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Therapeutics 2 Final Exam > Hypertensive Crisis > Flashcards

Hypertensive Crisis Flashcards

1
Q

What are the 2 types of Hypertensive Crisis?

A

Hypertensive Urgency

Hypertensive Emergency

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2
Q

What is hypertensive urgency?

A

Systolic BP > 180 and/or Diastolic BP >120

no evidence of target organ damage

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3
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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4
Q

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

A

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

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5
Q

What percent of adults in the US have hyperetension?

A

30%

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6
Q

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

A

1% to 3%

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7
Q

What are the risk factors for developing a hypertensive crisis?

A

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

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8
Q

What are the 2 most common causes of hypertensive crisis?

A

-Chronic Hypertension
Medication non-adherence

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9
Q

What are other causes of hypertensive crisis?

A

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

-Pregnancy

-Renal Disease

-Endocrine Disorders (thyroid disease, adrenal tumors)

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10
Q

What are the goals for hypertensive urgency?

A

-Reinstitute/ Intensify antihypertensive drug therapy

-Treat anxiety as applicable

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11
Q

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

A

FALSE
-no indication for this

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12
Q

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

A

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

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13
Q

What are the goals with hypertensive emergency?

A

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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14
Q

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

A

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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15
Q

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

A

TRUE

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16
Q

What medication type should be used to treat hypertensive emergency?

A

IV antihypertensives

*oral medications are not absorbed fast enough

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17
Q

Why should BP be lowered gradually?

A

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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18
Q

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

A

-Nicardipine

-Clevidipine

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19
Q

Which IV DHP Calcium Channel Blocker has less adverse effects?

A

Nicardipine

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20
Q

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

A

Severe Aortic Stenosis

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21
Q

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

A

Lack of accumulation in organ impairment

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

22
Q

What are some cons to using Nicardipine IV?

A

-Need to titrate cautiously with renal/hepatic impairment

-Reflex tachycardia

-Contraindicated in severe aortic stenosis

23
Q

What are some cons to using Clevidipine IV?

A

-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

24
Q

What are the 3 vasodilators available in IV formualtions?

A

-Nitroglycerin (nitrate)

-Sodium Nitroprusside (nitrate)

-Hydralazine

25
Q

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

A

Hydralazine

*not titratable

26
Q

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

A

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

27
Q

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

A

Titratable

28
Q

What are some benefits to using Hydralazine in IV form?

A

May be used in patients with bradycardia

29
Q

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

A

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

30
Q

What is a con for only Nitroprusside IV?

A

Cyanide toxicity

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

31
Q

What are some cons to using hydralazine IV?

A

-Not titratable
-Less predictable pharmacokinetics
-Rebound tachycardia

32
Q

What 2 beta blockers are available in IV form?

A

Labetalol (push followed by infusion)

Esmolol (infusion)

33
Q

What are some pros to using Labetolol in IV form?

A

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

34
Q

What are some pros to using Esmolol in IV form?

A

-Decreases HR
*added on as adjunct with medications that cause tachycardia to prevent it

-Cardioselective
*is tolerated in reactive airway diseases

35
Q

What are some cons to using Labetalol in IV form?

A

-IV infusion is normally more appropriate (this medication is push + infusion)

-Decreases HR (+ or -)

-Contraindicated with: severe bradycardia, ADHF, reactive airway disease

36
Q

What are some cons to using Esmolol in IV form?

A

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

37
Q

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

A

Emergencies related to renin excess

38
Q

Why has Enalaprilat IV fallen out of favor?

A

-Long duration of action makes it less predictable (6 hours)

-Delayed onset (about 15 mins)

39
Q

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

A

Clonidine

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

40
Q

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

A

Clonidine

41
Q

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

A

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

42
Q

Which medication is most likely to cause bradycardia as a side effect?

A. Nicardipine
B. Sodium Nitroprusside
C. Labetalol
D. Enalaprilat

A

C. Labetalol

(this is a side effect of beta blockers)

43
Q

Which medication should be avoided in patients with a verified soy allergy?

A. Clevidipine
B. Hydralazine
C. Esmolol
D. Clonidine

A

A. Clevidipine

44
Q

Which medication is not available as a titratable IV infusion?

A. Hydralazine
B. Clevidipine
C. Labetalol
D. Nitroglycerin

A

A. Hydralazine (push)

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

45
Q

What are the IV drugs of choice for hypertensive emergency with ACUTE DECOMPENSATED HF WITH PULMONARY EDEMA?

AND: What drugs should be avoided

A

PREFER: Nitroglycerine or Sodium Nitroprusside
nitrates preferred

Alternatives: Nicardipine or Clevidipine

AVOID: Beta Blockers and Non-DHP CCBs

46
Q

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

And why?

A

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

47
Q

What are the IV drugs of choice for hypertensive emergency with ACUTE CORONARY SYNDROMES?

And what drugs should be avoided?

A

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

48
Q

What are the IV drugs of choice for hypertensive emergency with AKI?

And what drugs should be avoided?

A

PREFER: Most are acceptable

Caution with: Sodium nitroprusside (cyanide toxicity)

AVOID: Enalaprilat
(do not want to increase K)

49
Q

What are the IV drugs of choice for hypertensive emergency with ECLAMPSIA/SEVERE PRE-ECLAMPSIA?

And what drugs should be avoided?

A

PREFER: Hydralazine, Labetalol, Nicardipine

AVOID: Enalaprilat and Nitroprusside

50
Q

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

A

Nicardipine
Clevidipine
Labetalol

Therapeutics 2 Final Exam (3 decks)

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