Hypertensive Crisis/Urgency/Emergency

Question 1

Definition of hypertensive crisis

Answer 1

SBP >180mmHg, DBP >120mmHg, or both

Question 2

Definition of hypertensive urgency

Answer 2

acute condition of very high BP without evidence of new or worsening target organ damage

Question 3

Definition of hypertensive emergency

Answer 3

acute condition of very high BP and evidence of new or worsening target organ damage

Question 4

End-organ dysfunction: CV system

Answer 4

acute pulmonary/flash pulmonary edema, acute LV dysfunction, acute MI

Question 5

End-organ dysfunction: neurological

Answer 5

hypertensive encephalopathy, acute intracranial bleeding, cerebral infarction, seizures

Question 6

End-organ dysfunction: vascular system

Answer 6

acute aortic dissection, eclampsia/preeclampsia

Question 7

End-organ dysfunction: renal

Answer 7

AKI

Question 8

End-organ dysfunction: liver

Answer 8

elevated function tests, acute liver failure

Question 9

End-organ dysfunction: other

Answer 9

Retinopathy, retinal hemorrhage

Question 10

Risk factors for hypertensive crisis

Answer 10

Female, obesity, hypertensive/coronary heart disease, presence of a somatoform disorder, higher number of antihypertensive agents at baseline

Question 11

Common causes of hypertensive crisis

Answer 11

Non-adherence

Abrupt withdrawal of certain antihypertensives → rebound HTN: Clonidine, beta-blockers

Substance abuse: Cocaine, amphetamines, ecstasy

DDIs: Serotonin syndrome

Drug-food interactions: Tyramine containing foods with MAOIs

Drug-disease state interactions: NSAIDs, sympathomimetics in patients with HTN

Withdrawal: alcohol, opioids, BZDs

Question 12

Clinical presentation of hypertensive crisis

Answer 12

May appear asymptomatic (urgency) or with evidence of target organ damage (hypertensive emergency)

Question 13

Symptoms of hypertensive crisis

Answer 13

HA, N/V, epistaxis, SOB, chest pain, dizziness, paresthesia, vision changes

Question 14

Signs of hypertensive crisis

Answer 14

focal neurological deficits, crackles on lung auscultation, increased SCr/BUN, LFTs, new/worsening hematuria/proteinuria, EKG changes, changes on fundoscopic examination of the eye, changes on CT of the head (bleed), MRI evidence of CVA

Question 15

Timing of BP lowering in hypertensive urgency

Answer 15

Lower BP slowly over 24-48 hours using PO medication, no need for ICU admission

Question 16

Timing of BP lowering in hypertensive emergency: 1st hour

Answer 16

decrease DBP by 10-15% or MAP by 25% with a goal DBP ≥100mmHg

Question 17

Timing of BP lowering in hypertensive emergency: hours 2-6

Answer 17

SBP 160mmHg and/or DBP 100-110mmHg

Question 18

Timing of BP lowering in hypertensive emergency: hours 6-24

Answer 18

Maintaining above goals from the first 6 hours

Question 19

Timing of BP lowering in hypertensive emergency: hours 24-48

Answer 19

gradually decrease BP to normal outpatient goal

Question 20

Special considerations: aortic dissection

Answer 20

SBP ≤120mmHg within first hour, ideally the first 20 minutes (and HR <60 BPM)

Question 21

Aortic dissection treatment

Answer 21

Esmolol, then a vasodilator (nicardipine, clevidipine, nitroprusside)

Question 22

Special considerations: ischemic stroke

Answer 22

tPA: BP <185/110 before tPA and <180/105 during tPA infusion
No tPA: SBP <220mmHg

Question 23

Treatment for ischemic stroke

Answer 23

Nicardipine, clevidipine, labetalol

Avoid sodium nitroprusside

Question 24

Special considerations: hemorrhagic stroke

Answer 24

SBP >220mmHg: lower with infusion and monitor
SBP 150-220 mmHg: <140mmHg in 60 minutes

Question 25

Treatment for hemorrhagic stroke

Answer 25

Same as ischemic stroke

Question 26

Special considerations: severe preeclampsia or eclampsia

Answer 26

SBP <140mmHg in 60 minutes

Question 27

Preeclampsia/eclampsia treatment

Answer 27

Hydralazine, labetalol, nicardipine AVOID RAAS INHIBITORS AND SODIUM NITROPRUSSIDE

Question 28

Vasodilators used in hypertensive crisis/emergency

Answer 28

Sodium nitroprusside, NTG, hydralazine

Question 29

Sodium nitroprusside MoA

Answer 29

Breaks down into NO → relaxation/dilation of smooth muscle Direct venous and arterial vasodilator

Question 30

Onset of sodium nitroprusside

Answer 30

<2 mins

Question 31

Duration of sodium nitroprusside

Answer 31

1-10 minutes

Question 32

Sodium nitroprusside dosing

Answer 32

0.25-10mcg/kg/min

Question 33

Sodium nitroprusside ADEs

Answer 33

Potent hypotension, N/V, muscle twitching Cyanide toxicity; accumulation occurs most commonly at higher doses (>2mcg/kg/min) and longer treatment duration

Question 34

Sodium nitroprusside pearls

Answer 34

Caution in high intracranial pressure, azotemia, CKD

Question 35

NTG MoA

Answer 35

NTG converted into NO → activates guanylate cyclase → increase of cGMP in smooth muscle → dephosphorylation of myosin light chains → vasodilation

Question 36

NTG onset

Answer 36

Immediate

Question 37

NTG duration

Answer 37

3-5 mintues

Question 38

NTG dosing

Answer 38

5-200mcg/min IV infusion

Question 39

NTG ADEs

Answer 39

Hypotension, HA, methemoglobinemia, tolerance with prolonged use

Question 40

NTG pearl

Answer 40

Most often used in situations with coronary ischemia

Question 41

Hydralazine MoA

Answer 41

Direct-acting smooth muscle relaxant and acts as a vasodilator primarily in the smooth muscle of the arterial bed

Question 42

Hydralazine onset

Answer 42

10-80 minutes

Question 43

Hydralazine duration

Answer 43

Up to 12 hours

Question 44

Hydralazine dosing

Answer 44

IV bolus: 10-20mg IV q4-6h

Question 45

Hydralazine ADEs

Answer 45

Hypotension, tachycardia, flushing, HA

Question 46

Hydralazine pearls

Answer 46

Concern with unpredictable PK profile → difficult to assess what the effect will be and how long it will last Safe in pregnancy

Question 47

Beta-blockers used in hypertensive emergency

Answer 47

Labetalol, metoprolol, esmolol

Question 48

Beta-blocker MoA

Answer 48

Competitively block the binding of NE and epinephrine to beta-adrenergic receptors

Question 49

Beta-blocker ADEs

Answer 49

Hypotension, bradycardia/heart block

Question 50

Labetalol-specific ADE

Answer 50

orthostatic hypotension

Question 51

Labetalol onset

Answer 51

5-10 minutes

Question 52

Labetalol duration

Answer 52

180-360 mins

Question 53

Labetalol dosing

Answer 53

Bolus: 10-20mg IV q10min Infusion: 0.5-2mg/min

Question 54

Labetalol pearls

Answer 54

Used in most HTN emergencies Safe in pregnancy Caution in acute HF

Question 55

Metoprolol onset

Answer 55

5-20 minutes

Question 56

Metoprolol duration

Answer 56

120-360 mins

Question 57

Metoprolol dosing

Answer 57

Bolus: 5-15mg IV q5-15min

Question 58

Metoprolol pearl

Answer 58

Caution in acute HF

Question 59

Esmolol onset

Answer 59

1-2mins

Question 60

Esmolol duration

Answer 60

10-20mins

Question 61

Esmolol dosing

Answer 61

Bolus: 250-500mcg/kg/min Infusion: 50-100 mcg/kg/min

Question 62

Esmolol pearls

Answer 62

Drug of choice in aortic dissection Caution in acute HF

Question 63

CCBs used in hypertensive emergency

Answer 63

Clevidipine, nicardipine

Question 64

CCBs MoA

Answer 64

Bind to and block voltage-gated L-type calcium channels found on smooth muscle cells of arterial vessels → vasodilation

Question 65

Clevidipine onset

Answer 65

2-4 mins

Question 66

Clevidipine duration

Answer 66

5-15 mins

Question 67

Clevidpine dosing

Answer 67

1-2mg/hr infusion

Question 68

Clevidipine ADEs

Answer 68

Hypotension, HA, tachycardia, hypertriglyceridemia (lipid formulation)

Question 69

Clevidipine pearls

Answer 69

Most hypertensive emergencies Caution in coronary ischemia CI’ed in soy/egg allergy

Question 70

Nicardipine onset

Answer 70

5-10mins

Question 71

Nicardipine duration

Answer 71

15-30 minutes

Question 72

Nicardipine dosing

Answer 72

2.5-5mg/hr

Question 73

Nicardipine ADEs

Answer 73

Hypotension, tachycardia, HA, flushing, local phlebitis

Question 74

Nicardipine pearls

Answer 74

Most hypertensive emergencies Not generally utilized in acute HF Caution with coronary ischemia