Hypertensive Crisis Flashcards by TheOneandOnly Ash

What are the 2 types of Hypertensive Crisis?

Hypertensive Urgency

Hypertensive Emergency

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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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What are some common symptoms of target organ damage from hypertensive emergency?

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

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What percent of adults in the US have hyperetension?

30%

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What percent of patients with hypertension will have a hypertensive crisis in their life?

1% to 3%

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What are the risk factors for developing a hypertensive crisis?

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

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What are the 2 most common causes of hypertensive crisis?

-Chronic Hypertension
Medication non-adherence

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What are other causes of hypertensive crisis?

-Medication/Substance Related (cocaine, meth, stimulants)

-Pregnancy

-Renal Disease

-Endocrine Disorders (thyroid disease, adrenal tumors)

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What are the goals for hypertensive urgency?

-Reinstitute/ Intensify antihypertensive drug therapy

-Treat anxiety as applicable

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True or False: Patients experiencing hypertensive urgency should be sent to the emergency department/hospital

FALSE
-no indication for this

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True or False: Patients experiencing hypertensive urgency should NOT have their blood pressure immediately reduced

TRUE
-overcorrection may cause harm and offers no benefit
-no need for IV drugs

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What are the goals with hypertensive emergency?

Hour 1: Reduce BP by MAX of 25%

Hours 2-6: Reduce BP <160/100-110

Hours 6-18: Reduce BP to goal

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Why do we want to rapidly decrease blood pressure with hypertensive emergency?

If you do not rapidly decrease blood pressure, it causes more organ damage which we do not want

(want to preserve organ function)

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True or False: patients experiencing hypertensive emergency should be referred to the hospital

TRUE

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What medication type should be used to treat hypertensive emergency?

IV antihypertensives

*oral medications are not absorbed fast enough

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Why should BP be lowered gradually?

In hypertensive patients, the body adjusts to having a higher baseline level of blood pressure. When BP is decreased too quickly, the body is not prepared to autoregulate at that level

-this can lead to decreased blood flow to the brain and tissue ischemia

(vasculature collapses)

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What are the two DHP Calcium Channel Blockers available as titratable IV infusions?

-Nicardipine

-Clevidipine

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Which IV DHP Calcium Channel Blocker has less adverse effects?

Nicardipine

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What contraindication is associated with both IV DHP calcium channel blockers?

Severe Aortic Stenosis

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What is a pro for using clevidipine over nicardipine for IV infusion?

Lack of accumulation in organ impairment

*still likely would prefer nicardipine though because of increased adverse effects

What are some cons to using Nicardipine IV?

-Need to titrate cautiously with renal/hepatic impairment

-Reflex tachycardia

-Contraindicated in severe aortic stenosis

What are some cons to using Clevidipine IV?

-Lipid formula (contraindicated in soy/egg allergy)

-Contraindicated in aortic stenosis

-Elevates triglycerides

-Need to change IV line every 12 hours

-Induces Afib (can introduce arrythmia)

-More adverse effects

What are the 3 vasodilators available in IV formualtions?

-Nitroglycerin (nitrate)

-Sodium Nitroprusside (nitrate)

-Hydralazine

Which vasodilator is only available in IV push form and not IV infusion?

Hydralazine *not titratable

What are some benefits to using the vasodilator Nitroglycerin in IV form?

-Titratable -Beneficial in coronary ischemia (increases blood flow to heart)

What are some benefits to using the vasodilator Sodium Nitroprusside in IV form?

Titratable

What are some benefits to using Hydralazine in IV form?

May be used in patients with bradycardia

What cons are associated with using Nitroglycerin and Sodium Nitroprusside in IV form?

*Both these medications are nitrates* -Tolerance with prolonged use (Max 1-2 days) -Interact with PDE-5 inhibitors (do not use with tadalafil or sildenafil) -Dose-limiting headache + reflex tachycardia -Caution with high ICP (intracranial pressure) -Excessive hypotension with hypovolemia

What is a con for only Nitroprusside IV?

Cyanide toxicity -in renal and hepatic impairment cyanide can accumulate and become toxic

What are some cons to using hydralazine IV?

-Not titratable -Less predictable pharmacokinetics -Rebound tachycardia

What 2 beta blockers are available in IV form?

Labetalol (push followed by infusion) Esmolol (infusion)

What are some pros to using Labetolol in IV form?

-Decreases HR and BP -Can be given as titratable infusion

What are some pros to using Esmolol in IV form?

-Decreases HR *added on as adjunct with medications that cause tachycardia to prevent it -Cardioselective *is tolerated in reactive airway diseases

What are some cons to using Labetalol in IV form?

-IV infusion is normally more appropriate (this medication is push + infusion) -Decreases HR (+ or -) -Contraindicated with: severe bradycardia, ADHF, reactive airway disease

What are some cons to using Esmolol in IV form?

-Used as adjunct, not monotherapy for BP reduction -Avoid in severe bradycardia and ADHF

When would the IV formulation of Enalaprilat (ACEi) be used?

Emergencies related to renin excess

Why has Enalaprilat IV fallen out of favor?

-Long duration of action makes it less predictable (6 hours) -Delayed onset (about 15 mins)

What drug can be used for hypertensive urgency as a one-time dose?

Clonidine (alpha-2 agonist) PO (not used for emergency)

If IV access cannot be established, what drug may be given PO?

Clonidine

What are some cons to using Clonidine in the setting of hypertensive crisis?

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

Which medication is most likely to cause bradycardia as a side effect? A. Nicardipine B. Sodium Nitroprusside C. Labetalol D. Enalaprilat

C. Labetalol (this is a side effect of beta blockers)

Which medication should be avoided in patients with a verified soy allergy? A. Clevidipine B. Hydralazine C. Esmolol D. Clonidine

A. Clevidipine

Which medication is not available as a titratable IV infusion? A. Hydralazine B. Clevidipine C. Labetalol D. Nitroglycerin

A. Hydralazine (push) *enalaprilat is the other one (push) and clonidine (PO)

What are the IV drugs of choice for hypertensive emergency with ACUTE DECOMPENSATED HF WITH PULMONARY EDEMA? AND: What drugs should be avoided

PREFER: Nitroglycerine or Sodium Nitroprusside *nitrates preferred* Alternatives: Nicardipine or Clevidipine AVOID: Beta Blockers and Non-DHP CCBs

What are the IV drugs of choice for hypertensive emergency with AORTIC DISSECTION? And why?

Beta blocker then initiate vasodilator/CCB (nicardipine, clevidipine, nitroprusside) -Want to lower BP quickly and prevent reflex tachycardia -This disease state has unique BP goals

What are the IV drugs of choice for hypertensive emergency with ACUTE CORONARY SYNDROMES? And what drugs should be avoided?

PREFER: Esmolol, Labetalol, Nitroglycerin, Sodium Nitroprusside, Nicardipine Caution With: non-DHP CCBs AVOID: Beta Blockers when: Reduced EF, HR < 60 bpm, SBP < 100mmHg, 2nd or 3rd degree heart block, reactive airway disease

What are the IV drugs of choice for hypertensive emergency with AKI? And what drugs should be avoided?

PREFER: Most are acceptable Caution with: Sodium nitroprusside (cyanide toxicity) AVOID: Enalaprilat (do not want to increase K)

What are the IV drugs of choice for hypertensive emergency with ECLAMPSIA/SEVERE PRE-ECLAMPSIA? And what drugs should be avoided?

PREFER: Hydralazine, Labetalol, Nicardipine AVOID: Enalaprilat and Nitroprusside

What are the IV drugs of choice for hypertensive emergency with STROKE (INTRACRANIAL HEMORRHAGE/ISCHEMIC)?

Nicardipine Clevidipine Labetalol