L5 HTN emergency

HTN emergency

• severe elevations in blood pressure w/ evidence of acute target organ damage

  • BP>180 and/or >120 mmHG

  • admission to the ICU for likely treatment with intravenous medication is recommended

• tied to high in-hospital mortality rate or inc one year risk of cardiovascular morbidity and mortality

what to do with elevated blood pressure without target damage

NOT an HTN emergency

• likely can use oral med for treatment

• ICU admission not required

Acute target organ damage for HTN emergency

Target organs include the retina, brain, heart, large arteries, and the kidneys

• Retina: hemorrhages, papilledema, cotton wool spots

• Brain: cerebral hemorrhage stroke, acute ischemic stroke, encephalopathy

• Heart: acute coronary syndrome (STEMI or MI), left ventricular failure + pulmonary edema, aortic dissection

• Arteries: hemolytic anemia, thrombocytopenia

• Kidneys: acute kidney injury

gnereal presentation of HT emergency

• headaches, neurologic symptoms and/or dizziness

• visual disturbances

• chest pain

• dyspnea - can be tied to hemolytic anemia

• + more un-specific presentation

think the target it affect and damage

BP goal in most HTN emergengencies

• systolic BP reduced no more than 25% within first hour

• <160/100 mmHg within the next 2-6 hours

• SBP of 130-140 mmHg next 24 to 48 hours

BP goal for acute aortic dissection

• SBP < 120 mmHg during the first hour

acute sympathetic discharge or catecholamine excess states

debatable

• SBP <140 mmHg within 1 hour

general consideration for drug selection in hospital for HTN emergency

• IV formulation

• quick onset

• rapidly titratable

• consideration for moa and site of action

IV infusion vs IV bolus

• IV infusion - consistent infusion

• IV bolus (IVP) - helpful for transition

  • ex. waiting for drug coming from pharmacy

CCB moa

• inhibition of L-type Ca channels in myocyte and vascular smooth muscle → vasodilation

  • non-DHP: bind to myocytes + VSM

    • affect nodal conduction, contractility - dec/same HR

  • DHP: bind more selectively to VSM → greater vasodilation

    • compensation → inc HR

nicardipine (cardene) VS Clevidipine (Cleviprex)

• IV or IV bolus

• titration

• acting/onset

• formulation

• other note

both IV

adrenergic blocker moa

Labetalol (trandate) vs Esmolol (brevibloc)

• IV or IVP

• titration

• formulation

• other note

• labetalol:

  • IV - smaller range of titration

  • IVP

• esmolol:

  • IV - larger range of titration

  • start with IV bolus but then IV - so primarily IV - NO USE FOR PATIENT TRANSITIONING

NO moa

NO vs Nitroprusside

• IV or IVP

• moa

• preparation and caution

• clinical pearl

• NO

  • IV - higher range of titration - allow room to move

    • increment of 5 mcg/min every 3-5 min

• Nitroprusside

  • IV: titrate increment 0l5 mcg/kg/min every 5 min

Hydralazine

• moa

• duration of action: long or short

• IVP or IV

• clinical pearl

• highly specific for arterial vasodilation

• longer duration of action

• IVP

• less predictable response and potential dose stacking

  • if add IV push together, they add up → sudden drop of BP

enalaprilat

• Uses

• IVP or IV

• CI

• rarely used, for patient with strict No PO

• IV ACEi - block conversion AGI to AGII

  • long acting

• CI: pregnancy and bilateral renal artery stenosis

Fenoldopam

• MOA

• IVP or IV

• caution

• DA receptor agonist - dec peripheral vasculature resistance (vasodilation) w/ inc renal blood flow and diuresis

• IV

• caution in pts with glaucoma due - inc intraocular P

  • dilate vessels in the eye → increased fluid (aqueous humor) formation or reduced drainage → ↑ intraocular pressure.

• avoid patients with sulfite allergy

Phentolamine

• MOA

• IVP or IV

• Uses

• competitive alpha blocker - antagonism of circulating EP and NE

• IVP or IV

• useful for HTN emergencies induced by catecholamine excess (pheochromocytoma)

Post stabilization follow-up

• pts typically require frequent adjustment of antiHTN med after stabilization

• regimen simplification and lifestyle modification may be helpful

• monthly follow-ups are recommended until BP is regularly controlled and any residual target oran damage has resolved