Hypertensive Crisis

Question 1

nicardipine AE

Answer 1

• palpitation
• flushing
• HA
• dizziness

Question 2

sodium nitroprusside special consideration

Answer 2

• liver/renal failure: metabolite accumulation
• cyanide toxicity with prolonged use
• elevation in ICP
• ***USE HAS FALLEN OUT OF FAVOR DUE TO RISKS

Question 3

nicardipine is a

Answer 3

CCB

for acute stroke and most HTN crises

Question 4

if a pt is having a stroke ___________

Answer 4

DO NOT LOWER BP

want to ensure adequate perfusion to the brain

Question 5

pharmacologic tx considerations

Answer 5

• based on extent of end-organ damage
• use of IV medications
• should always be managed in ICU (need continuous BP monitoring)
• avoid extremely rapid decrease in BP (may consider in aortic dissection)

Question 6

esmolol is a

Answer 6

beta 1 blocker

for aortic dissection, ACS

Question 7

nitroglycerin is a

Answer 7

direct vasodilator

ACS, acute HF, pulmonary edema

Question 8

oral anti-hypertensives

Answer 8

• captopril (ACEi)
• nicardipine (CCB)
• labetalol (alpha and beta 1 blocker)
• clonidine (alpha 2 agonist)

Question 9

Phentolamine indication and special consideration

Answer 9

• catecholamine excess

- use with benzodiazepine is treating cocaine-induced HTN

Question 10

BP pressure must be done ______ and in a __________

Answer 10

slowly ; controlled environment

Question 11

Clonidine AE

Answer 11

• sedation
• dry mouth
• orthostatic hypotension

Question 12

For hypertensive crises: When switching from IV to Po

Answer 12

• restart home BP medications
• titrate IV antihypertensive down to achieve desired BP
• add on additional oral maintenance medications as needed

Question 13

Labs during initial work up of hypertensive crisis

Answer 13

• complete blood count (CBC)
• electrolytes (MAINLY K+)
• liver function tests (ASL/ALT)
• serum creatinine

Question 14

vitals and labs need to be ___________________

Answer 14

continually monitored

Question 15

nitroglycerin special considerations

Answer 15

• tachyphylaxis

- flushing, HA, erythema often limit dose titration

Question 16

_______ agents may need to be used to successfully lower BP

Answer 16

multiple

Question 17

Labetalol AE

Answer 17

• nausea

- dizziness

Question 18

Results of Patel et al. study

Answer 18

• determine if referral to hospital is associated with better outcomes than outpt management of hypertensive urgency
• visits to ED associated with more hospitalizations but not improved outcomes
• most patients still had uncontrolled HTN 6 months later

Question 19

Presentation of hypertensive crisis

Answer 19

• increased BP
• numbness/weakness
• chest pain
• shortness of breath
• back pain
• HA
• blurry vision

Question 20

What reading is considered an emergency hypertensive crisis?

Answer 20

severe elevation in BP WITH evidence of target organ dysfunction

ORGAN DAMAGE, admit to ICU, IV therapy

Question 21

Goals of therapy: If emergency

Answer 21

• reduction of BP by 25% over first hour
• target 160/100 over next 6 hours
• target normal within 24 - 48 hours
• parenteral therapy

Question 22

labetalol special considerations

Answer 22

• avoid in acute HF

- avoid in bradycardia

Question 23

Possible affected organs during hypertensive crisis

Answer 23

• brain (altered mental status, HA)
• kidneys (increased Scr, reduced urine, back pain)
• heart (chest pain, arrhythmias)
• can also affect liver, respiratory and GI fxn

Question 24

examples of parenteral anti-hypertensives

Answer 24

• sodium nitroprusside
• nicardipine
• esmolol
• labetalol
• nitroglycerin

Question 25

consider ____________ when selecting agents

Answer 25

patient specific factors

Question 26

if pt is asymptomatic, emergent reduction of BP does not improve outcomes

Answer 26

encourage compliance with maintenance medications or increase maintenance regimen

Question 27

sodium nitroprusside is a

Answer 27

direct venous dilator most indications EXCEPT intracranial pressure elevations and acute coronary syndrome (ACS)

Question 28

Goals of therapy: If urgent

Answer 28

- reduce BP < 160/100 over 24 hours*** | - oral therapy preferred

Question 29

Clevidipine indication and special consideration

Answer 29

- acute stroke - reflex tachycardia - avoid with egg or soy allergy - oil-in-water formulation

Question 30

captopril AE

Answer 30

- hyperkalemia - angioedema - renal failure

Question 31

Enalaprilat indication and special consideration

Answer 31

- acute HF - avoid in pregnancy - prolonged duration of action

Question 32

Consequences of uncontrolled BP > 180/120

Answer 32

- stroke/heart attack - memory loss - eye damage - kidney injury - back pain - aortic dissection

Question 33

labetalol is a

Answer 33

alpha and beta 1 blocker acute stroke, aortic dissection, ACS, pregnancy

Question 34

Important complicating conditions to be on look out for with hypertensive BP

Answer 34

- aortic dissection - preeclampsia/eclampsia - stroke - pheochromocytoma (tumor in adrenal gland that releases hormone which increases BP)

Question 35

Hydralazine indication and special consideration

Answer 35

- pregnancy - long t1/2 = potential hypotension - reflex tachycardia - HA

Question 36

What reading is considered urgent hypertensive crisis?

Answer 36

severe elevation in BP SBP >/= 180 and/or DBP >/= 120 NO ORGAN DAMAGE, optimize medications, oral therapy

Question 37

For hypertensive crises: Follow-up

Answer 37

- at discharge, optimize home medications - educate pt on proper BP monitoring critique - pt should follow-up with PCP in 2 - 4 weeks

Question 38

Causes of hypertensive emergency

Answer 38

- drugs - stroke/heart attack - endocrine disorders - renal disorders - pregnancy (eclampsia/preeclampsia)

Question 39

esmolol special consideration

Answer 39

- avoid in acute HF | - contraindicated in pts using home beta blocker or bradycardia

Question 40

Fenoldopam indication and special consideration

Answer 40

- most indications - increased ICP and intraocular pressure - reflex tachycardia - worsen glaucoma - hypokalemia

Question 41

nicardipine special consideration

Answer 41

reflex tachycardia

Question 42

titrate meds _________ and _____________

Answer 42

carefully ; appropriately