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Gen Med Unit 7: Cardio > Malignant HTN > Flashcards

Malignant HTN Flashcards

1
Q

Define Malignant HTN

A
  1. Potentially life-threatening situation secondary to elevated BP
  2. Requires immediate BP reduction (not necessarily to normal range) to prevent or limit target organ disease
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2
Q

What is the etiology of malignant HTN?

A
  1. Abrupt BP ↑ in pt w/ chronic HTN
  2. Pregnancy complication
  3. Vascular surgery
  4. Withdrawal from antihypertensive meds
    A. “Rebound HTN”, esp. beta blockers
  5. Use of sympathomimetics
    A. Cocaine, amphetamines, PCP
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3
Q

Define HTN urgencies

A
  1. Significant BP elevation
  2. Should be corrected w/in 24 hr
  3. No target organ damage
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4
Q

Define HTN emergencies

A
  1. Significant BP elevation
  2. Requires rapid BP reduction w/in 1 hr
  3. Target organ damage starting
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5
Q

What are the criteria for HTN urgencies?

A
  1. SBP ≥ 180 mm Hg
  2. DBP ≥ 120 mm Hg
  3. No physical signs of end organ damage
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6
Q

What are the risk factors for progressive target organ damage in HTN urgencies?

A
  1. Hx CHF
  2. Unstable angina
  3. Pre-existing renal insufficiency
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7
Q

What are the potential end organ complications from HTN urgencies?

A
  1. Cerebral infarction (24.5%)
  2. Pulmonary edema (22.5%)
  3. Hypertensive encephalopathy (16.3%)
  4. Congestive heart failure (12%)
  5. Others:
    Intracranial hemorrhage, aortic dissection, and eclampsia
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8
Q

What are the treatment options for HTN urgency If BP >180/110 mm Hg?

A
  1. Lifestyle modifications
  2. Patient should have follow-up w/in1 week
  3. Consider initiating med Tx in ED
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9
Q

What are the treatment options for HTN urgency If BP >210/120 mm Hg?

A
  1. Initiate med Tx

2. Arrange close follow-up within 1 week

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10
Q

What is timeline for bp reduction for HTN urgencies?

A

Goal to ↓ BP in 24 hr

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11
Q

Why does a pt with chronic HTN develop LVH? What can LVH lead to?

A
  1. Left ventricle is unable to compensate for an acute rise in systemic vascular resistance
  2. Can lead to left ventricular failure and pulmonary edema or myocardial ischemia
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12
Q

Define cerebral autoregulation

A

The inherent ability of the cerebral vasculature to maintain a constant cerebral blood flow (CBF)

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13
Q

How does malignant HTN cause cerebral edema?

A
  1. Rapid rises in BP can cause hyperperfusion and ↑ CBF
  2. Can lead to ↑ intracranial pressure
    → cerebral edema
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14
Q

Why can pts with chronic HTN tolerate higher MAP before their autoregulation system is disrupted?

A

Have increased cerebrovascular resistance & more prone to cerebral ischemia when flow (BP) drops

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15
Q

How are pts with HTN urgency who have had previously treated HTN managed?

A
  1. Increase dose of existing anti-hypertensive med or add another agent
  2. Addition of diuretic if pt has increased salt intake
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16
Q

How are pts with HTN urgency who have NOT had previously treated HTN managed?

A
  1. Relatively rapid initial BP reduction over hours or days
  2. Observe pt for several hrs after Tx
  3. Close outpt follow up
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17
Q

What drugs are used in pts with HTN urgency who have NOT had previously treated HTN, if you want to decrease their bp over hours?

A 
1. Furosemide (Lasix)  20-40 mg IM/IV
A. Repeat q 2 hr prn
B. Max 600 mg/d
2. Clonidine (Catapres) 0.1-0.3 mg PO bid
A. Titrate by 0.1 mg/qd q wk
B. Max 2.4 mg/d
3. Captopril (Capoten) 12.5-25 mg PO bid-tid
A. Titrate 12.5-25 mg/dose q 1-2 wk
B. Max 450 mg/d
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18
Q

What is the desired response after treatment in pts with HTN urgency who have NOT had previously treated HTN, if you want to decrease their bp over hours?

A

Acceptable response is ↓ BP by 20-30 mm Hg

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19
Q

What drugs are used in pts with HTN urgency who have NOT had previously treated HTN, if you want to decrease their bp over days?

A
  1. Metoprolol succinateXL (Toprol XL) 25-100 mg PO qd
    A. Titrate weekly
    B. Max 400 mg/d
    C. Monitor HR
  2. Metoprolol tartrate (Corgard) 50 mg PO bid
    A. Titrate weekly
    B. Max 450 mg/d
    C. Monitor HR
  3. Nifedipine ER (Procardia XL, Adalat) 30-60 mg PO qd
    A. Titrate q 7-14 days
    b. Max 120 mg/d
  4. Ramipril (Altace) 2.5-5 mg PO qd-bid
    A. Titrate by 2.5 mg qd q 5-7 d, max 20 mg/d
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20
Q

Define HTN emergencies

A

Acute severe HTN w/ signs of acute or rapidly progressive target organ damage

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21
Q

What are the signs of end organ damage in HTN emergencies?

A 
1. CNS
A. Ischemic stroke, SAH, Intracranial hemorrhage,  encephalopathy, eclampsia
2. Pulmonary
A. Pulmonary edema
3. Cardiovascular 
A. MI, aortic dissection, heart failure
4. Renal
A. Nephropathy
CKD
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22
Q

What are the neurologic sxs of HTN emergencies?

A 
1. CNS involvement
Confusion
H/A
Altered level of consciousness
Blurred vision, transient blindness
N/V
Hemiparesis
Focal neurologic deficits 
Seizures
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23
Q

What cardiovascular sxs may be present in HTN emergencies?

A

Chest pain

Dyspnea

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24
Q

What renal sxs may be present in HTN emergencies?

A

Azotemia

Fluid retention, ↓ UO

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25
Q

What retinal sxs may be present in HTN emergencies?

A

Copper-wire, silver-wire, A-V nicking, flame shaped hemorrhages, cotton wool spots, hard exudates, papilledema

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26
Q

What is the bp in HTN emergencies?

A

BP > 180/120

27
Q

What physical exams need to be performed in HTN emergency?

A
  1. Neuro
  2. Fundoscopic
  3. Cardiovascular
28
Q

What is seen in a neuro exam in a HTN emergency pt and what do they suggest?

A

Confusion, obtunded, coma +/- focal deficits suggest encephalopathy
Focal deficits suggest stroke

29
Q

What is seen in a fundoscopic exam in a HTN emergency pt and what do they suggest?

A

Severe retinopathy present with HTN encephalopathy

30
Q

What is seen in a cardiovascular exam in a HTN emergency pt and what do they suggest?

A

JVD, 3rd heart sound, basilar rales suggest pulmonary edema/CHF
Asymmetry of pulses in arms suggests aortic dissection (>20mm/Hg)

31
Q

What dx tests are indicated in HTN emergencies and what may you find?

A 
1. Very high BP (> 220/120 mm Hg)
Identify end organ involvement
2. EKG
A. LVH
B. Acute ischemia
3. Renal involvement
A. UA
B. RBC’s, RBC casts, proteinuria
C. ↑ BUN, creatinine
3. Head CT(noncontrast) if neurologic findings
A. Intracranial bleed
B. Edema
C. Infarction
4. CXR for chest pain/dyspnea
A. Cardiomyopathy
B. Pulm. edema
32
Q

What tx is indicated in HTN emergency?

A

Focus on close monitoring
Goal to ↓ BP in 1 hr
Be familiar with a few agents that will serve in most situations
Vigilant neurologic monitoring is mandatory in all hypertensive emergencies

33
Q

What CNS problems can occur from lowering BP too rapidly?

A

Hypertensive Encephalopathy
Acute Ischemic Stroke
Acute Intracranial Hemorrhage
Acute Subacrachnoid Hemorrhage

34
Q

What Cardiovascular problems can occur from lowering BP too rapidly?

A

Aortic Dissection-reduce to normal BP***
Acute Coronary Syndrome
Acute Heart Failure

35
Q

What other problems can occur from lowering BP too rapidly?

A

Cocaine toxicity
Pheochromocytoma
Preeclampsia/eclampsia
Perioperative HTN

36
Q

Why shouldn’t p be lowered to normal after HTN emergency?

A

Rapid reduction in BP below the cerebral, renal, and/or coronary autoregulatory range results in marked reduction in organ blood flow, possibly leading to ischemia and infarction

37
Q

What is the goal of MAP reduction in the first hour?

A

MAP should be lowered by no more than 20% in the first hour of Tx

38
Q

What is the goal of MAP reduction in the 2-6 hours?

A

If pt remains stable, BP should then be lowered to 160/100-110 mm Hg in the next 2-6 hours

39
Q

What bp changes are asst with a stroke? How is this managed?

A
  1. Acute ischemic strokes often asst with marked ↑ BP which will ↓ spontaneously
  2. Anti-hypertensives should be used only if BP > 220/120 mm Hg
  3. BP should be reduced cautiously by 10-15%
40
Q

What bp is used to prevent hemorrhagic stroke?

A

target MAP < 130 mm Hg

41
Q

What is the usual MAP range?

A

Usual MAP range: 70-110 mmHg

42
Q

What MAP level is needed to perfuse the brain, heart and kidneys?

A

60 mmHg

43
Q

What are the preferred meds for Intracerebral Hemorrhage, SAH, Encephalopathy Tx?

A

Labetalol
Nicardipine
Esmolol

44
Q

What are the contraindicated meds for Intracerebral Hemorrhage, SAH, Encephalopathy Tx?

A

Nitroprusside

Hydralazine

45
Q

What are the preferred meds for acute ischemic stroke?

A

Labetalol

Nicardipine

46
Q

when is tx indicated in acute ischemic stroke?

A
  1. Tx if BP >220/120 mm Hg
  2. UNLESS pt is receiving IV fibrinolysis (tPA)
    A. Then BP goal <180/105 mm Hg for 24 hours
47
Q

What are the preferred meds for acute coronary syndrome?

A

Beta-blockers

Nitroglycerin

48
Q

when is tx indicated in acute coronary syndrome?

A

Treat if BP >160/100 mm Hg
Reduce BP by 20-30% of baseline
Thrombolytics contraindicated if BP is >185/100 mm Hg

49
Q

What are the preferred meds for perioperative HTN?

A

Nitroprusside
Nitroglycerin
Esmolol

50
Q

What are the preferred meds for preeclampsia/eclampsia?

A

Hydralazine
Labetalol
Nifedipine

51
Q

How are seizures prevented in preeclampsia/eclampsia?

A

Treat w/ IV magnesium sulfate to avoid seizures

52
Q

What class is nicardipine (cardene)? How is it dosed?

A
  1. CCB
  2. 5 mg/h IV
  3. Titrate 2.5 mg/h IV q 5-15 min prn
  4. Max 15 mg/h
    * 50% effect in 45 min
53
Q

What class is Nitroprusside (Nipride)? How is it dosed? What is it used for?

A
  1. Nitrate
  2. Drug of choice for most HTN emergencies
  3. Rapid and easily controlled action
  4. Direct arteriolar and venous dilation
  5. 3-4 mcg/kg/min IV
  6. Titrate to goal BP (10-15% reduction)
  7. Max 10 mcg/kg/min x 10 min
54
Q

What class is IV Nitroglycerin? How is it dosed? What is it used for?

A
  1. Nitrate
    2 Reserved for HTN emergencies w/myocardial ischemia
  2. 5 mcg/min IV
    A. Titrate by 5 mcg/min q 3-5 min until goal (20-30% reduction)
    B. Max 20 mcg/min
55
Q

What class is Hydralazine (Apresoline)? How is it dosed? When do you change to PO?

A
  1. Nitrate
  2. 10-20 mg IM/IV q 2-4 h
  3. Change to PO ASAP
    A. 10-25 mg PO tid, titrate 25 mg/dose wk
    B. Max 300 mg/d
56
Q 
What class is Labetolol (Trandate)
 How is it dosed? What do you need to monitor when using this drug?
A
  1. Alpha & beta blocking agent
  2. 40-80 mg IV q 10 min prn
  3. Max 2400 mg/d
  4. Monitor HR
57
Q 
What class is Esmolol (Brevibloc)
 How is it dosed? What is it used for?
A
  1. Beta blocker approved for SVT but used in hypertensive emergencies
  2. 1000 mcg/kg IV bolus, then 150 mcg/kg/min IV prn
  3. Max 300 mcg/kg/min
  4. Monitor HR
58
Q

How does HTN emergency therapy change when pt bp is controlled?

A

Once BP is controlled, pt should be switched to oral antihypertensive therapy

59
Q

What HTN emergency etiology rarely requires specific treatement?

A

HTN & tachycardia from cocaine toxicity rarely require specific treatment

60
Q

What are the long term effects of HTN emergencies?

A

Even with effective Tx, most patients w/ malignant HTN still have moderate - severe chronic and acute vascular damage
↑ risk for coronary, cerebrovascular, and renal Dz

61
Q

What concomitant disease decreases the survival rate from HTN emergencies?

A

CKD

62
Q

What are the 1 yr survival rates after HTN emergencies that were not treated?

A

10-20%

63
Q

What are the 5 yr survival rates after HTN emergencies that were treated?

A

70-90%

Gen Med Unit 7: Cardio (13 decks)

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