Hypertensive Crises

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