Hypertensive Crisis Flashcards
What are the acute elevations in Blood Pressure
Signs of End-Organ dysfunction (present) -> Hypertensive Emergency (present) -> Treatment Goal -> Exceptions (Aorta Dissection, Stroke, Preeclampsia and Eclampsia)
What is hypertensive crisis
SBP greater than 179 mmHg and/or diastolic blood pressure greater than 109 mmHg
What is a hypertensive emergency
Abrupt rise in BP WITH ACUTE END ORGAN DAMAGE; DBP usually greater 120 mmHg
What is a hypertensive urgency
Abrupt rise in BP with NO signs of end-organ damage
What patient groups are more likely to have a hypertensive emergency
Elderly, blacks, and Men
What is the most common cause of hypertensive emergency/ other causes
Medication non-adherence/ Medication withdrawal, renal drugs, cocaine, post-operative, pre-eclampsia and eclampsia
What medications are known to have withdrawal symptoms that could lead to hypertensive crisis from abrupt disocontinue or use
Clonidine, beta-blockers, cocaine, amphetamines
What is the pathophysiology of HTN crisis
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
What are the three determinants of end organ damage
Cardiac output %. oxygen consumption, autoregulartory dependence
What organs keep the highest percent of cardiac output
Kidney, gastrointestinal tract, skeletal muscle, brain
Which organs have the highest oxygen consumption
Skeletal muscle, gastrointestinal tract/spleen, brain, heart muscle, kidney, skin
Which organs have excellent autoregulation (most likely to dysfunction during a hypertensive emergency), moderate, little to none
Heart muscle, brain, kidney/ skeletal muscle and GI tract/ skin
What organ dysfunction caused by a hypertensive emergency effecting the brain would be seen in a patient
Cerebral Infarction (stroke), Encephlapothy, Intracerebral or Subarrachnoic Hemmorhage
What organ dysfunction caused by a hypertensive emergency effecting the heart would be seen in a patient
Acute pulmonary edema, acute congestive failure, acute myocardial infarction or unstable angina
What organ dysfunction caused by a hypertensive emergency effecting the kidney would be seen in a patient
Acute kidney injury
What labs that can be obtained to diagnose a hypertensive emergency
CBC, X-ray, urine studies, CT scan, LFT, BNPs, Troponin, CPK
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
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
T/F: For Hypertensive urgency a patient can recieve oral medication and a reduction of MAP within 24-48 hours
True
What are the exceptions to the goal blood pressure targets for other hypertensive emergencies and why
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
What is the goal parameters for treating aortic dissection and in what amount of time
Heart rate less than 60 BPM and SBP less than 120 mmHg within minutes
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
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
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
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
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
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
What is given for pre-eclampsia or eclampisa to prevent seizures
Magnesium 4-6 gram IV bolus in 100 ml over 15 minutes, followed by 1-2 grams per hour
What is blood pressure variability, why is it important
Standardized way of representing changes in blood pressure over time, able to possibly give more insight into risk and outcomes
What are the main reasons for medication selection
Target organ damage and symptoms
What vasodilators are used in hypertensive emergencies
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
What are the beta-blockers used in hypertensive emergencies
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)
What patients cannot recieve Esmolol, how should it be used in aortic dissection, metabolized
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
Which beta-blockers are useful in tachyarrhythmias
Esmolol and metoprolol
T/F: Hypertensive urgency should be treated aggresively
False: Hypertensive urgency can be treated by starting the home medication (no need for ICU)
T/F: For aortic dissection esmolol should be given with a vasodilator in order to treat aortic dissection
True
What drugs can be used for hypertensive urgency and at what doses
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
What are the doses used for the vasodilators used in hypertensive emergencies
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.
What are the doses for beta-blockers used in hypertensive emergencies
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
