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PBL PY2 Fall > Hypertension Emergencies Therapeutics > Flashcards

Hypertension Emergencies Therapeutics Flashcards

1
Q

what numbers are the arbitrary threshold for severe high BP?

A

180/110mmHg or more

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2
Q

since numbers are arbitrary and can be different for everyone, an elevated BP must be interpreted in the context of what 3 things?

A
  1. what is their baseline BP?
  2. how quickly did the BP increase to the current level?
  3. are there signs and symptoms of end organ damage?
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3
Q

what characterizes a HTN urgency?

A

severe BP elevation that is mildly symptomatic or asymptomatic that is not due to an acutely reversible cause (pain, urinary retention) and there is no evidence of target organ damage

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4
Q

what characterizes HTN emergency?

A

severe BP elevation in the presence of acute symptoms or target organ damage in the brain, eye, heart, or kideny

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5
Q

what is the BP for urgency given by CHEP?

A

asymptomatic DBP >130mmHg

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6
Q

what is the BP for urgency given by AHA?

A

SBP >180 or a DBP >120 and no sx or organ dx

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7
Q

what is the BP for urgency given by JNC 7?

A

SBP >180 or a DBP >120

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8
Q

when a BP is _____mmHg or above, it rarely normalizes without medication

A

180/110

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9
Q

a HTN urgency requires ___ treatment

A

urgent

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10
Q

a HTN urgency requires BP lowering within what timeframe and with what types of therapies?

A

over 24-48 hours with PO medications

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11
Q

t/f a HTN urgency is life-threating

A

t

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12
Q

a HTN emergency needs BP lowering treatment within what timeframe?

A

1 hour

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13
Q

what is the 1 year mortality rate for untreated HTN emergency patients?

A

79%

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14
Q

what is the route of medications given for HTN mergency?

A

parenteral (IV)

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15
Q

HTN emergency is severe BP elevation in the setting of any of which 9 conditions?

A
  1. HTN encephalopathy
  2. acute aortic dissection
  3. acute left ventricular failure
  4. acute coronary syndrome
  5. acute kidney injury
  6. intracranial hemorrhage
  7. acute ischemic stroke
  8. pre-eclampsia or eclampsia
  9. cathecholamine-associated HTN
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16
Q

severe headache during a HTN emergency may indicate ____

A

encephalopathy

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17
Q

agitation, delirium, stupor, seizure in HTN emergency may indicate ___

A

intracranial process

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18
Q

visual disturbances in HTN emergency may indicate ___

A

stroke, retinopathy

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19
Q

focal neurological signs during HTN emergency indicate ___

A

stroke

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20
Q

numbness or weakness during HTN emergency may indicate ___

A

stroke

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21
Q

dyspnea and chest pain in a HTN emergency may indicate ____

A

ACS

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22
Q

nausea & vomiting is HTN emergency may indicate ___

A

elevated intracranial pressure

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23
Q

acute/severe back pain in a HTN emergency may indicate ___

A

aortic dissection

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24
Q

urinary retention during HTN crisis may indicate ___

A

acute kidney injury (AKI)

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25
Q

fundoscopy can be used to check for ___

A

hemorrhages, exudates (cotton wool spots), or papilledema-HTN retinopathy

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26
Q

CBC and liver enzyme testing can be done to check for ___

A

HELLP syndrome in pregnancy

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27
Q

an ECG can be performed to check for ___

A

left ventricular hypertrophy, ACS

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28
Q

cardiac enzyme testing can be done to check for ____

A

ACS

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29
Q

urinalysis and renal function testing can be done to test for ___

A

proteinuria and AKI

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30
Q

imaging can be performed to check for ___

A

aortic dissection or suspected stroke

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31
Q

what are 4 potential causes of HTN crisis?

A
  1. exogenous substances
  2. non-adherence to antihypertensives
  3. renal artery stenosis
  4. hormonal
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32
Q

what are 5 hormonal conditions that can lead to HTN crisis?

A
  1. hyperthyroidism
  2. hyperparathyroidism
  3. hyperaldosteronism
  4. Cushing’s syndrome
  5. pheochromocytoma
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33
Q

what Rx drugs can increase HTN?

A
  1. NSAIDs (including selective Cox-2)
  2. corticosteroids and anabolic steroids
  3. OCPs and sex hormones
  4. vasoconstricting / sympathomimetic decongestants
  5. calcineurin inhibitors (cyclosporin, tacrolimus)
  6. erythropoeitin and analogues
  7. antidepressants: MAOIs, SSRIs, SNRIs
  8. Midodrine
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34
Q

what are natural substances that can raise BP?

A
  1. licorice root
  2. stimulants like cocanine
  3. salt
  4. excessive alcohol intake
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35
Q

stroke volume is affected by what 3 things?

A
  1. preload
  2. afterload
  3. contractility
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36
Q

how is MAP (mean arterial pressure calculated)?

A

MAP = (1/3 x SBP) + (2/3 x DBP)

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37
Q

general pathophysiology of how HTN turns into end organ damage

A
  1. triggering factors like a vasoconstrictor causes an increase in systemic vascular resistance (big squeeze)
  2. endothelial injury
  3. coagulation cascade
  4. reduced perfusion to organs
  5. additional vasoactive mediators (RAAS)
  6. ischemia
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38
Q

in HTN urgency, you want to lower the BP to ___mmHg in 24 hours and then ____mmHg in 48 hours and then to target 140/90mmHg in ___ (timeframe)

A

180-190/110; 160-100; 140/90

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39
Q

dose of captopril

A

12.5-25mg SL or PO q6h

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40
Q

onset of captopril

A

SL: 10-15min
PO: 1-2hr

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41
Q

time for captopril to peak

A

SL: 1hr
PO: 1-2hr

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42
Q

duration of captopril

A

4-8hr

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43
Q

captopril should be avoided in what conditions?

A

pregnancy and renal failure

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44
Q

what is the drug class of clonidine?

A

alpha 2 agonist

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45
Q

dose of clonidine

A

0.1-0.2mg PO q8h (max 0.8mg/day)

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46
Q

onset of clonidine

A

30-60min

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47
Q

time to peak for clonidine

A

2-4 hrs

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48
Q

duration of action for clonidine

A

8-12 hours

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49
Q

what are some of the ADRs associated with clonidine?

A

drowsiness, bradycardia, rebound HTN when stoppedn

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50
Q

what is the drug class of labetolol?

A

mixed alpha 1 and B1/2 blocker

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51
Q

dosing of labetalol as PO therapy for urgency

A

100-400mg PO q6h

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52
Q

oral bioavailability of labetolol

A

25%

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53
Q

onset of labetalol

A

30-120min

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54
Q

time to peak for labetolol

A

3-4 hrs

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55
Q

duration for labetolol

A

6-8hr

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56
Q

what are some ADRs of labetolol?

A

bradychardia, bronchospasm

57
Q

can labetolol be used in pregnancy?

A

yes

58
Q

what is the drug class for hydralazine?

A

vasodilator

59
Q

what is the PO dosing of hydralazine for urgency?

A

10-25mg PO q6h

60
Q

what is the PO bioavailability of hydralazine?

A

50%

61
Q

onset for PO hydralazine

A

20-30min

62
Q

time to peak for PO hydralazine

A

1-2 hrs

63
Q

duration for PO hydralazine

A

8hr

64
Q

what are some of the ADRs of PO hydralazine?

A

reflex tachycardia, lupus-like syndrome

65
Q

PO hydralazine is c/i in what condition?

A

renal failure

66
Q

can hydralazine be used in pregnancy?

A

yes

67
Q

if a short acting agent is used for initial control, once that control has been reached what type of agent should be used?

A

a long acting

68
Q

what are 4 short-acting oral agents that can be used in HTN urgency?

A

captopril, clonidine, labetolol, hydralazine

69
Q

in addition to tretment with the oral agents for HTN crisis, what other agents could be used to lower BP gradually in 1-2 days

A

DHP CCBs, ACE/ARB, thiazide-like diuretics

70
Q

why is SL (immediate release) nifedipine not given anymore?

A

causes an uncontrollable rapid drop in BP, peripheral vasodilation resulting in coronary steal phenomena & or reflex tachycardia and have been cases of MI and stroke

71
Q

genral MOA of CCBs

A

blocks transmembrane influx of Ca ions into cardiac smooth muscle cells and reduces peripheral vascular resistance by acting directly on vascular smooth muscle

72
Q

list 3 DHP CCBs used for treatment of HTN urgency

A
  1. amlodipine
  2. nifedipine
  3. felodipine
73
Q

which DHP CCB can be used in pregnancy?

A

Nifedipine XL

74
Q

dose of amlodipine for urgency

A

2.5-10mg daily

75
Q

ADME for amlodipine

A

A: peak in 6hrs
D: 20L/kg
M: hepatic CYP3A4 & inhibits CYP1A2
E: duration 24hrs

76
Q

dose of Nifedipine XL for urgency

A

30-120mg daily

77
Q

ADME of nifedipine XL

A

A: peak in 2 hrs
D: highly protein bound
M: hepatic CYP3A4 and CYP1A2
E: duration 24hrs

78
Q

dose of felodipine XL for urgency

A

2.5-20mg daily

79
Q

ADME for felodipine XL

A

A: peak 2-5hrs
D: highly protein bound
M: hepatic, CYP3A4 and 2C8
E: duration 24hrs

80
Q

what are some ADRs of DHP CCBs?

A

peripheral edema, flushing, headache, reflex tachycardia

81
Q

use caution if using a DHP CCB in patients with what condition?

A

aortic stenosis

82
Q

can the nifedipine XL or felodipine XL be chewed or crushed?

A

no

83
Q

when should the headache associated with urgency be gone?

A

within 24hrs

84
Q

following HTN urgency, when should BP be monitored?

A

2-3 hours, then 24 hours, 48 hrs, 1 month, then 3 months

85
Q

following a HTN urgency, when should electrolytes be measured?

A

3-4 weeks later

86
Q

when should the patient follow up to ask about peripheral edema?

A

1 month after

87
Q

in a hypertensive emergency, you want to decrease the MAP by ___% within what time frame? Then what?

A

decrease by 20-25% within 1 hour, then to 160/110mmHg after 2-6 hours, then further normalization within the nest 24-48hrs

88
Q

t//f the choice of agent and blood pressure goals are dependent on the specific HTN emergency

A

t

89
Q

list 6 parenteral medications used for HTN emergency?

A
  1. enalprilat
  2. esmolol
  3. hydralazine
  4. labetolol
  5. nitroglycerin
  6. phentolamine
90
Q

dose, onset , duration of parenteral enalprilat for HTN E

A

1.25-5mg IV q6h ; 15-30min, 6-12hrs

91
Q

dose, onset, and duration of parenteral esmolol for HTN E

A

bolus 500 mcg/kg IV; continuous 50-300mcg/kg/min; 1-2min, 10-20min

92
Q

what is the drug category of enalaprilat?

A

ACEi

93
Q

what is the typical indiaction for using enalprilat in HTN E?

A

if patient has acute LV failure

94
Q

can enalaprilat be used in pregnancy?

A

no

95
Q

what is an ADR of enalprilat?

A

acute renal injury

96
Q

what is the drug class of esmolol?

A

cardioselective B blocker

97
Q

what are some of the ADRs of esmolol?

A

bronchospasm, heart block, heart failure

98
Q

in what cases of HTN E is esmolol typically used?

A

aortic dissection and perioperative

99
Q

dose, onset and duration of IV hydralazine for HTN E

A

5-20mg IV q4-6h, may repeat 5mg in 20min; 10-20min, up to 12h

100
Q

what are some of the ADRs of parenteral hydralazine?

A

tachycardia, flushing, enpredictable effect

101
Q

when is hydralazine typically used for HTN E?

A

pregnancy or if B blockers need to be avoided

102
Q

dose, onset, and duration for parenterla labetolol for HTN E

A

20-80mg iv q10min bolus, continuous 0.5-2mg/min IV; 5-10min, 3-6h

103
Q

what are some of the ADRs of labetolol?

A

bronchospasm, bradycardia, heart block

104
Q

when is labetolol used to treat HTN E?

A

most cases

105
Q

can labetolol be used in pregnancy?

A

yes

106
Q

what drug class is nitroglycerin?

A

veno/vasodiliator

107
Q

what is the dose, onset and duration of parenteral nitroglycerin for HTN E?

A

continuous 5-200mcg/min IV; 2-5min; 5-10 min

108
Q

what are some of the ADRs of parenteral nitroglycerin?

A

headache, reflex tachycardia, tachyphylaxis

109
Q

what are the typical uses for nitroglycern in HTN E?

A

coronary ischemia, cerebral ischemia

110
Q

what drug class is phentolamine?

A

alpha blocker

111
Q

what is the dose, onset, and duration of parenteral phentolamine for HTN E?

A

IV bolus 10-15mg q 5-15min prn, continuous 1-40mg/h; 1-2min; 10-30min

112
Q

what are some of the ADRs of phentolamine?

A

hypotension, flushing

113
Q

when is phentolamine typically used in HTN E?

A

if there is increased catecholamine activity (ex: pheo, tyramine reaction)

114
Q

which parenteral agent had been used in the past for HTN E, but is not recommended anymore?

A

Nitroprusside

115
Q

why is nitroprusside not recommended anymore?

A

decreased cerebral blood flow and increased intracranial pressure

116
Q

in what indications should nitroprusside reallyyy be avoided?

A

hypertensive encephalopathy or following cerebrovascular accident

117
Q

in patients with CAD, nitroprusside was demonstrated to cause ___

A

coronary steal

118
Q

nitroprusside is associated with creating what toxic chemical at recommended rates of infusion?

A

cyanide

119
Q

what is the onset and duration of nitroprusside?

A

less than 1 min, lasts 2 min

120
Q

what BP signifies acute-onset HTN (HTN E) in pregnancy?

A

SBP 160+ and or DBP 110+ that lasts 15min or longer

121
Q

what should be done if a person is diagnosed with acute onset HTN in pregnancy?

A

immediately should go to the ER

122
Q

when should you hope to resolve HTN related SOB?

A

within 4 hours

123
Q

goal BP and timeframe for acute HTN E in pregnancy

A

160/110 in 1 hr, then 150/100 by the second hour

124
Q

goal HR and timeframe for acute HTN E in pregnancy

A

<100 within 1 hr

125
Q

what are the complications we are trying to avoid when treating acute HTN E in pregnancy?

A

stroke, seizures, AKI, fetal distress, premature delivery, initial agressive drop in BP

126
Q

if the HR >60bpm, what is the recommended therapy for acute HTN E in pregnancy?

A

labetolol 10-80mg IV q10min (double the dose each time) until goal is achieved or until patient recieves the max of 300mg

127
Q

if HR is <60bpm, what is the recommendation for acute HTN E in pregnancy?

A

hydralazine 5-20mg IV q20min until goal achieved or until max dose of 30mg is reached (use caution as hydralazine can have long duration of action & unpredictable BP lowering)

128
Q

when does BP and HR need to be monitored in acute HTN E in pregnancy?

A

Q10min until BP is <160mmHg and then Q1hr

129
Q

if patient has SOB in acute HTN E in pregnancy, when does O2 saturation need to be monitired after starting therapy? When will the lungs need to be ausculatated?

A

in 1 hour also in 1 hour

130
Q

for acute HTN E in pregnancy patients, how often do they need to be asked if they are experiencing chest pain, dizziness or light-headedness?

A

q 30 min

131
Q

are aortic dissection and aortic aneurysm the same thing?

A

no

132
Q

what drugs are typically given for acute aortic dissection?

A

IV labetolol with or without a vasodilator to decrease pulsatile stress, but you need surgery ASAP

133
Q

what drug should be avoided in aortic dissection?

A

hydralazine alone may cause reflex tachycardia

134
Q

what is the BP goal in aortic dissection?

A

SBP 100-120mmHg within 20min

135
Q

what is the HR goal for aortic dissection?

A

<60bbm within 20min

136
Q

what is done is a patient is experiencing ischemic stroke and is not eligible for thrombolytic therapy?

A

treat if SBP>220 or DBP >120; reduce BP by ~15% over the first 24hrs with gradual reduction thereafter

137
Q

what is done if a patient is experiencing an ischemic stroke and is eligible for thrombolytic therapy?

A

if high BP (>185/110mmHg) should be treated concurrently before giving thrombolytic drug and maintained for at least 24hrs

138
Q

what are the 2 drugs of choice for ischemic stroke HTN E?

A

IV labetolol is the preferred option, but IV hydralazine can also be used (not preferred bc of unpredictable BP changes when you are really needing very carefully controlled BP management)

PBL PY2 Fall (21 decks)

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