Hypertensive Crisis

Question 1

Emergency VS Urgency

Answer 1

-severe elevation of BP: >180 / > 120

Urgency: severe elevated BP without end-organ damage, no signs of systemic damage

Emergency: severe elevated BP with end-organ damage -> ICU

Question 2

What are complications caused by hypersensitive crisis?

Answer 2

-Heart attack: cardiomyopathy (disorder affecting the heart muscle, MI, HF

-Neurologic: Stroke, dementia
-renal failure: AKI
-Retinopathy: visual loss
-Blood vessel damage: Atherosclerosis, Aneurysm
-Headache: Confusion, convulsion

Question 3

What to do in a hypertensive crisis?

Answer 3

-In emergency: immediate reduction of BP (not necessarily to normal) to prevent further organ damage

in Urgency: reimplementing meds if they stopped or increase the dose -> don’t need to be referred

Question 4

Evidence of acute organ damage

Answer 4

-Clinical (severe headache, AMS, anuria, oliguria)

-Labs (elevated SCr, troponin-I)

Question 5

What are compelling indications for a hypertensive emergency?

Answer 5

-Aortic dissection (swelling of aorta)
-Stroke (ischemic vs hemorrhagic) !!!
-MI
-Acute kidney injury
-Pheochromocytoma

Question 6

Why is an ischemic stroke different from a hemorrhagic stroke when treating an emergency?

Answer 6

-hemorrhagic: bleeding in the brain -> lower BP aggressively

-ischemic: BP may be high for a while -> the brain is compensating for the high BP, lowering it too fast can be dangerous

Question 7

Which drugs to choose in an urgency?

Answer 7

-PO: if initiating new meds choose quick onset/short-acting
Captopril over Lisinopril
Labetalol (mixed beta blocker, alpha-2 antagonist)
Clonidine
avoid fast acting nifedipine

Question 8

Which drug is recommended in a hypertensive emergency?

Answer 8

-IV meds, especially if a more aggressive goal
-typically in a ICU setting (monitors, staff)
-Nicardipine recommended (weak evidence)

-avoid ACEi in AKI or pregnancy

Question 9

When to lower BP aggressively

Answer 9

-Emergency

-not urgency

Question 10

Reduction in BP in an Urgency

Answer 10

-reduce by <25% over the first hour (max lowering)
f.e. if the patient has a SBP of 200 -> 25% = 150
so don’t treat to below 150 over the first hour

from >200/>120
-then to 160/100-110 mmHg over 2-6h
-then to normal over 24-48h