hypertensive crises - gilmore

somehow this is only 1 hour ~ 5 questions

what is the cause of essential hypertension?

widely unknown

list causes of secondary hypertension

• CKD

• cushing’s

• obstructive sleep apnea (OSA)

• hyperthyroidism

• meds

• excessive consumption of sodium, alcohol, or licorice

what is considered normal blood pressure? (SBP and/or DBP)

a. < 120 and < 80

b. 120-129 and < 80

c. 130-139 or 80-89

d. ≥ 140 or ≥ 90

a.

what is considered elevated blood pressure?

a. < 120 and < 80

b. 120-129 and < 80

c. 130-139 or 80-89

d. ≥ 140 or ≥ 90

b.

what is considered Stage 1 HTN?

a. < 120 and < 80

b. 120-129 and < 80

c. 130-139 or 80-89

d. ≥ 140 or ≥ 90

c.

what is considered Stage 2 HTN?

a. < 120 and < 80

b. 120-129 and < 80

c. 130-139 or 80-89

d. ≥ 140 or ≥ 90

d.

how is hypertension diagnosed?

average of ≥ 2 separate readings at separate encounters

what is the goal BP for all patients?

< 130/80

what is first line tx for elevated BP?

when do we reassess

non-pharm

reassess: 3-6 months

list nonpharm therapy options

• healthy weight

• DASH diet

• reduce salt intake

  • < 1500 mg

• enhanced intake of potassium

  • 3,500 - 5,000

• physical activity

  • 150 minutes per week

• moderate alcohol consumption

• smoking cessation

what is first line for stage 1 HTN with presence of clinical CVD, DM, CKD, or ASCVD risk ≥ 10%?

reasess?

nonpharm ± BP lowering medication

reasess monthly

what is first line for stage 1 HTN with ASCVD risk < 10% in patients without CVD, DM, CKD?

reassess?

nonpharm

reassess 3-6 months

what is first line for stage 2 HTN?

reassess?

nonpharm + 2 BP lowering meds (2 diff classes)

reassess monthly until goal is met

list first line BP lowering meds (drug classes)

• RAAS agent

  • ACE-I or ARB

• thiazide diuretic

• CCB

comorbid conditions — idk come back because can’t see the picture

what BP level is a hypertensive crisis?

SBP > 180

DBP > 120

which of the following is a hypertensive crisis WITHOUT target organ damage?

a. hypertensive urgency

b. hypertensive emergency

a.

which of the following is a hypertensive crisis WITH target organ damage?

a. hypertensive urgency

b. hypertensive emergency

b.

what is the most common risk factor for hypertensive crisis?

medication non-adherence

which of the following is generally asymptomatic and headache is common?

a. hypertensive urgency

b. hypertensive emergency

a.

which of the following has a clinical presentation of target organ dysfunction, dyspnea, and chest pain?

a. hypertensive urgency

b. hypertensive emergency

b.

how do we handle hypertensive URGENCY?

re-institute/intensify oral antihypertensive drug therapy and arrange follow-up

how do we handle hypertensive EMERGENCY?

admit to ICU and treat per compelling conditions (target organ damage)

hypertensive URGENCY, there is more risk with ________, which can cause ischemic stroke, MI, or renal ischemia

lowering BP too rapidly

what kind of agents should we use for hypertensive emergency?

a. fast onset and fast duration (quick on/quick off)

b. fast onset and slow duration (quick on/slow off)

c. slow onset and slow duration (slow on/slow off)

d. slow onset and fast duration (slow on/fast off)

a.

what ROA is preferred for treating hypertensive emergency?

when would we use something else?

continuous IV infusion preferred

if IV access unavailable —> oral

knowledge check

why would a patient need admitted to an ICU in order to receive the medications that are used to treat hypertensive emergencies?

continuous BP monitoring

parenteral admin

an ideal pharmacotherapy agent for hypertensive crisis should have: (SATA)

a. fast onset and quick duration of action

b. predictable kinetics

c. minimal ADRs

d. oral formulations

a. b. c.

list the CCBs used in hypertensive crisis

note: we only talked about DHP CCBs"

• nicardipine

• clevidipine (cleviprex)

which kind of calcium channel blockers have minimal activity in the heart and don’t affect contractility or heart rate, so we’ll use more for hypertensive crisis?

a. DHP

b. non-DHP

a.

what kind of calcium channel blockers are more selective for cardiac cells and have more effects on the cardiac conduction system and are used more for arrhythmias?

a. DHP

b. non-DHP

b.

what CCB is the GO TO drug used in hypertensive emergencies?

a. nicardipine

b. clevidipine (cleviprex)

c. diltiazem

d. verapamil

a.

nicardipine can cause _______

reflex tachycardia

what do we need to monitor pts for when they’re on nicardipine?

volume overload

nicardipine is used in most hypertensive emergencies except with ______

acute heart failure

what is the advantage of clevidipine (cleviprex) over nicardipine?

does it have better outcomes?

advantage: quicker onset and duration; lack of accumulation in renal/hepatic impairment

does NOT have better outcomes

what is the CI of nicardipine?

clevidipine (cleviprex)?

nicardipine: severe aortic stenosis

clevidipine: severe aortic stenosis, soy or egg allergy

clevidipine is used in most hypertensive emergencies, but need to use caution in pts with _______

cardiac ischemia

what is the MOA of nitroglycerin?

smooth muscle relaxation

converted to nitric oxide —> vasodilation

when is nitroglycerin contraindicated?

• use of a PDE-5 inhibitor

  • 12 hours for avanafil

  • 24 hours for sildenafil and vardenafil

  • 48 hours for tadalafil

T/F nitroglycerin is contraindicated in pts who have suspected intracranial pressure

TRUE

what is nitroglycerin used in?

coronary ischemia

what is the MOA of sodium nitroprusside?

why is it not used as often now?

MOA: prodrug converted to active form via dissociation of NO and cyanide when it interacts with sulfhydryl groups on erythrocytes and plasma proteins

used sparingly: toxic metabolite —> cyanide (especially in renal and hepatic impairment)

what vasodilator is available IV and PO, administered on a PRN basis, is NOT considered first line, has limited use because of unpredictable effect on BP, and can cause MI?

a. nitroglycerin

b. sodium nitroprusside

c. hydralazine

c.

what is hydralazine used in?

eclampsia

when is labetalol useful?

why?

useful when you need both heart rate and BP control

bc of it’s MOA: mixed alpha1 and nonselective beta1 and beta2 antagonist

when is labetalol used?

most hypertensive emergencies

-exception: pts with acute HF or heart block

what beta blocker is a rapid acting selective beta1 antagonist with it’s main effect being on heart rate?

a. labetalol

b. esmolol

c. metoprolol

b.

what is esmolol generally administered with and why?

admin with a vasodilator, useful adjunct when rate control is needed (because remember it doesn’t affect rate control alone)

what is esmolol used for?

aortic dissection

which of these is a cardio selective beta blocker?

a. labetalol

b. metoprolol

b.

why is metoprolol not an ideal medication for BP control in the hypertensive emergency setting?

administered via IV intermittently

used to treat rebound tachycardia associated with other antihypertensive meds

what med is an IV ACE inhibitor is used in acute left ventricular heart failure?

enalaprilat

why is enalaprilat not an ideal agent?

when is it contraindicated?

not ideal bc it takes a long time to reach peak and prolonged effect

CI: AKI and hyperkalemia

when do we use oral clonidine?

only if IV access can NOT be obtained

patients with ____ have an increased risk of morbidity and mortality and commonly present with a high elevation of blood pressure acutely

ICH

T/F the ideal BP goal in pts with an ICH is NOT known

TRUE

what is considered first line in a pt with ICH to minimize fluctuations when closely monitoring for signs of ischemia during acute BP lowering?

nicardipine

clevidipine

if a pt is not going to get reperfusion therapy, what is the blood pressure goal?

lower by 15% if BP is ≥ 220/120

if a pt is going to get reperfusion therapy, what is the blood pressure goal before administering?

while administering?

before: < 185/110

while: ≤ 180/105

what is first line in acute coronary syndrome/cardiac ischemia?

nitroglycerin

also recommended: beta blockers

patients with acute pulmonary edema and severe elevations in BP can present in __________

respiratory distress and hypoxia due to fluid overload

what is the target of therapy in pulmonary edema?

increase in afterload (we want to decr. it)

tx of choice: nitroglycerin and loops

what do we first do in aortic dissections?

control HR to < 60 bpm and SBP < 120 within 20 minutes

(labetalol probs most effective)

(use esmolol if pts have asthma or HF)

AKI requires blood pressure lowering by ____ within the ______

what meds are considered first?

lower by 25% within first hour

first line: DHP CCBs

if a pt with severe HTN is pregnant, how soon should treatment be initiated?

SBP goal?

first line agents?

initiate tx within 30-60 minutes

target SBP: < 140

first line: hydralazine or labetalol

pts on IV antihypertensives should have their blood pressures monitored ______ while being titrated

routinely — every 15 minutes

once a stable BP/dose is achieved, BP should be monitored every ______

can we switch to an oral agent? how?

every hour

consider converting to oral agent

continue IV therapy while oral is started in a stepwise fashion