Hypertensive Crisis Flashcards
What is hypertensive urgency?
-Systolic BP > 180 and/or diastolic BP > 120
-No evidence of target organ damage
What is hypertensive emergency?
-Systolic BP >180 and/or diastolic BP >120
-Evidence of target organ damage (new or worsening)
Symptoms of hypertensive crisis
-Headache
-Chest pain
-Shortness of breath
-Back pain
-Numbness/weakness
-Change in vision
-Difficulty speaking
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
Common causes of a hypertensive crisis
-Chronic hypertension
-Medication non-adherence
-Medication/substance related
-Pregnancy
-Renal disease
-Endocrine disorders
Goals of therapy for hypertensive urgency
-Reinstitute/intensification of antihypertensive drug therapy
-Treatment of anxiety as applicable
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
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
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
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
What other tests should be done on a patient who may be in a hypertensive crisis?
-EKG
-Head CT
-Chest x-ray
-Eye exam
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
Which DHP calcium channel blockers are used for the treatment of hypertensive emergency?
-Nicardipine
-Clevidipine
What are the pros to nicardipine?
-Titratable
-Relative lower risk for AE
What are the cons to nicardipine?
-Contraindicated in severe aortic stenosis
-Titrate cautiously with renal/hepatic impairment
-Reflex tachycardia
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
