medical history should you look for in a patient who may be in a hypertensive crisis?

-History of HTN
-Home medications
-Social and family history

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What physical characteristics of a patient should be looked for in order to diagnose a hypertensive crisis?

-Symptoms
-SBP >180 and/or DBP >120
-Focal neurologic deficits
-Crackles on lung auscultation

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What labs should you look for in a patient who may be in a hypertensive crisis?

-CBC
-CMP (electrolytes, SCr, BUN, LFTs, Glucose)
-Toxicology
-Troponin
-Pregnancy

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What other tests should be done on a patient who may be in a hypertensive crisis?

-EKG
-Head CT
-Chest x-ray
-Eye exam

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How do you decide what medication to use on a patient who is in a hypertensive emergency?

-Should be treated with IV medications (unless unable to establish IV access)
-Medications with a predictable action such as medications that have a fast onset/offset, predictable pharmacokinetics, and minimal adverse effects
-Patient-specific factors and type of organ damage

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Which DHP calcium channel blockers are used for the treatment of hypertensive emergency?

-Nicardipine
-Clevidipine

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What are the pros to nicardipine?

-Titratable
-Relative lower risk for AE

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What are the cons to nicardipine?

-Contraindicated in severe aortic stenosis
-Titrate cautiously with renal/hepatic impairment
-Reflex tachycardia

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What are the pros of clevidipine?

-Titratable
-Lack of accumulation in organ impairment

What are the cons of clevidipine?

-Contraindicated in severe aortic stenosis
-Contraindicated with soy/egg allergies
-Elevates triglycerides
-Must change IV lines every 12 hours
-Induces atrial fibrillation

Which vasodilators are used for the treatment of hypertensive emergency?

-Nitroglycerin
-Sodium nitroprusside
-Hydralazine

What are the pros of nitroglycerin?

-Titratable
-Beneficial in coronary ischemia

What are the pros of sodium nitroprusside?

-Titratable

What are the pros of hydralazine?

-May be used in patients with bradycardia

What are the cons of nitroglycerin and sodium nitroprusside?

-Tolerance with prolonged use
-Interacts with PDE5-i
-Dose-limiting headache and reflex tachycardia
-Caution with high ICP
-Excessive hypotension in hypovolemia
-Cyanide toxicity (nitroprusside only)

What are the cons of hydralazine?

-Not titratable
-Less predictable pharmacokinetics
-Rebound tachycardia

Which beta blockers are used for the treatment of a hypertensive emergency?

-Labetalol
-Esmolol

What are the pros of labetalol?

-Decrease HR and BP -Can be given as a titratable infusion

What are the cons of labetalol?

-Usually, an IV infusion is more appropriate -Decreases HR -Contraindication with severe bradycardia, ADHF, reactive airway disease

What are the pros of esmolol?

-Decreases HR -Cardioselective

What are the cons of esmolol?

-Adjunct, not monotherapy for BP reduction -Avoid in severe bradycardia and ADHF

What are the pros of enalaprilat?

-May be beneficial in emergencies related to renin excess

What are the cons of enalaprilat?

-Delayed onset and peak -Contraindicated in acute kidney injury, hyperkalemia, acute MI, bilateral renal artery stenosis, pregnancy

What are the pros of clonidine?

-Oral option when IV access can not be established

What are the cons of clonidine?

-Often used inappropriately in hypertensive emergency -Delayed onset -Can cause hypertensive crisis on withdrawal

What medications should you use if the patient also has acute decompensated heart failure with pulmonary edema?

-Nitroglycerin or sodium nitroprusside (nicardipine and clevidipine are acceptable alternatives) -Avoid beta blockers and non-DHP CCBs

What medications would you want to use if the patient also has aortic dissection?

-Initiate beta blocker then vasodilator (e.g., nicardipine, clevidipine, nitroprusside) -Lower blood pressure quickly and prevent reflex tachycardia

What medications would you want to use if the patient also has 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, second or third degree heart block, or reactive airway disease

What medications would you want to use if the patient also has acute kidney injury?

-Most IV antihypertensives are acceptable -Use caution with sodium nitroprusside; avoid enalaprilat

What medications would you want to use if the patient also has eclampsia/severe pre-eclampsia?

-Hydralazine, labetalol, or nicardipine -Contraindicated: enalaprilat and nitroprusside

What medications would you want to use if the patient also has a stroke (intracranial hemorrhage/ischemic)?

-Nicardipine, clevidipine, or labetalol