Acute Hypertensive Crisis

Question 1

What are the criteria for Hypertensive urgency?

Hypertensive emergency?

Answer 1

1. SBP > 180, DBP > 120
2. SBP > 180, DBP > 120, PLUS ACUTE ORGAN INJURY

Question 2

What are examples of organ injury?

Answer 2

Encephalopathy
AKI
TIA/STROKE
Retinopathy
HF,MI, Angina
Vascular Disease

Question 3

What are some common etiologies?

Answer 3

-non adherence to antihtn meds
-drug withdrawal (bzd’s , alcohol)
-Anxiety /pain
-Delirium
-Volume overload
-Acute stroke

Question 4

What are some less common etiologies?

Answer 4

-Pheochromocytoma
* Malignant
hyperthermia
* Neuroleptic malignant
syndrome
* Serotonin syndrome
* Autonomic dysreflexia
* Elevated intracranial
pressure (ICP)

Question 5

Common presenting Subjective Sx’s ? (5)

Answer 5

SOB, Chest pain, HA, altered mental status, focal neurological deficit

Question 6

Management of Hypertensive Crisis

1. If pt is in hypertensive urgency, what 2 options do u have?

Answer 6

reinstitute or intensify oral anti-HTN therapy and arrange follow up

optional : PRN dosing of short acting meds

Question 7

Short acting Medications : Pros and cons of each

1. Clonidine
2. Captopril
3. Labetalol
4. Minoxidil

Answer 7

1. Fast onset In clinic
   administration
   con : bradycardia and sedation
2. fast onset + titratable
   con : AKI, Hyperkalemia
3. Vasodilating beta-blocker
   Decrease sympathetic nervous system
   con : bradycardia, longer half life
4. potent vasodilator
   con : edema, reflex tachycardia

Question 8

Hypertensive Emergency :

1) Admit them to ICU where they’ll need ___ and ___

2) If conditions are present such as aortic dissection, severe preeclampsia/eclampsia or pheochromocytoma crisis what are BP goals?

3. if they dont have these conditions what are ur BP goals?

Answer 8

1. arterial line
   -continous BP monitoring
2. decr SBP to < 140 mm Hg during 1st hour or to <120 mmhg if aortic dissection
3. decr BP by max of 25% over 1st hr then to 160/100-110 over next 2-6 hrs then to normal over the next 24-48 hrs

Question 9

What are some hypertensive emergency pharmacotherapy ideal characteristics?

Answer 9

IV
Fast onset
Fast offset
Non renal elim/hepatic metab
minimal side effects
addresses underlying pathology

Question 10

Direct vasodilators : See chart

Answer 10

See chart

Question 11

CCB’s : Which ones are usually used? and why is this?

See chart

Answer 11

DHP’s preferred because of vascular selectivity

-Non DHP’s have selectivity for cardiac myocytes (not helpful in this case)

Question 12

IV BETA Blockers : See Chart

Answer 12

See chart

Question 13

In general, what’s the preferred IV push agent?
-However this is not preferred in which patients?

What’s the preferred IV continuous agent?

Answer 13

LABETALOL
-unless pt’s have acute HF, bradycardia, or possibly in pt’s with asthma or COPD

Nicardipine

Question 14

Preferred Agent in ACUTE MI? (4)
Which should u avoid?

Answer 14

Nitroglycerin, esmolol, labetalol, metoprolol

Avoid : Nitroprusside (coronary steal)

Question 15

Preferred agent in acute decomp HF? (2)
Avoid?

Answer 15

Nitroglycerin ; nitroprusside

beta blockers; non DHP CCBs

Question 16

Aortic Dissection requires RAPID reduction to SBP of?
Preferred agent in aortic dissection? (4)
Avoid? (2)

Answer 16

<120 in first hr

nitropruss or nicardipine + [Esmolol OR labetalol] to prevent reflex tachycardia

hydralazine, minoxidil

Question 17

AKI : Preferred? (3)
Avoid? (3)

Answer 17

Nicardipine, clevidipine, labetalol

Diuretics, ACEI’s, nitroprusside

Question 18

HYPERADRENERGIC STATES : Such as drugs, pheochromocytoma, serotonin syndrome , or abrupt withdrawal?

Preferred ? (3)
Avoid? (1)

Answer 18

Phentolamine, nitropruss, beta blockers with alpha activity such as Labetalol

Beta blockers w/out alpha activity

Question 19

Pre-eclampsia

Preferred? (4)
Avoid? (3)

Answer 19

Magnesium + [labetalol or nicardipine or hydralazine]

Diuretics, acei’s, nitroprusside

Question 20

HTN emergency associated with Hemorrhagic and Ischemic Stroke :

If Hemorrhagic Stroke that’s acute (<3hrs) –>

A. if initial SBP >= 220, what BP should u target and what should u use?

B. If Initial SBP is < 220 and pt has mild to mod ICH whats the goal SBP? What should u not lower it to?
-If Severe ICH?

Answer 20

No guideline rec ! but , target SBP 130-150, use IV meds

-Goal SBP 140, dont lower to <130

-No guideline rec but reasonable to target SBP 130-150

Question 21

If Ischemic stroke that’s acute (<72 hrs from sx onset) and elevated BP –>

A. If pt is candidate for IV thrombolysis whats ur BP goal? (lower and maintain)

B. If pt is NOT a candidate for IV thrombolysis and BP is <220/110 what is witnessed?

C. If pt is NOT a candidate for IV thrombolysis and BP is >=220/110 what should be BP goal?

Answer 21

A. Lower to <185/110 before tPA
-maintain BP <185/110 for 24 hrs s/p tPA

B. Initiating within 48-72 hrs has no benefit

C. DECR BP by 15% during 1st 24 hrs to target BP < 220

Question 22

What are the preferred agents for Hypertensive emergencies associated with hemorrhagic and ischemic stroke?

What should u avoid?

Answer 22

Nicardipine , labetalol

Nitroprusside