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Therapeutics II > Hypertensive Crisis > Flashcards

Hypertensive Crisis Flashcards

1
Q

What is hypertensive urgency?

A

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

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2
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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3
Q

Symptoms of hypertensive crisis

A

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

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4
Q

Risk factors for the development of a hypertensive crisis

A

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

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5
Q

Common causes of a hypertensive crisis

A

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

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6
Q

Goals of therapy for hypertensive urgency

A

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

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7
Q

Goals of therapy for a hypertensive emergency

A

-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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8
Q

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

A

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

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9
Q

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

A

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

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10
Q

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

A

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

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11
Q

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

A

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

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12
Q

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

A

-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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13
Q

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

A

-Nicardipine
-Clevidipine

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14
Q

What are the pros to nicardipine?

A

-Titratable
-Relative lower risk for AE

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15
Q

What are the cons to nicardipine?

A

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

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16
Q

What are the pros of clevidipine?

A

-Titratable
-Lack of accumulation in organ impairment

17
Q

What are the cons of clevidipine?

A

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

18
Q

Which vasodilators are used for the treatment of hypertensive emergency?

A

-Nitroglycerin
-Sodium nitroprusside
-Hydralazine

19
Q

What are the pros of nitroglycerin?

A

-Titratable
-Beneficial in coronary ischemia

20
Q

What are the pros of sodium nitroprusside?

A

-Titratable

21
Q

What are the pros of hydralazine?

A

-May be used in patients with bradycardia

22
Q

What are the cons of nitroglycerin and sodium nitroprusside?

A

-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)

23
Q

What are the cons of hydralazine?

A

-Not titratable
-Less predictable pharmacokinetics
-Rebound tachycardia

24
Q

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

A

-Labetalol
-Esmolol

25
Q

What are the pros of labetalol?

A

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

26
Q

What are the cons of labetalol?

A

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

27
Q

What are the pros of esmolol?

A

-Decreases HR
-Cardioselective

28
Q

What are the cons of esmolol?

A

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

29
Q

What are the pros of enalaprilat?

A

-May be beneficial in emergencies related to renin excess

30
Q

What are the cons of enalaprilat?

A

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

31
Q

What are the pros of clonidine?

A

-Oral option when IV access can not be established

32
Q

What are the cons of clonidine?

A

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

33
Q

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

A

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

34
Q

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

A

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

35
Q

What medications would you want to use if the patient also has acute coronary syndromes?

A

-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

36
Q

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

A

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

37
Q

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

A

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

38
Q

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

A

-Nicardipine, clevidipine, or labetalol

Therapeutics II (33 decks)

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