HTN Part 2 Flashcards by Thao Hoang

f/u visits should be at ____ intervals until BP is at goal

4-6 wk

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should expect to see a BP reduction of __ mmHg per agent added at optimum dose

10 mmHg

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Consider ____ a patient’s antihypertensive therapy
Evaluate _____ that could benefit from specific antihypertensive drugs

individualizing
comorbid conditions

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two categories of hypertensive crises

urgency
emergency

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Severe HTN, but NO sx
BP >220/125 mmHg or >180 and/or 120
No evidence of acute target-organ damage
Typically a result of poorly controlled chronic HTN
what type of HTN crisis?

urgency

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how to approach HTN urgency

Evaluation should include a thorough H&P to evaluate for s/s of organ damage
May also obtain a BMP, UA, and EKG
Rarely requires emergent therapy / monitoring

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goal of HTN urgency tx

reduce BP within hours

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5 in office agents available for HTN urgencies

Clonidine (Catapres)
Captopril (Capoten)
Metoprolol Tartrate (Lopressor)
Hydralazine
Nifedipine

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onset of top 3 quickest HTN urgency meds

Hydralazine - 10 min
Nifedipine - 15 min
Captopril - 15-30 min

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which HTN urgency tx has a SE of sedation
rebound HTN may occur

clonidine

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which HTN urgency tx has a SE of excessive hypotension

captopril

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which HTN urgency tx has a SE of excessive hypotension, bradycardia

metoprolol tartrate

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which HTN urgency tx has SE of tachycardia, HA, GI

hydralazine

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which HTN urgency tx has SE of Excessive hypotension, tachycardia, headache, angina, myocardial infarction, stroke
Response unpredictable

Nifedipine

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Severe HTN WITH signs and/or symptoms of end-organ damage
BP typically >220/130
what type of HTN crisis?

HTN emergency

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initial evaluation of HTN emergency

Problem-focused H&P
CBC, CMP, EKG CXR, CT head (w/o 1st), UA, UDS, and so on
Individualized based on complication you suspect

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why would you need CT w/o contrast first when evaluation a HTN emergency?

potential hemorrhagic stroke, do not more pressure

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goals of HTN emergency TX (3)

Parenteral therapy
Lower BP by no more than 25% in first 2 hrs
BP of 160/100 over next 2-6 hrs

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HTN emergency of Ischemic CVA BP goal

SBP between 180-200 mmHg with slow reduction

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HTN emergency of Hemorrhagic CVA BP goal

SBP is <140 mmHg

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HTN emergency of Aortic Dissection BP goal

SBP <120 mmHg

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HTN emergency of MI BP goal

will need anticoagulation and oxygen; typically use NTG for BP reduction, but no set goal

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tx pharm options/classes for HTN emergency (5)

BB
CCB
ACE inhibitors
Direct vasodilators
Nitrates

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what is the caution with just using vasodilators

Open up vasculature = reduces preload = reduces stroke volume
preload and contractility will increase to keep CO up = Rebound tachycardia
= more stress on an already ischemic heart

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why are BB and CCBs typically 1st line with cardiac involvement

they act to reduce the stress on the heart and limit the rebound tachycardia

Nicardipine

dihydropyridine - CCB

SE of Nicardipine

1. Hypotension 2. tachycardia 3. HA 4. Possible myocardial ischemia

Clevidipine

CCB

SE of Clevidipine

HA, N/V

which HTN emergency med tx is known for Lipid emulsion CI in pts with allergy to soy or egg

Clevidipine

Labetalol

Beta- and alpha-blocker

SE of labetalol

GI, hypotension, bronchospasm, bradycardia, heart block.

avoid labetalol in who?

acute LV systolic dysfunction, asthma

what HTN emergency meds may be continued orally

labetalol enalaprilat

Esmolol

SE of esmolol

Bradycardia, nausea.

avoid esmolol in who?

Avoid in acute LV systolic dysfunction, asthma. Weak antihypertensive.

Fenoldopam

Dopamine receptor agonist

SE of Fenoldopam

1. Reflex tachycardia 2. hypotension 3. increased intraocular pressure

which HTN emergency med may protect kidney function

Fenoldopam

SE of Enalaprilat

Excessive hypotension.

what HTN emergency med is an additive with diuretics, may be continued orally

Enalaprilat

SE of furosemide

Hypokalemia, hypotension.

which HTN emergency med is an adjunct to vasodilator

Furosemide

SE of Nitroglycerin

1. HA 2. N 3. hypotension 4. bradycardia 5. Tolerance may develop

which HTN emergency med may be useful primarily with myocardial ischemia.

Nitroglycerin

which HTN emergency med is known for thiocyanate and cyanide toxicity, therefore is no longer a first-line agent

nitroprusside SE: GI, CNS; thiocyanate and cyanide toxicity, especially with renal and hepatic insufficiency; Decreased cerebral blood flow, increased intracranial pressure

CO increases by ?% during pregnancy

40% Mostly d/t increased stroke volume

HR increased by ~10 bpm during what trimester

3rd

BP tends to ____ during the ____ trimester d/t _____

decrease 2nd decrease in systemic vascular resistance

abnormal BP in pregnant pts

≥ 140/90

criteria to diagnose HTN During Pregnancy

two elevated readings at least 4 hours apart

HTN (BP ≥ 140/90) after 20 weeks gestation w/o pre-existing HTN or proteinuria what type of HTN pregnancy

Gestational

new onset HTN (BP ≥ 140/90) and proteinuria (24h urinary protein >300 mg/24h or creatinine ratio ≥0.3) after 20 weeks gestation what type of HTN pregnancy

preeclampsia

HTN (BP ≥ 140/90) before 20 weeks gestation or longer than 12 weeks postpartum what type of HTN pregnancy

Chronic Preeclampsia superimposed on chronic HTN

what HTN meds are CI for HTN during pregnancy

ACEIs and ARBs

acute BP tx for HTN pregnancy

IV labetalol, IV hydralazine, oral immediate-release nifedipine

chronic BP tx for HTN pregnancy

labetalol, ER nifedipine, or methyldopa

target BP for HTN pregnancy

130-150/80-100 NOT recommended to reduce BP by more than 25% over 2 hours like the rest

the failure to reach BP control in patients who are adherent to full doses of an appropriate **3-drug regimen, including a diuretic**

Resistant HTN Medication noncompliance is a major issue

What should be do for patients with resistant hypertension?

Rule out secondary causes Check for white-coat HTN Consider switching diuretic to aldosterone receptor blocker (spironolactone) Refer to a HTN specialist (Nephrology or Cardiology)

causes of resistant HTN (5)

1. Improper bp measurement 2. Volume overload and pseudotolerance - Excess sodium intake - Volume retention from kidney disease - Inadequate diuretic therapy 3. Associated conditions - Obesity - Excess alcohol intake 4. Identifiable/Secondary causes of hypertension 5. Drug-induced or other causes

slowest Hypertensive Urgency Treatment

Clonidine - 30-60 minutes Hydralazine - 10-80 min

quickest Hypertensive Emergency tx

1. Esmolol - 1-2 mins 2. Nicardipine - 1–5 min *Nitroprusside no longer first line*

slowest HTN emergency tx

Enalaprilat (Vasotec) Furosemide (Lasix) both 15 min

HTN Part 2 Flashcards

(65 cards)