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Cardiovascular > Hypertensive emergency > Flashcards

Hypertensive emergency Flashcards

1
Q

Which are the preferred antihypertensives for a dissecting aneurysm? Which should be avoided?

A

-nitroprusside + beta-blocker
-nicardipine +/- beta-blocker
-labetolol

Avoid
-direct vasodilators alone (nitroprusside hydralazine)

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2
Q

Which are the preferred antihypertensives for a pulmonary edema? Which should be avoided?

A

-nitroprusside
-nitrates
-nicardipine
-fenoldopam
-diuretics

Avoid
-beta-blockers (unless from diastolic dysfunction)
-labetalol

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3
Q

Which are the preferred antihypertensives for angina/MI? Which should be avoided?

A

-beta-blockers
-nitrates
-nicardipine
-Ca channel blockers
-labetalol

Avoid
-direct vasodilators alone (nitroprusside diazoxide hydralazine)
-phentolamine

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4
Q

Which are the preferred antihypertensives for a cerebral hemorrhage? Which should be avoided?

A

-no treatment versus nicardipine or nitroprusside

Avoid - clonidine

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5
Q

Which are the preferred antihypertensives for hypertensive encephalopathy? Which should be avoided?

A

-nitroprusside
-nicardipine
-labetalol
-fenoldopam

Avoid
-clonidine
-reserpine
-beta-blockers

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6
Q

Which are the preferred antihypertensives for catecholamine excess? Which should be avoided?

A

-phentolamine
-nicardipine
-nitroprusside + beta-blocker
-benzodiazepine as adjunct

Avoid
-beta blocker alone
-labetalol

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7
Q

Which are the preferred antihypertensives for postop HTN? Which should be avoided?

A

-esmolol
-nicardipine
-nitroprusside

Avoid
-long acting agents

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8
Q

Which are the preferred antihypertensives for preeclampsia? Which should be avoided?

A

-labetalol
-nicardipine

Avoid
-ACE inhibitors

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9
Q

What is the dosing and duration of PO clonidine for moderate HTN?

A

-initial 0.1 - 0.2mg
-subsequent 0.1mg q1hr to maximum 0.7mg
-8 - 12hr

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10
Q

What is the dosing and duration of PO nifedipine for moderate HTN?

A

-initial 10mg
-subsequent 10 - 20 q15min
-3 - 6hr

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11
Q

What is the pathophysiology behind organ damage in HTN?

A

Small vessel damage that results in:
-platelet and fibrin deposition
-loss of vascular autoregulation
-elevation of SVR

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12
Q

What is the basic MOA for the most efficacious HTN meds?

A

Reduction in afterload
-unless pt has renal failure ongoing HTN causes natriuresis and intramuscular volume contraction

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13
Q

What are the common causes of HTN crises?

A

-antiHTN drug withdrawal
-autonomic hyperactivity
-collagen vascular disease
-recreational drugs
-acute glomerulonephtitis
-head trauma
-preeclampsia
-renovascular HTN

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14
Q

During which part of the perioperative period is a HTN crisis most likely?

A

Early postop due to increased sympathetic tone

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15
Q

What are the common causes of periop HTN crises?

A

-cardiac surgery
-major vascular reconstruction
-NSGY
-H&N surgery
-renal txp
-major trauma

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16
Q

How do you calculate SVR?

A

= 79.9(MAP - CVP)/CO

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17
Q

What does a discrepancy between UE and LE BP’s indicate?

A

Aortic coarctation or distal dissection

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18
Q

What does a discrepancy between UE BP’s indicate?

A

Proximal aortic dissection

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19
Q

What physical exam finding is a sensitive indicator of HTN induced organ injury?

A

Retinopathy

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20
Q

What is the typical dosing of esmolol for severe HTN?

A

500mcg/kg load and 25 - 50mcg/kg/min infusion
-increase infusion 25mcg/kg/min q10m to max of 300mcg/kg/min

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21
Q

What is the typical dosing of enalaprilat for severe HTN?

A

1.25mg q6h
-increase by 1.25mg to max of 5mg q6hr

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22
Q

What is the typical dosing of fenoldopam for severe HTN?

A

0.1mcg/kg/min
-increase 0.1 - 1mcg/kg/min q15min to max 1.6mcg/kg/min

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23
Q

What is the typical dosing of hydralazine for severe HTN?

A

10 - 20mg bolus q30min

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24
Q

What is the typical dosing of labetolol for severe HTN?

A

20mg bolus q15min

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25
Q

What is the typical dosing of nicardipine for severe HTN?

A

5mg/h
-increase 2.5mg/h q10-15min to max 15mg/hr

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26
Q

What is the typical dosing of nitroglycerin for severe HTN?

A

5mcg/min
-increase 5-10mcg/min q5-10min to max 200mcg/min

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27
Q

What is the typical dosing of nitroprusside for severe HTN?

A

0.25mcg/kg/min
-increase 1-2mcg/kg/min q5-10min to max 10mcg/kg/min

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28
Q

What is the MOA of esmolol for severe HTN?

A

Beta-blocker

29
Q

What is the MOA of enalaprilat for severe HTN?

A

ACE inhibitor

30
Q

What is the MOA of fenoldopam for severe HTN?

A

Dopamine 1 agonist

31
Q

What is the MOA of hydralazine for severe HTN?

A

Direct vascular dilator arterial > venous

32
Q

What is the MOA of labetalol for severe HTN?

A

Alpha and beta-blocker

33
Q

What is the MOA of nicardipine for severe HTN?

A

Ca channel blocker and arterial dilator

34
Q

What is the MOA of nitroglycerin for severe HTN?

A

Direct vascular dilator venous > arterial

35
Q

What is the MOA of nitroprusside for severe HTN?

A

Direct vascular dilator

36
Q

What are the advantages of using esmolol for severe HTN?

A

-rapid on rapid off
-plasms metabolized

37
Q

What are the advantages of using enalaprilat for severe HTN?

A

-rapid on rapid off
-antiarrhythmic

38
Q

What are the advantages of using fenoldopam for severe HTN?

A

Increased renal blood flow

39
Q

What are the advantages of using hydralazine for severe HTN?

A

No CNS effects

40
Q

What are the advantages of using labetolol for severe HTN?

A

-no overshoot hypotension
-preserved cardiac output

41
Q

What are the advantages of using nicardipine for severe HTN?

A

-rapid on
-easily titrated
-coronary dilator

42
Q

What are the advantages of using nitroglycerin for severe HTN?

A

-rapid on
-coronary dilator

43
Q

What are the advantages of using nitroprusside for severe HTN?

A

-rapid on rapid off
-easily titrated
-nonsedating

44
Q

What are the SE of using esmolol for severe HTN?

A

-exacerbates CHF and asthma
-cardiac conduction blockade
-nausea

45
Q

What are the SE of using enalaprilat for severe HTN?

A

-hypotension in volume deplete patients
-can exacerbate renal failure
-headache
-not in pregnancy

46
Q

What are the SE of using hydralazine for severe HTN?

A

-reflex tachycardia
-overshoot hypertension
-headache
-vomiting

47
Q

What are the SE of using labetolol for severe HTN?

A

-exacerbates CHF and asthma
-cardiac conduction blockade
-tolerance with prolonged use

48
Q

What are the SE of using nicardipine for severe HTN?

A

-reflex tachycardia
-headache

49
Q

What are the SE of using nitroglycerin for severe HTN?

A

-weak arterial dilator
-headache
-ethanol vehicle
-absorbed by some IV tubing

50
Q

What are the SE of using nitroprusside for severe HTN?

A

-thiocyanate or cyanide toxicity
-reflex tachycardia
-vomiting
-light sensitivity

51
Q

What is severe HTN?

A

SBP > 160 or DBP > 100

52
Q

At what blood pressure in non pregnant patients is overt organ injury seen? In pregnant patients?

A

-220/130
-DBP >100

53
Q

Why are nitroprusside and nicardipine good to treat HTN encephalopathy?

A

Rapid onset and the encephalopathy starts to clear within hours of BP control

54
Q

Which stroke syndromes are potentially related to HTN?

A

-bland cerebral infarction
-subarchnoid hemorrhage
-intracerebral hemorrhage

55
Q

Which antihypertensive is efficacious in subsrachnoid hemorrhages and what is its MOA?

A

-nimodipine
-Ca channel blocker
-efficacious even in absence of BP reduction

56
Q

Why is clonidine not the antihypertensive of choice in cerebral ischemia/hemorrhage?

A

Has a sedating effects that can compromise ability to do neurostatus exams

57
Q

What physical exam findings are suspicious for aortic dissection?

A

HTN in patient with chest or back pain especially if concomitant BP discrepancies between UE and LE or asymmetry in b/l UE

58
Q

What is the immediate goal in aortic dissection?

A

Decrease in both mean BP and ejection velocity (the rate of increase in systolic pressure)

59
Q

Which antihypertensives are indicated for aortic dissection and why?

A

-beta blockers are effective for decreasing ejection velocity but don’t control BP quickly enough
-nitroprusside or nicardipine are rapid onset vasodilators to be used with beta blockers
-combined alpha and beta blockers (labetolol) can be used alone

60
Q

What is the goal when treating HTN induced pulmonary edema?

A

Decrease SVR as pulm edema is usually due to excessive LV afterload or acutely worsened diastolic dysfunction

61
Q

Which antihypertensive is good for pulmonary edema and myocardial ischemia?

A

Nitroglycerin

62
Q

Why is HTN control important in myocardial ischemia?

A

-preserve endangered myocardium
-reducing afterload
-increases myocardial perfusion

63
Q

Why are arterial vasodilators avoided in MI?

A

They cause tachycardia which increases myocardial oxygen consumption

64
Q

At what rate should HTN emergency be corrected?

A

decreased by no more than 20-25% in the first hour then to 160/110 during next 2-6hrs

65
Q

What is the definition of a HTN crisis? HTN emergency?

A

-crisis is SBP > 180 or DBP >110
-emergency is HTN mediated organ damage

66
Q

At what rate should HTN emergency be corrected in a pt w/ a concomitant aortic dissection?

A

lower SBP to 100 - 120mmHg w/in 20 min to reduce aortic shearing forces

67
Q

What is the risk of using ACE inhibitors for BP control in pregnancy?

A

risk of fetal renal damage

68
Q

Which beta blockers are safe to use in pregnancy, which one is not?

A

-labetalol and metoprolol
-atenolol is not

Cardiovascular (6 decks)

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