HTN Crisis - DUNN

What organ’s blood flow is sacrificed first in hypertensive crisis?

cerebral blood flow is sacrificed first

Which organ is often the first to show damage in hypertensive crisis?

the kidney are the first to go

What role does diastolic blood pressure (DBP) and systolic blood pressure (SBP) play in cerebral perfusion?

cerebral blood flow depends on mean arterial pressure, which is influenced by DBP, SBP, and time in diastole

What antihypertensive is called a “repeat offender” in hypertensive crisis due to rebound hypertension?

clonidine is a repeat offender for reflex/rebound hypertension

What is the first question to ask about a patient’s blood pressure in crisis?

ask what their normal BP usually is

What symptoms should be specifically checked in a hypertensive crisis?

current symptoms, especially vision changes 

What should be reviewed about the patient’s medications?

prescribed meds, compliance, OTC drugs, and herbals

What should always be screened for in patient history during hypertensive crisis evaluation?

recreational drug use

Which class of antidepressants may contribute to hypertensive crisis?

SNRIs (serotonin-norepinephrine reuptake inhibitors)

What blood pressure level defines Stage 2 hypertension in the notes?

greater than or equal to 140/90 mmHg

Where is Stage 2 hypertension often encountered?

outpatient settings

What example BP is given in the notes for hypertensive crisis?

203/0 mmHg

What should be considered if a patient is already on antihypertensive meds but presents with severe hypertension?

poor adherence, drug resistance, or secondary cause of hypertension

What route of administration is recommended for acute hypertensive crisis?

parenteral therapy with continous tiratable IV infusion

Which IV drug should not be used for hypertensive emergencies?

enalaprilat should not be used

Why are continuous IV infusions preferred over bolus therapy in hypertensive crisis?

they allow tirtration to safely reduce BP without overshooting

Which patients should avoid β-blockers during hypertensive crisis?

patients with bronchospastic airways disease

What is the specific indication for β-blocker use in hypertensive emergencies?

only for rate control not ischemia management

Which type of calcium channel blockers are highlighted in the hypertensive crisis notes?

dihydropyridine calcium channel blockers

What comorbidity is specifically noted in relation to antihypertensive choice in crisis?

kidney failure (important consideraiton for drug selection)

Which type of calcium channel blockers are highlighted in the hypertensive crisis “Sacrificed first” note refers to cerebral perfusion

brain is highly vulnerable to BP changes

“Ser kidneys first to go” indicates

renal injury is an early complication

Clonidine note:

commonly cause rebound hypertension if stopped suddenly or misused 

Evaluation emphasis

always ask baseline BP, assess complinance, check OTC/herbals (like decongestant) and screen recreational drugs (cocaine, amphetamine, etc)

Parenteral titratable infusions

are the standard of care for emergencies (nicardipine, clevidipine, nitroprusside, nitroglycerin, esmolol, labetalol)

Enalaprilat (IV ACE inhibitor)

is specifically not recommended due to slow onset and unpredictable effects

β-blockers

should be avoided in asthma/COPD, labetalol and esomolol maybe be used selectively. not for MI/ischemia in acute setitng.. mainly for HR control

Calcium channel blockers

dihydropyridine (nicardipine, clevidipine) are preffered for rapid tirtration

Kidney failure

drug clearance and renal perfusion are critical factors in crisis management 

What is a hypertensive crisis?

a severe elevation in blood pressure that requires urgent or emergent medical attention

What are the two major categories of hypertensive crisis?

hypertensive urgency (very high BP without acute target organ damage) and hypertenive emergency (very high BP with acute target organ damage)

Which three pressure parameters are critical for cerebral blood flow regulation?

diastolic blood pressure, systolic blood pressure, and mean arterial pressure 

Why is time spent in diastole important for cerebral blood flow?

because cerebral perfusion occurs largely during diastole, and prolonged uncontrolled HTN disrupts autoregulation

What happens once cerebral autoregulation is exceeded?

risk of hypertensive encephalopathy, ischemia, or hemorrhage

Which organs are most vulnerable in hypertensive crisis

kidneys (first to go), brain (vision changes, confusion, stroke-like symptoms), and heart/vasculature (LV strain, MI, dissection)

What baseline should always be established in hypertensive crisis?

the patient’s usual or normal BP

What neurologic symptoms may suggest hypertensive crisis?

vision changes, confusion, headache, seizures

What cardiac symptoms should be checked?

chest pain and palpitations 

What pulmonary symptom is important in assessment?

shortness of breath

What common cause of hypertensive crisis is related to medications?

missed doses/non-adherenece

Which OTC and herbal medications may trigger crisis?

decongestant, NSAIDs, stimulants

Which recreational drugs are potent triggers of hypertensive crisis?

cocaine, amphetamines, MDMA

Which antihypertensive drug is known as a “repeat offender” in hypertensive crisis?

clonidine due to rebound hypertension when abruptly stopped

Which antidepressant class may increase BP and cause crisis?

SNRIs such as venlafaxine and duloxetine, especially at higher dose 

List other agents that may induce hypertensive crisis.

stimulants, cocaine, amphetamine, decongestant

What BP defines Stage 2 hypertension?

greater than or equal to 140/90 mmHg

What BP levels are often seen in urgency or emergency?

SBP > 180 and/or BDP >120 mmHg

What is the key factor distinguishing urgency from emergency?

presence or absence of acute target organ damage

How is hypertensive urgency typically managed?

oral antihypertensive, gradual BP lowering over 24-48 hours, outpatient/ER follow up

How is hypertensive emergency managed?

hospital admission with continous IV tiratable antihypertensives

Why is enalaprilat not appropriate in hypertensive emergencies?

too long-acting and unpredictable

What type of antihypertensives are preferred in emergencies?

continous, tirtatable IV infusions

Which drugs should be avoided in hypertensive emergency?

enalaprilat (unpredictable, long-acting) and short-acting nifedipine (rapid BP drop which leads to ischemia)

Which patients should not receive β-blockers?

those with broncospatic airway disease (asthma, COPD)

What is the role of β-blockers in hypertensive emergencies?

used only for rate control (aotric dissection, tachyarrythmias)

Why must drug selection be cautious in renal failure?

some vasodilators worsen kidney function; renally cleared drugs can accumualtes

What organ is often the first to be damaged in hypertensive crisis?

kidney

Why is clonidine a common culprit in hypertensive crisis?

some withdrawal cause rebound hypertension

Why is compliance check critical in hypertensive crisis assessment?

non-adherence is one of the most common cause of crisis

When is outpatient management appropriate?

only for urgenecy (not emergency)

What type of therapy should never be used in emergencies?

long-acting one shot oral drugsWhat determines classification of crisis: BP numbers or organ damage? 

What determines classification of crisis: BP numbers or organ damage?

end organ damage

Which two organs are most vulnerable early in hypertensive crisis?

kidneys and brain

Which medication withdrawal is a common cause of crisis?

clonidine

Which drug classes/substances must always be considered as causes?

SNRIs, stimulants, illicit drugs, NSAIDs

What is the gold-standard therapy for hypertensive emergency?

IV titratable antihypertensive

How does severe hypertension (“urgency”) present?

marked BP elevation without processing target-organ damage; develops over delays weeks; managed with oral meds 

How does hypertensive emergency present?

marked BP elevation with acute end-organ damage; develop rapidly (hours-days); requires immediate IV therapy

Why must BP reduction be cautious in chronic hypertension patients?

their cerebral autoregulation curve is shifted upward; rapid lowering can cause hypoperfusion

What is the general principle of BP reduction in emergencies?

lower BP enough to stop organ damage but avoid excessive rapid drops 

What is the BP goal in aortic dissection?

reduce SBP to < 120 mmHg within 20 minutes

What is the first-line drug class in aortic dissection?

beta blockers to reduce shear stress

What are BP goals in acute ischemic stroke?

if candidate for thrombolysis, keeps BP < 185/110; otherwise avoid excessive lowering 

How should BP be managed in hemorrhagic stroke?

lower cautiously, avoid drugs that raise intracranial pressure

What therapy is used in acute pulmonary edema with systolic dysfunction?

vasodilators (nitrorpusside, nitroglycerin) + diuretics

How should severe hypertension without organ damage be treated?

gradual reduction with oral therapy over hours-days 

What is the MOA of nicardipine?

DPH calcium channel blocker, arterial vasodilaiton

What are nicardipine’s key features?

onset 5-10 minute, long duration; side effect include reflex tachycardia, flushing, edema

What is the MOA of clevidipine?

ultra-short acting DHP CCB

What are clevidipine’s unique cautions?

lipid emulsion (avoid in soy/egg allergy or lipid metabolism disorder); very short onset/offset

What is labetalol’s MOA?

alpha 1 and nonselective Beta-blocker leads to decrease resistance and HR

When is labetalol especially useful?

emergencies including pregnancy and stroke

What are labetalol’s side effects?

bradycardia, bronchospasm, heart block

What is esmolol’s profile?

short-acting B1-selective blockers; half-life minutes; easily tirtratable

What are esmolol’s adverse effects?

bradycardia, heart block

What is sodium nitroprusside’s MOA?

potent arterial and venous vasodilator; immediate onset

What are risks with nitroprusside?

cyanide/thicyanate toxicity (esp.renal/hepatic dsyfunction) increased ICP

What is nitroglycerin’s primary effect?

predominantly venodilator —> reduces preload; best for ischemia and pulmonary edema 

What contraindication applies to nitroglycerin?

PDE-5 inhibitor use

What is fenoldopam’s MOA?

dopamine-1 receptor agonist —> arterial/renal vasodilation

What is a unique adverse effect of fenoldopam?

increase intraocular pressure 

What is hydralazine’s MOA?

direct arteriolar vasodilator

When is hydralazine often used?

in pregnancy

What are hydralazine’s adverse effects?

reflex tachycardia, headache, lupus-like syndrome 

What is enalaprilat’s MOA?

is IV ace inhibitor which reduce afterload 

Why is enalaprilat less favored?

it has a slower onset, unpredictable effect; contraindicated in pregnancy and bilateral RAS

What is phentolamine’s MOA?

nonselective alpha blocker

When is phentolamine indicated?

catecholamine excess (pheochromytoma, stimulant crisis)

What are the first stabilization steps in hypertensive emergency?

airway, breathing, circulation; IV acesss, continous monitoring

What rapid assessments are needed?

neuro exam, ECG, troponins, renal function, urine output