Hypertensive crisis Flashcards
(68 cards)
1
Q
what are the two types of hypertensive crisis
A
urgency and emergency
2
Q
what is hypertensive urgency
A
- systolic BP >180 and/or diastolic BP >120
- no evidence of target organ damage
3
Q
what is hypertensive emergency
A
- systolic BP >180 and/or diastolic BP >120
- evidence of target organ damage (new or worsening)
4
Q
what are common Sx of target organ damage
A
headache, chest pain, SOB, back pain, numbness/weakness, change in vision, difficulty speaking
5
Q
what are the risk factors for development of a hypertensive crisis
A
- obesity, female gender, hx of CV disease
- higher number of prescribed antihypertensive meds
- nonadherence w/ antihypertensive meds
6
Q
common causes of hypertensive crisis
A
- chronic htn
- med non-adherence (most common and biggest factor to developing htn emergency)
- medication/substance related
- pregnancy
- renal disease
- endocrine disorders
7
Q
goals of therapy for hypertensive urgency
A
- reinstitute/intensification of antihypertensive drug therapy
- tx of anxiety as applicable
8
Q
in a hypertensive urgency, there is no indication for:
A
- referral to emergency department
- immediate reduction in BP
- hospitalization
9
Q
goals of therapy for hypertensive emergency
A
- hour 1: reduce BP by a max of 25%
- hour 2-6: reduce BP <160/100-110
- hours 6-48: reduce BP to goal
10
Q
in a hypertensive emergency, there is indication for:
A
- referral to emergency department
- hospital admission
- IV antihypertensives
11
Q
why should BP be lowered gradually in a hypertensive emergency?
A
- HTN pts’ bodies adjust to functioning at increased BP
- if BP is dropped too quickly, there is risk of tissue ischemia
12
Q
how should hypertensive emergency be treated
A
with IV meds
13
Q
why are IV meds preferred in a hypertensive emergency
A
- fast onset/offset
- predictable PK
- minimal AEs
14
Q
DHP CCBs agents for hypertensive emergency
A
Nicardipine
Clevidipine
15
Q
what is nicardipine dosing
A
2.5-15 mg/hr titratable IV infusion
16
Q
what is nicardipine onset
A
5-10 min
17
Q
what is nicardipine duration
A
15-30 min
18
Q
what are pros of using nicardipine
A
- titratable
- relative lower risk of AE
19
Q
what are cons of using nicardipine
A
- CI in severe aortic stenosis
- titrate cautiously w renal/hepatic impairment
- reflex tachycardia
20
Q
what is clevidipine dosing
A
1-32 mg/hr titratable IV infusion
21
Q
what is clevidipine onset
A
2-4 min
22
Q
what is clevidipine duration
A
5-15 min
23
Q
what are pros of clevidipine
A
- titratable
- lack of accumulation in organ impairment
24
Q
what are cons of clevidipine
A
- CI in severe aortic stenosis
- lipid formula (CI w/ soy/egg allergy; elevates TGs, change IV lines q12h)
- induces arterial fibrillation
25
vasodilator agents for hypertensive emergency
Nitroglycerin (nitrate)
Sodium nitroprusside (nitrate)
Hydralazine
26
what is nitroglycerin dosing
5-200 mcg/min titratable IV infusion
27
what is nitroglycerin onset
2-5 min
28
what is nitroglycerin duration
5-10 min
29
what are pros of nitroglycerin
- titratable
- beneficial in coronary ischemia
30
sodium nitroprusside dosing
0.25-10 mcg/kg/min titratable IV infusion
31
sodium nitroprusside onset
seconds
32
sodium nitroprusside duration
2-3 min
33
sodium nitroprusside pros
-titratable
34
nitroglycerin and sodium nitroprusside cons
- tolerance w/ prolonged use (beyond 24-48 hrs)
- interacts w/ PDE-5i
- dose limiting headache and reflex tachycardia
- excessive hypotension in hypovolemia
35
sodium nitroprusside specific con
cyanide toxicity
36
hydralazine dosing
10-20 mg IV push q4-6h
37
hydralazine onset
10-20 min
38
hydralazine duration
60-240 min
39
hydralazine pros
may be used in pts w/ bradycardia
40
hydralazine cons
- not titratable
- less predictable PK
- rebound tachycardia
41
B blocker agents for hypertensive emergency
Labetalol
Esmolol
42
labetalol dosing
10-20 mg IV push followed by 20-80 mg q10min or titratable IV infusion
43
labetalol onset
5-10 min
44
labetalol pros
- decreases HR and BP
- can be given as titratable infusion
45
labetalol cons
- IV infusion > IV push
- decreases HR
- CI w/ severe bradycardia, ADHF, reactive airway disease
46
esmolol dosing
titratable IV infusion
47
esmolol onset
1-2 min
48
esmolol duration
10-20 min
49
esmolol pros
- decreases HR
- cardioselective (tolerated in reactive airway diseases)
50
esmolol cons
- adjunct, not monotherapy for BP reduction
- avoid in severe bradycardia and ADHF
51
what is a possible problem w/ esmolol
only decreases the HR in a pt with hypertensive emergency and doesn't affect the BP
52
other meds for hypertensive emergency
Enalaprilat -> ACEi
Clonidine -> alpha 2 agonist
53
enalaprilat dosing
1.25-5 mg IV push q6h
54
enalaprilat onset
<= 15min
55
enalaprilat duration
about 6h
56
enalaprilat pros
maybe be beneficial in emergencies related to renin excess
57
enalaprilat cons
- delayed onset and peak
- CI in AKI, hyperkalemia, acute MI, bilateral renal artery stenosis, pregnancy
58
clonidine dosing
0.1-0.2 mg PO repeat q1h (max of 0.7 mg)
59
clonidine onset
30-60 min
60
clonidine duration
- hours
- max effect at 2-4h
61
clonidine pros
PO option when IV access cannot be established
62
clonidine cons
- often used inappropriately in hypertensive emergency
- delayed onset
- can cause hypertensive crisis on withdrawal
63
what meds are 1st line in pts w/ acute decompensated HF with pulmonary edema experiencing a hypertensive emergency
- nitroglycerin or sodium nitroprusside
- nicardipine and clevidipine are acceptable alternatives
- avoid B blockers and non-DHP CCBs
64
what meds are 1st line in pts w/ aortic dissection experiencing a hypertensive emergency
- initiate B blocker then vasodilator (e.g. nicardipine, clevidipine, nitroprusside)
- lower blood pressure quickly and prevent reflex tachycardia
65
- what meds are 1st line in pts w/ acute coronary syndromes experiencing a hypertensive emergency
- B blockers, nitroglycerin or sodium nitroprusside, or nicardipine
- use caution w/ non-DHP CCBS
- avoid B blockers in setting of reduced EF, Hr <60 bpm, SBP <100 mmHg, 2nd or 3rd degree heart block, or reactive airway disease
66
what meds are 1st line in pts w/ AKI experiencing a hypertensive emergency
- most IV antihypertensives are acceptable
- use caution w/ sodium nitroprusside
- avoid enalaprilat bc it increases SCr and K
67
what meds are 1st line in pts w/ eclampsia/severe pre-eclampsia experiencing a hypertensive emergency
- hydralazine, lebetalol, or nicardipine
- CI: enalaprilat and nitroprusside
68
what meds are 1st line in pts w/ stroke (intracranial hemorrhage/ischemic) experiencing a hypertensive emergency
- nicardipine, clevidipine, lebetalol
