Hypertensive Crisis

Question 1

What are the acute elevations in Blood Pressure

Answer 1

Signs of End-Organ dysfunction (present) -> Hypertensive Emergency (present) -> Treatment Goal -> Exceptions (Aorta Dissection, Stroke, Preeclampsia and Eclampsia)

Question 2

What is hypertensive crisis

Answer 2

SBP greater than 179 mmHg and/or diastolic blood pressure greater than 109 mmHg

Question 3

What is a hypertensive emergency

Answer 3

Abrupt rise in BP WITH ACUTE END ORGAN DAMAGE; DBP usually greater 120 mmHg

Question 4

What is a hypertensive urgency

Answer 4

Abrupt rise in BP with NO signs of end-organ damage

Question 5

What patient groups are more likely to have a hypertensive emergency

Answer 5

Elderly, blacks, and Men

Question 6

What is the most common cause of hypertensive emergency/ other causes

Answer 6

Medication non-adherence/ Medication withdrawal, renal drugs, cocaine, post-operative, pre-eclampsia and eclampsia

Question 7

What medications are known to have withdrawal symptoms that could lead to hypertensive crisis from abrupt disocontinue or use

Answer 7

Clonidine, beta-blockers, cocaine, amphetamines

Question 8

What is the pathophysiology of HTN crisis

Answer 8

Vasoconstrictors (angiotensin 2) and cellular adhesion molecules (CAMs) cause vasoconstriction and breakdown endothelial vasoconstriction and vasodilation control leading to platelet aggregation, inflammation, fibrinoid edema, and perivascular edema

Question 9

What are the three determinants of end organ damage

Answer 9

Cardiac output %. oxygen consumption, autoregulartory dependence

Question 10

What organs keep the highest percent of cardiac output

Answer 10

Kidney, gastrointestinal tract, skeletal muscle, brain

Question 11

Which organs have the highest oxygen consumption

Answer 11

Skeletal muscle, gastrointestinal tract/spleen, brain, heart muscle, kidney, skin

Question 12

Which organs have excellent autoregulation (most likely to dysfunction during a hypertensive emergency), moderate, little to none

Answer 12

Heart muscle, brain, kidney/ skeletal muscle and GI tract/ skin

Question 13

What organ dysfunction caused by a hypertensive emergency effecting the brain would be seen in a patient

Answer 13

Cerebral Infarction (stroke), Encephlapothy, Intracerebral or Subarrachnoic Hemmorhage

Question 14

What organ dysfunction caused by a hypertensive emergency effecting the heart would be seen in a patient

Answer 14

Acute pulmonary edema, acute congestive failure, acute myocardial infarction or unstable angina

Question 15

What organ dysfunction caused by a hypertensive emergency effecting the kidney would be seen in a patient

Answer 15

Acute kidney injury

Question 16

What labs that can be obtained to diagnose a hypertensive emergency

Answer 16

CBC, X-ray, urine studies, CT scan, LFT, BNPs, Troponin, CPK

Question 17

What is the goal blood pressure target to treat a hypertensive emergency within the first hour, 2- 6 hours, 6-24 hours, 24-48 hours

Answer 17

Reduction of MAP greater than 25% or reduce DBP by 10-15% (goal DBP of greater than or equal to 100 mmHg), SBP of 160 mmHg and/or DBP 100-110 mmHg, SBP of 160 mmHg and/or DBP 100-110 mmHg during the first 24 hours, JNC-8 outpaitent goals

Question 18

T/F: For Hypertensive urgency a patient can recieve oral medication and a reduction of MAP within 24-48 hours

Answer 18

True

Question 19

What are the exceptions to the goal blood pressure targets for other hypertensive emergencies and why

Answer 19

Aortic dissertion: control sheer stress, Ischemic stroke and Hemorrhagic stroke: maintain CPP, Pre-eclampsia and Eclampsia : maintain fetal blood flow and avoid maternal/fetal complications

Question 20

What is the goal parameters for treating aortic dissection and in what amount of time

Answer 20

Heart rate less than 60 BPM and SBP less than 120 mmHg within minutes

Question 21

If patient has an ischemic stroke when is the only time their hypertensive emergency will be treated, what are the goal blood pressure parameters and in what amount of time

Answer 21

If thrombolytic therapy is required the goal BP is less than 185/110 before using TPA then less than 185/105 mmHg after starting and through the first 24 hours of tPA, all must be done within minutes/ Other target organ damage OR SBP greater than 220 mmHg and/or DBP greater than 120 mmHg and the goal is to have a MAP reduction 15-20% over 24 hours

Question 22

If a patient has hemorrhagic stroke without an increase in ICP what is the blood pressure target and how long is needed to achieve this, with an increase in ICP and how long

Answer 22

BP less than 140 mmHg or less than 160 mmHg within minutes/ If a patient has a large hematoma or extreme elevations (SBP greater than 220 mmHg) need to be treated, goal BP is less than 180mmHg and/or MAP less than 130mmHg over 24 hours

Question 23

When is the only time a hypertensive crisis would be treated in a pregnant mother with Eclampsia or pre-eclampsia, goal BP and time needed

Answer 23

Severe HTN (SBP greater than 160 mmHg or DBP greater than 100 or has eclampsia), less than or equal to 140/90 mmHg in minutes

Question 24

What is given for pre-eclampsia or eclampisa to prevent seizures

Answer 24

Magnesium 4-6 gram IV bolus in 100 ml over 15 minutes, followed by 1-2 grams per hour

Question 25

What is blood pressure variability, why is it important

Answer 25

Standardized way of representing changes in blood pressure over time, able to possibly give more insight into risk and outcomes

Question 26

What are the main reasons for medication selection

Answer 26

Target organ damage and symptoms

Question 27

What vasodilators are used in hypertensive emergencies

Answer 27

Nitropusside (not used in stroke patients and coronary infarctions or ischemia), Hydralazine (best used in pregnancy), Nitroglycerin (coronary ischemia/infracton, acute left ventricular failure, pulmonary edema), Clevidipine and Nicardipine (acute ischemic or hemmorhagic stroke), fenoldopam

Question 28

What are the beta-blockers used in hypertensive emergencies

Answer 28

Esmolol (aortic dissection, coronary ischemia and infarction), labetalol (acute ischemic or hemorrhagic stroke, aortic dissection, coronary ischemia/infaraction and pregnancy), metoprolol (aortic dissection, coronary ischemia and infarction)

Question 29

What patients cannot recieve Esmolol, how should it be used in aortic dissection, metabolized

Answer 29

Acute decompensated heart failure, initiate esmolol first due to delayed onset and should always be used in conjucntion with a vasodilator, hydrolozyed by esterases in the blood

Question 30

Which beta-blockers are useful in tachyarrhythmias

Answer 30

Esmolol and metoprolol

Question 31

T/F: Hypertensive urgency should be treated aggresively

Answer 31

False: Hypertensive urgency can be treated by starting the home medication (no need for ICU)

Question 32

T/F: For aortic dissection esmolol should be given with a vasodilator in order to treat aortic dissection

Answer 32

True

Question 33

What drugs can be used for hypertensive urgency and at what doses

Answer 33

Captopril: 25 to 50 mg at 1-2 hour intervals, Clonidine: 0.2 mg followed by hourly dosing of 0.2 mg until DBP is less than 110 mmHg (reserved for rebound HTN due to clonidine withdrawal), Labetalol: 200 to 400 mg followed by additional doses every 2 to 3 hours, Hydralazine: 10 to 25 mg three to four times a day, Nicardipine: 20 mg three times a day

Question 34

What are the doses used for the vasodilators used in hypertensive emergencies

Answer 34

Nitroprusside 0.3-0.5 mcg/kg/min IV infusion, titrate by 0.5 mcg/kg/min every few minutes, up to 10 mcg/kg/min (reasonable up to 2 mcg/kg/min to avoid toxicity)(Reasonable to avoid if concerned for increased ICP)// Nitroglycerin 10-20 mcg/min IV infusion, titrate every 5-15 minutes, up to 200 mcg/min// Clevidipine 1-2 mg/hr IV infusion, doses may be doubled at 90 second intervals, then every 5-10 minutes, up to 21mg/hour// Nicardipine 5mg/hr IV infusion, titrate by 2.5mg/hour at 5-15 minute intervals, up to 15mg/hour// Fenoldopam 0.01-0.3 mcg/kg/min IV infusion, titrate by 0.05-0.1 mcg/kg/min every 15 minutes, up to 1.6 mcg/kg/min. Reasonable to avoid if concerned for increased ICP.

Question 35

What are the doses for beta-blockers used in hypertensive emergencies

Answer 35

Esmolol: 500 to 1000 mcg/kg/min IV over 1 minute followed by 50 mcg/kg/min IV infusion. Bolus dose may be repeated and the infusion may be increased in increments of 50 mcg/kg/min as needed to MAX 200 mcg/kg/min// Labetalol: 10 to 20 mg IV, then 20 to 80 mg every 10 to 30 minutes to a MAX cumulative dosage of 300 mg; OR 1 to 2 mg/min IV infusion; initiate within 30 to 60 minutes