Dr. Ferraro
What is the BP level that is considered a hypertensive crisis?
BP > 180/120 mmHg
What are the two types of hypertensive cries?
Hypertensive urgency and hypertensive emergency
What is hypertensive urgency?
Severely elevated BP WITHOUT end organ damage
What is hypertensive emergency?
Severely elevated BP WITH end organ damage
What are some types of end-organ damage?
HTN encephalopathy (confusion), Stroke (AIS or ICH: brain bleed), Ocular changes, Aortic dissection, Aortic coronary syndrome, Acute liver failure, Pulmonary edema (fluid forming around the lungs), Acute renal failure, Eclampsia (elevated maternal BP)
What is aortic dissection?
A tear in inner blood vessel branching off the heart.
What is acute ischemic stroke (AIS)?
Occurs when a blood clot blocks or narrows an artery leading to the brain
What is intracranial hemorrhage (ICH)?
Occurs when a blood vessel inside the brain ruptures and causes bleeding
What are some causes of hypertension crisis?
Medication noncompliance, medication causes (withdrawal or introduction), patients >60 years, African American, and Male
What drugs cause rebound HTN?
BB: Metoprolol, alpha-2 agonists: clonidine, & CCB: amlodipine (occasionally)
What drugs when introduced to a patient can cause HTN?
Illicit drugs: stimulants (Meth, cocaine), Monoamine Oxidase Inhibitors (MAO-i) → used for CNS disorders in older patients, OTC medications (decongestants: pseudoephedrine)
What are the therapeutic approaches for hypertensive urgency?
Gradual BP lowering, within 24 to 48 hours, ORAL medications (may start or intensify home medications), Setting: outpatient (ED, home), and prevent the start of end organ damage
What are the therapeutic approaches for hypertensive emergency?
Rapid BP lowering, within minutes to hours, continuous IV infusion of a short-acting titratable agent, setting: inpatient (ICU, medical floor), and prevent worsening of end organ damage
What are the treatment targets for hypertension emergency?
Lower SBP by no more than 25% within the first hour, if stable, reduce to 160/100 mmHg within the next 2 to 6 hours, cautiously, target “normal” BP over the following 24 to 48 hours (so we do not drop their brain perfusion)
What are the treatment targets for hypertension urgency?
Reduction in BP of 20-30 mmHg, discharge when symptoms improved and BP <180/110 mmHg, “normal” BP should be targeted over 1-2 days (patient specific)
What are the oral agents for HTN crisis?
Captopril, Clonidine, & Labetalol
What is the MOA for Captopril?
ACE-i
What some AE of Captopril?
Cough, acute kidney injury, hypotension, hyperkalemia, angioedema
What is Captopril contraindicated in?
Pregnancy and angioedema
What is the MOA for Clonidine?
alpha-2 agonist
What are some AE of Clonidine?
bradycardia, dry mouth, drowsiness, hypotension
What drug form does Clonidine also come in?
A weekly patch
What is the MOA for Labetalol?
Combined alpha and non-selective B-blocker
What are some AE of Labetalol?
heart block, bronchospasm, bradycardia, hypotension
What are some patient counseling points for Labetalol?
Contraindicated in acute liver failure; caution in obstructive or reactive airway; avoid in 2nd or 3rd degree heart block
What are the DHP-CCB (Vasodilators) IV agents for HTN crisis?
Nicardipine, Clevidpine
What are some AE of Nicardipine?
Flushing, edema, N/V, dizziness, tachycardia, headache
What are some counseling points for Nicardipine?
Avoid in acute heart failure, contraindicated in advanced aortic stenosis (aorta is stiff → cannot contract)
What are some counseling points for Clevidipine?
Contains egg and soy, contraindicated in patients with defective lipid metabolism (comes in lipid emulsion), can only use for 3 days, and expensive
What are the Nitric Oxide dependent (vasodilators) IV agents for HTN crisis?
Nitroglycerin, Sodium Nitroprusside
What is the MOA for Nitroglycerin?
Potent vasodilator (activates cGMP → smooth muscle relaxation); (vein > arteries)
What are some AE of Nitroglycerin?
flushing, tachycardia, headache, syncope (fainting), hypotension
What are some counseling points for Nitroglycerin?
Use for ACS (heart attack/chest pain) or pulmonary edema, tolerance with prolonged use; avoid with PDE-5 inhibitors (Sildenafil)
What is the MOA for Sodium Nitroprusside?
Potent vasodilator (veins=arteries)
What are some SE of Sodium Nitroprusside?
Cyanide toxicity, chromaturia (red urine), erythema (red, itch, swell), flushing, sweating, and muscle twitching, elevate ICP
What are some counseling points for Sodium Nitroprusside?
Avoid use in kidney/renal impairment (toxic metabolites → cyanide) and in ACS (higher mortality)
What are the miscellaneous vasodilator IV agents for HTN crisis?
Hydralazine, Enalaprilat, Fenoldopam
What is the MOA for Hydralazine?
Direct vasodilator
What are some counseling points for Hydralazine?
Caution: prolonged and unpredictable effect (can cause hypotension and hyperperfusion)
What is the MOA for Enalaprilat?
ACE-i
What is a AE of Enalaprilat?
Cough
What is some counseling points for Enalaprilat?
Contraindicated in pregnancy and angioedema, avoid in acute MI; rarely used
What is the MOA for Fenoldopam?
D1 agonist → decreases vascular resistance, increases renal blood flow, diuresis, and natriuresis
What are some AE of Fenoldopam?
Elevates IOP and ICP
What are some counseling points for Fenoldopam?
Contraindicated with increased IOP (glaucoma) or ICP (Increased cranial pressure); avoid with sulfa allergy
What are the adrenergic inhibitor IV agents for HTN crisis?
Esmolol, Labetalol, Metoprolol, Phentolamine
What is the MOA of Esmolol?
Cardio-selective B-blocker; class II antiarrhythmic
What are some counseling points for Esmolol?
Contraindicated in acute heart failure or bradycardia; metabolized by red blood cells
What is the MOA for Labetalol?
Combined alpha, and non-selective B-blocker
What are some counseling points for Labetalol?
Contraindicated in acute heart failure; caution in obstructive or reactive airway; avoid in 2nd or 3rd degree heart block
What is the MOA for Metoprolol?
Cardio-selective B-blocker
What are some counseling points for Metoprolol?
Avoid in acute HF, bradycardia, and 2nd or 3rd degree heart block
What is the MOA for Phentolamine?
Competitive blocker of alpha-adrenergic receptors; + inotrope & chronotrope
What are some counseling points for Phentolamine?
Used in catecholamine excess → a lot of NE released (ex: pheochromocytoma → tumor because of higher catecholamines, interactions between MOA-I and other drugs or food, cocaine toxicity, amphetamine overdose, or clonidine withdrawal)
What do we monitor in HTN Urgency?
BP monitoring for a few hours in the ED or urgent care, AE of medication use, discussion about adherence, initiate or intensify chronic, oral medications for HTN
What do we monitor in HTN Emergency?
Continuous BP monitoring inpatient, signs and symptoms of end organ damage, AE of medication used, initiate or intensify chronic, oral medications for HTN (~6-12 hours after starting IV)
How do we follow-up for HTN Urgency?
1-7 days at PCP office, continue to adjust meds over weeks and months to meet chronic BP goal
How do we follow-up for HTN Emergency?
Hourly (BP) checks while inpatient, 1-7 days at PCP office, evaluation and treatment of secondary cause of HTN emergency, continue to adjust meds over weeks and months to meet chronic BP goal