Hypertensive Crises

Week 12 -> Dr. McMath

What is the definition of a hypertensive crisis in regard to BP?

SBP >180 mmHg and/or DBP >120 mmHg

If BP is >180/120 mmHg and there is also a presence of new or worsening end-organ damage, is this a hypertensive urgency or hypertensive emergency?

Hypertensive emergency

What organs are affected during a hypertensive emergency?

• Brain (ischemic or hemorrhagic stroke, encephalopathy, cerebral edema)

• Eyes (papilledema, retinal hemorrhage)

• Heart (acute HF, MI)

• Vascular (rupture of aneurysm or major vessel dissection)

• Kidney (acute or acute on chronic kidney injury)

_________ _________ does not require immediate BP reduction because the benefit does not outweigh the risk.

Hypertensive urgency

________ ________ is a medical emergency that requires acute hospitalization, frequent monitoring, and, in most cases, IV antihypertensive therapy to control BP.

Hypertensive emergency

How is a hypertensive urgency typically managed?

Resume omitted antihypertensive therapy, increase current doses of antihypertensives, or add additional agents to achieve control

What is the standard of care for managing hypertensive emergencies?

IV antihypertensive agents

In patients with chronically uncontrolled HTN, what makes intensive BP lowering suboptimal for organ perfusion?

Shifts in autoregulation

What is the patient at risk for if aggressive BP lowering therapy is initiated?

Ischemic complications

In patients with hypertensive urgency, what is considered the safest treatment approach?

Gradual lowering of BP with oral antihypertensives

In patients with hypertensive crises & AKI, what is the BP target?

Reduce by ≤ 25% in the 1^st hour

• Reduce to 160/110 in 2-6 hours

• Reduce to normotensive over the next 24-48 hours

In patients with hypertensive crises & AKI, what is the IV antihypertensive of choice?

Most are acceptable; use caution with prolonged use of sodium nitroprusside due to renal clearance of toxic metabolite thiocyanate

• Avoid enalaprilat — risk of worsening AKI

In patients with hypertensive crises & decompensated HF + pulmonary edema, what is the BP target?

Reduce by ≤ 25% in the 1^st hour

• Reduce to 160/110 in 2-6 hours

• Reduce to normotensive over the next 24-48 hours

In patients with hypertensive crises & decompensated HF + pulmonary edema, what is the IV antihypertensive of choice?

Nitroglycerin or Sodium Nitroprusside (Nicardipine and Clevidipine are acceptable alternatives)

• Avoid β blockers and non-DHP CCBs due to decompensation

In patients with hypertensive crises & aortic dissection, what is the BP target?

SBP ≤ 120 mmHg within the 1^st hour (ideally within 20 minutes)

In patients with hypertensive crises & aortic dissection, what is the HR target?

< 60 bpm

In patients with hypertensive crises & aortic dissection, what is the IV antihypertensive of choice?

1^st: β blocker — blocks heart’s response to tachycardia when adding a vasodilator

2^nd: Vasodilator (e.g., nicardipine, clevidipine, or nitroprusside) — prevent reflex tachycardia

In patients with hypertensive crises & intracranial hemorrhage, what is the BP target?

If SBP > 220 mmHg → Lower and monitor

If SBP 150-220 mmHg → SBP < 140 mmHg within 1 hour

In patients with hypertensive crises & intracranial hemorrhage, what is the IV antihypertensive of choice?

Nicardipine & Labetalol

• Clevidipine is an option as well, but less effective

In patients with hypertensive crises & ischemic stroke, what is the BP target?

If receiving fibrinolytic:

• BP < 185/110 mmHg before starting

• < 180/105 mmHg during treatment

If not receiving fibrinolytic (if not a candidate for alteplase or tenecteplase):

• SBP < 220 mmHg

In patients with hypertensive crises & ischemic stroke, what is the IV antihypertensive of choice?

Nicardipine & Labetalol

• Clevidipine is an option as well, but less effective

In patients with hypertensive crises & hypertensive encephalopathy, what is the BP target?

Reduce by ≤ 25% in the 1^st hour

• Reduce to 160/110 in 2-6 hours

• Reduce to normotensive over the next 24-48 hours

In patients with hypertensive crises & hypertensive encephalopathy, what is the IV antihypertensive of choice?

Most are acceptable

• Use most readily available/safe option

In patients with hypertensive crises & ACS, what is the BP target?

Reduce by ≤ 25% in the 1^st hour

• Reduce to 160/110 in 2-6 hours

• Reduce to normotensive over the next 24-48 hours

*Fixing thrombus/clot and adding a stent will help lower BP*

In patients with hypertensive crises & ACS, what is the IV antihypertensive of choice?

• Esmolol

• Labetalol

• Nitroglycerin

• Nicardipine

• Sodium nitroprusside is an option, but has toxic metabolites

• Use caution with non-DHP CCBs

• Avoid β blockers in: rEF bradycardia (HR < 60 bpm), hypotension (SBP < 100 mmHg), poor peripheral perfusion, 2nd/3rd degree heart block, or reactive airway disease

In patients with hypertensive crises & retinopathy, what is the BP target?

Reduce by ≤ 25% in the 1^st hour

• Reduce to 160/110 in 2-6 hours

• Reduce to normotensive over the next 24-48 hours

In patients with hypertensive crises & retinopathy, what is the IV antihypertensive of choice?

Most are acceptable

• Avoid fenoldopam

Dose of Esmolol

250-500 mcg/kg/min IV bolus, then 50-100 mcg/kg/min IV infusion

• May repeat bolus after 5 mins or increase infusion to 300 mcg/min

• Titrate infusion by 50 mcg/kg/min no more than every 4 mins until at goal

Duration of Esmolol therapy

10 to 20 minutes

ADEs associated with Esmolol

Hypotension, bradycardia, nausea, asthma, 1st degree heart block, HF

Indications & Precautions for Esmolol

Indication: Aortic dissection

Precaution: Avoid in patients treated with a β blocker, bradycardic, or decompensated HF

Dose of Hydralazine

10-20 mg IV every 4-6 hours (max. 40 mg)

Duration of Hydralazine therapy

60 to 240 minutes

ADEs associated with Hydralazine

Hypotension, tachycardia, flushing, HA, vomiting, aggravation of angina

Indication for Hydralazine

Eclampsia

Dose of Labetalol

10-20 mg IV bolus, followed by 20-80 mg every 10 minutes until BP controlled, followed by 0.5-2 mg/min IV infusion

• Increase infusion by 0.5 mg/min every 15 mins until at goal

Duration of Labetalol therapy

180 to 360 minutes

ADEs associated with Labetalol

Hypotension, bradycardia, N/V, scalp tingling, bronchoconstriction, dizziness, heart block, orthostatic hypotension

Indications & Precautions for Labetalol

Indications: Most hypertensive emergencies

Precautions: Acute HF, heart block

Dose of Nicardipine

2.5-5 mg/hr IV infusion

• Increase infusion by 2.5 mg/hr every 5-15 mins until at goal

Duration of Nicardipine therapy

15 to 30 minutes

ADEs associated with Nicardipine

Hypotension, tachycardia, HA, flushing, local phlebitis

Indications & Precautions for Nicardipine

Indications: Most hypertensive emergencies

Precautions: Acute HF, coronary ischemia

Dose of Nitroglycerin

5-200 mcg/min IV infusion

• Increase infusion by 5 mcg/min every 2-5 mins (if no response at a dose of 20 mcg/min, increase by 10-20 mcg/min every 3-5 mins until at goal)

Duration of Nitroglycerin therapy

5 to 10 minutes

ADEs associated with Nitroglycerin

Hypotension, HA, vomiting, methemoglobinemia, tolerance with prolonged use (tachyphylaxis — loses efficacy if used for 16-24 hrs)

Indication for Nitroglycerin

Coronary ischemia

Dose of Sodium nitroprusside

0.25-10 mcg/kg/min IV infusion

• Increase infusion by 0.5 mcg/kg/min every 3 mins until at goal

Duration of Sodium nitroprusside therapy

1 to 2 minutes

ADEs associated with Sodium nitroprusside

Hypotension, N/V, muscle twitching, sweating, thiocyanate and cyanide intoxication

Indications & Precautions for Sodium nitroprusside

Indications: Most hypertensive emergencies

Precautions: High intracranial pressure, azotemia, CKD