Hypertensive Crisis

Question 1

What is Hypertensive Crisis?

Answer 1

Hypertensive Urgency
* Systolic BP > 180 and/or Diastolic BP > 120
* No evidence of target organ damage
Hypertensive Emergency
* Systolic BP > 180 and/or Diastolic BP > 120
* Evidence of target organ damage (new or worsening)

Question 2

Target Organ Damage

Answer 2

Symptoms Patients Report
* Headache
* Chest pain
* Shortness of breath
* Back pain
* Numbness/weakness
* Change in vision
* Difficulty speaking
organs at most risk from acute injury during hypertensive emergency: lungs + heart –> brain –> blood vessels –> kidneys –> eyes

Question 3

Epidemiology

Answer 3

30% of adults in the United States have hypertension
*1% to 3% of patients with hypertension will have a hypertensive crisis during
their lifetime
Risk factors for development of a hypertensive crisis
* Obesity
* FemaleGender
* History of CV disease
*Higher number of prescribed antihypertensive medications
* Nonadherence with antihypertensive medications

Question 4

Common causes

Answer 4

• Chronic Hypertension
• Medication Non-Adherence (biggest factor contributing to it/most common cause)
• Medication/Substance Related
• Pregnancy (placenta releases pro-inflammatory cytokines)
• Renal Disease (accumulation of renin)
• Endocrine Disorders
  also cocaine, ecstasy, methamphetamine

Question 5

Goals of Therapy & Patient Workup: hypertensive urgency

Answer 5

Goals
*Reinstitute/Intensification of antihypertensive drug therapy
* Treatment of anxiety as applicable
There is NO indication for
* Referral to emergency department
*Immediate reduction in blood pressure (overcorrection may cause harm and offers no benefit) - no need to be using IV meds
* Hospitalization

Question 6

Goals of Therapy & Patient Workup: hypertensive emergency

Answer 6

Goals
* Hour 1: Reduce BP by max of 25%
* Hours 2 – 6: Reduce BP < 160/100-110
* Hours 6 – 48: Reduce BP to goal
There is indication for
* Referral to emergency department
* Hospital admission
* IV antihypertensives - need to get BP down fast, don’t use oral
Know that there are conditions with specific BP goals: stroke, aortic dissection, severe eclampsia/preeclampsia, pheochromocytoma crisis

Question 7

Why BP should be lowered gradually?

Answer 7

if drop BP too quickly, decrease blood flow to brain; chance of tissue ischemia, cut off oxygen supply to organs

Question 8

Patient Workup

Answer 8

checking to see if organs are affects by the high BP
past medical history:
* History of HTN
* Home medications
* Social & Family History
physical:
* Symptoms
* SBP >180 and/or DBP > 120
* Focal neurologic deficits
* Crackles on lung auscultation
labs:
* CBC
* CMP (electrolytes, SCr, BUN, LFTs, Glucose)
* Toxicology
* Troponin (cardiac damage)
* Pregnancy
other tests:
*EKG
* Head CT
* Chest x-ray
* Eye exam

Question 9

Pharmacotherapy: factors that affect choice of pharmacologic agents

Answer 9

Hypertensive emergency should be treated with IV medications (unless unable to establish IV access)
Prefer medications with predictable action
* Fast onset/offset
* Predictable pharmacokinetics
* Minimal adverse effects
Patient-specific factors and type of target organ damage should be considered when selecting patient therapy

Question 10

DHP Calcium Channel Blockers

Answer 10

nicardipine - titratable IV infusion
clevidipine - titratable IV infusion

Question 11

Nicardipine pros + cons

Answer 11

Pros
* Titratable
* Relative lower risk for AE
Cons
* Contraindicated in severe aortic stenosis
* Titrate cautiously with
renal/hepatic impairment
* Reflex tachycardia

Question 12

Clevidipine pros + cons

Answer 12

Pros
* Titratable
* Lack of accumulation
in organ impairment
Cons
* Contraindicated in severe aortic stenosis
* Lipid formula (contraindicated with soy/egg allergy; elevates triglycerides, change IV lines Q12hours)
* Induces atrial fibrillation

Question 13

Vasodilators

Answer 13

nitroglycerin (nitrate) - titratable IV infusion
sodium nitroprusside (nitrate) - titratable IV infusion
hydralazine - IV push

Question 14

Nitroglycerin pros + cons

Answer 14

Pros
* Titratable
* Beneficial in coronary ischemia (decrease cardiac load)
Cons
* Tolerance with prolonged use (Max 24-48 hours)
* Interact with PDE-5i
* Dose-limiting headache & reflex tachycardia
* Caution with high ICP
* Excessive hypotension in hypovolemia

Question 15

Sodium nitroprusside pros + cons

Answer 15

Pros
titratable
Cons
* Tolerance with prolonged use (Max 24-48 hours)
* Interact with PDE-5i
* Dose-limiting headache & reflex
tachycardia
* Caution with high ICP
* Excessive hypotension
in hypovolemia
* Nitroprusside only: Cyanide toxicity

Question 16

Hydralazine pros + cons

Answer 16

Pros
* May be used in patients with bradycardia
Cons
* Not titratable
* Less predictable pharmacokinetics
* Rebound tachycardia

Question 17

Beta blockers

Answer 17

labetalol - IV push or titratable IV infusion
esmolol - titratable IV infusion (beta selective, doesn’t effect BP, treats HR)

Question 18

Labetalol pros + cons

Answer 18

Pros
* Decreases HR & BP
* Can be given as a titratable infusion
Cons
* Usually, an IV infusion is more appropriate
* Decreases HR
* CI with severe
bradycardia, ADHF, reactive airway disease

Question 19

Esmolol pros + cons

Answer 19

Pros
* Decreases HR
* Cardioselective
(tolerated in reactive airway diseases)
Cons
* Adjunct, not monotherapy for BP reduction
* Avoid in severe bradycardia and ADHF

Question 20

Other medications

Answer 20

enalaprilat (ACEi) - IV push
clonidine (alpha-2 agonist) - PO

Question 21

Enalaprit pros + cons

Answer 21

Pros
* May be beneficial in emergencies related to renin excess
Cons
* Delayed onset and peak
* CI in AKI, hyperkalemia, acute MI, bilateral renal artery stenosis, pregnancy

Question 22

Clonidine pros + cons

Answer 22

not for hypertensive emergency
Pros
* PO option when IV access can not be established
Cons
* Often used inappropriately in hypertensive emergency
* Delayed onset
* Can cause
hypertensive crisis on withdrawal

Question 23

Factors that affect choice of pharmacologic agents

Answer 23

acute decompensated HF with pulmonary edema
aortic dissection
acute coronary syndromes
AKI
eclampsia/severe pre-eclampsia
stroke (intracranial hemorrhage/ischemic)

Question 24

Acute decompensated HF with pulmonary edema

Answer 24

*Nitroglycerin or sodium nitroprusside (nicardipine and clevidipine are acceptable alternatives)
*Avoid Beta Blockers and non-DHP CCBs

Question 25

Aortic Dissection

Answer 25

*Initiate Beta blocker then vasodilator (e.g., nicardipine, clevidipine, nitroprusside) - want to decrease BP and HR
*Lower blood pressure quickly and prevent reflex tachycardia

Question 26

Acute Coronary Syndromes

Answer 26

*Esmolol, labetalol, nitroglycerin, nicardipine, or sodium nitroprusside
*Use caution with non-DHP CCBs; avoid Beta Blockers in the setting of reduced EF, HR < 60 bpm, SBP < 100 mmHg, 2nd or 3rd degree heart block, or reactive airway disease

Question 27

AKI

Answer 27

• Most IV antihypertensives are acceptable
• Use caution with sodium nitroprusside (due to cyanide toxicity); avoid enalaprilat (don’t want to increase serum creatinine)

Question 28

Eclampsia/Severe Pre-eclampsia

Answer 28

• Hydralazine, labetalol, or nicardipine
• Contraindicated: enalaprilat and nitroprusside

Question 29

Stroke (Intracranial Hemorrhage/Ischemic)

Answer 29

• Nicardipine, clevidipine, or labetalol
  nitrates not preferred due to increased intracranial pressure