Hypertensive Crisises (Exam #3)

Median survival for a hypertensive emergency if untreated

10.5 months

In-hospital mortality ranges for hypertensive emergencies

between 0.2% and 11% ż

Asymptomatic markedly elevated BP

Severely elevated BP WITHOUT end organ damage

BP > 180/120 mmHg

Hypertensive Emergency

Severely elevated BP WITH end organ damage

BP > 180/120 mmHg

Hypertensive Crisises BP

BP > 180/120 mmHg

Encephalopathy

Altered brain function or structure

- somnolence

- confusion

- seizures

- coma

- elevated ammonia level

Ocular changes

Sclerosis of the retinal vasculature

- visual deficits

- blindness

- a/v nicking

- papilledema

Acute coronary syndrome (ACS)

Decreased blood flow to heart caused by partial or complete blockage of arteries

- Left sided chest pain

- Neck or jaw pain

- Clammy skin

- Increased troponin

- EKG changes

Pulmonary edema

Accumulation of fluid in the interstitial spaces & alveoli (often from LV dysfunction)

- dyspnea

- chest pain

- anxiety

- pink/frothy sputum

- Inc HR

- Inc RR

- Rates

- Positive chest x-ray

Acute renal failure

Rapid loss of kidney's ability to remove waste and balance fluids/electrolytes

- flank pain

- edema

- little or no urine

- hematuria

- proteinurea

- Inc SCr

- Dec CrCl

Eclampsia (pre-eclampsia)

Elevated maternal BP, usually after 12th week of pregnancy

- proteinuria

- edema

- abdominal pain

- sudden weight gain

- visual changes

- mental confusion

Aortic Dissection

diagnosis in which the arterial wall splits apart

• About 2,000 new cases in US each year

+ High probability of diagnosis if the patient has:

1. Severe chest pain

2. Unequal pulses

3. Widened media stinum

• Extremely high mortality risk

High probability of diagnosis of Aortic Dissection if the patient has:

1. Severe chest pain

2. Unequal pulses

3. Widened media stinum

Diagnosis for Aortic Dissection

Obtain CT or MRI of the chest

Acute ischemic stroke (AIS)

Occurs when a blood clot blocks or

narrows an artery leading to the brain

Intracranial hemorrhage (ICH)

Occurs when a blood vessel inside the brain ruptures and causes bleeding

HTN Crisis Clinical Manifestations for Asymptomatic Markedly Elevated BP

usually asymptomatic

--> If present:

- headache

- dyspnea

- dizziness

- lightheadedness

- epistaxis

HTN Crisis Clinical Manifestations for HTN Emergency

Most frequent presenting signs were

- Chest pain (27%)

- Dyspnea (22%)

- Lungs

- Neurologic deficits (21%)

- Brain

+ All of the high blood flow organs (including kidneys) are most effected

HTN Crisis: Causes & Risk Factors

+ Medication noncompliance

- Lack of a primary care physician

- Uninsured or underinsured

- Live in lower-income areas

+ Medication causes (withdrawal or introduction)

+ Older age (> 60 years)

+ African American

+ Male

What medication agents cause rebound HTN?

1. Beta Blockers (B1)

2. Alpha-2 Agonists

Introduction of what medications may cause rebound HTN?

+ Illicit drugs

• Cocaine

• Methanphetamine

+ Monoamine Oxidase Inhibitors (MAO-I)

• Inhibit the breakdown of neurotransmitters

+ OTC medications

• Pseudoephedrine

• NSAIDs

The _________________________ is more important than the actual BP

relative rise and rate of increase in BP

Treatment Goals for HTN Crises

1. Rapid recognition of the problem

2. Early initiation of appropriate antihypertensive treatment

3. Decrease and normalize heart rate and blood pressure

4. Minimize end organ damage safely

5. Maintain cerebral and tissue perfusion

Therapeutic Approach for Asymptomatic Markedly Elevated BP

+ Gradual BP lowering

- Within 24 to 48 hours

+ ORAL medications

- May restart or intensify home medications

+ Setting: Outpatient

- ED, home

+ Prevent the start of end organ damage

Therapeutic Approach for Hypertensive Emergency

+ Rapid BP lowering

- Within minutes to hours

+ Continuous IV infusion of a short-acting, titratable agent

+ Setting: Inpatient

- ICU, medical floor

+ Prevent the worsening of end organ damage

Treatment Targets for HTN 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

______________________ is a major issue for end organ damage

Diastolic BP > 130

Why do we lower BP slowly?

Decreasing BP to "normal" (ex. BP

BP should be lowered gradually to prevent _____________________

low perfusion to the brain

Treatment Targets for Asymptomatic Markedly Elevated BP

+ 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

Treatment for cyanide toxicity:

- Hydroxocobalamin

- Sodium nitrite & sodium thiosulfate

__________________ is used in combo with Sodium Nitroprusside to reduce cyanide toxicity

sodium thiosulfate

Cyanide toxicity can result in ___________________________

irreversible neurological changes & cardiac arrest

Oral Agents for HTN Crises

- Captopril

- Clonidine

- Labetalol

Captopril

+ MOA

+ Unique AE

+ Notes

+ MOA

- ACE-I

+ Unique AE

- hypotension

- cough

- angioedema

- AKI

- hyperkalemia

+ Notes

- Contraindicated in pregnancy & angioedema

Clonidine

+ MOA

+ Unique AE

+ Notes

+ MOA

- Alpha- 2 agonist

+ Unique AE

- hypotension

- bradycardia

- drowsiness, dry mouth

+ Notes

- Weekly patch available

- Typically reserved for resistant chronic hypertension

Labetalol Oral & IV

+ MOA

+ Unique AE

+ Notes

+ MOA

- Combined alpha1 and non-selective B-blocker

+ Unique AE

- hypotension

- bradycardia

- heart block

- bronchospasm

+ Notes

- Contraindicated in acute heart failure

- Caution in obstructive or reactive airway

- Avoid in 2nd or 3rd degree heart block

What oral medication should be avoided due to unpredictable BP reduction

Nifedipine

IV Agents (Vasodilators): CCB- Dihydropyridines

- Nicardipine

- Clevidipine

Nicardipine

+ MOA

+ Unique AE

+ Notes

+ MOA

- DHP CCB

+ Unique AE

- Tachycardia

- headache

- dizziness

- flushing

- edema

- N/V

+ Notes

- avoid in acute heart failure

- contraindicated in advanced aortic stenosis

Clevidipine

+ MOA

+ Unique AE

+ Notes

+ MOA

- DHP CCB w/ potent vasodilating activity

+ Unique AE

- Atrial fibrillation

- N/V

- headache

- edema

+ Notes

- contains soy/egg

- contraindicated in pts with defective lipid metabolism (comes in lipid emulsion)

IV Agents (Vasodilators): Nitric-oxide dependent

- Nitroglycerin

- Sodium Nitroprusside

Nitroglycerin

+ MOA

+ Unique AE

+ Notes

+ MOA

- Potent vasodilator

- Activates cGMP --> smooth muscle relaxation

- veins > arteries

+ Unique AE

- headache

- tachycardia

- flushing

- hypotension

- syncope

+ Notes

- use for ACS or pulmonary edema

- tolerance with prolonged use

- avoid w/ PDE-5 inhibitor

Sodium Nitroprusside

+ MOA

+ Unique AE

+ Notes

+ MOA

- Potent vasodilator

- veins = arteries

+ Unique AE

- Elevates ICP

- cyanide toxicity

- chromaturia

- erythema

- muscle twitching

- flushing

- sweating

+ Notes

- avoid use in kidney/renal impairment (toxic metabolites) and in ACS

IV Agents (Vasodilators): Miscellaneous

- Hydralazine

- Enalaprilat

- Fenoldopam

Hydralazine

+ MOA

+ Unique AE

+ Notes

+ MOA

- Direct vasodilator

+ Unique AE

- Tachycardia

- flushing

- headache

+ Notes

- caution: prolonged and unpredictable effect

Enalaprilat

+ MOA

+ Unique AE

+ Notes

+ MOA

- ACE-I

+ Unique AE

- Hypotension

- headache

- dizziness

- hyperkalemia

- cough

+ Notes

- contraindicated in pregnancy & angioedema

- avoid in acute MI

- rarely used (slow onset & long duration)

Fenoldopam

+ MOA

+ Unique AE

+ Notes

+ MOA

- D1 agonist decrease vascular resistance

- increase renal blood flow

- diuresis

- natriuresis

+ Unique AE

- Tachycardia

- headache

- flushing

- elevates IOP & ICP

+ Notes

- contraindicated with increased IOP (glaucoma) or ICP

- avoid with sulfite allergy

_________________ are most commonly used for cardiac effects

IV Agents (Adrenergic Inhibitors)

IV Agents (Adrenergic Inhibitors)

- Esmolol

- Labetalol

- Metoprolol

- Phentolamine

Esmolol

+ MOA

+ Unique AE

+ Notes

+ MOA

- Cardioselective B-blocker

- Class II antiarrhythmic

+ Unique AE

- bradycardia

- flushing

- first degree heart block

- Proarrythmic

• Inc PR Intervals

+ Notes

- contraindicated in acute heart failure or bradycardia

- metabolized by red blood cells

Metoprolol

+ MOA

- Cardioselective B-blocker

+ Unique AE

- hypotension

- bradycardia

- dizziness

- pruritus

- bronchospasm

- heart block

+ Notes

- avoid in acute HF

- bradycardia

- 2nd or 3rd degree heart block

Phentolamine

+ MOA

- Competitive blocker of alpha adrenergic receptors

+ inotrope & chronotrope

+ Unique AE

- tachycardia

- flushing

- headache

+ Notes

- Used for catecholamine excess (ex. pheochromocytoma, interactions between MAO-I and other drugs or food, cocaine toxicity, amphetamine overdose, or clonidine withdrawal)

avoid _________________ in acute HF

Metoprolol

__________________ is used for catecholamine excess (ex. pheochromocytoma, interactions between MAO-I and other drugs or food, cocaine toxicity, amphetamine overdose, or clonidine withdrawal)

- Phentolamine

- Nicardipine

- Clevidipine

IV agents to avoid in acute congestive heart failure

- Esmolol

- Labetalol

- Metoprolol

IV agents to avoid in intracerebral hemorrhage (ICH) and acute ischemic stroke (AIS)

- Nitroglycerin

- Hydralazine

Acute coronary syndrome (ACS) best IV agents

- Nicardipine

- Nitroglycerin

- Esmolol

- Labetalol

- Metoprolol

IV agents to avoid in acute coronary syndrome (ACS)

- Nitroprusside

- Enalaprilat

- Hydralazine

_____________ should be avoided in acute renal failure

Nitroprusside

IV agents to avoid in pulmonary edema

- Esmolol

- Labetalol

- Metoprolol

Cocaine-induced Hypertension Treatment

+ Treat with benzodiazepines to reduce the stimulant effects

+ Nitrates or CCBs should be used to control blood pressure

** Beta-blockers are contraindicated in the setting of cocaine-associated chest pain

- Beta blockade (with the use of B-blockers) in sympathomimetic drug overdose could exacerbate coronary vasospasm & ischemia by creating "unopposed" alpha adrenergic stimulation

_________________ are contraindicated in the setting of cocaine-associated chest pain

Beta-blockers

Asymptomatic Markedly Elevated BP Monitoring

+ BP: BP monitoring for a few hours in the ED or urgent care

+ AE of medication used

+ Discussion about adherence

+ Initiate or intensify chronic, oral medications for HTN

HTN Emergency Monitoring

+ BP: continuous BP monitoring inpatient

+ S/S of end organ damage

+ AE of medication used

+ Initiate or intensify chronic, oral medications for HTN (~6-12 hours after starting IV)

Initiate or intensify chronic, oral medications for HTN ~_________ hours after starting IV for a HTN Emergency

6-12

Asymptomatic Markedly Elevated BP Follow Up

+ 1-7 days at PCP office

+ Continue to adjust meds over weeks and months to meet chronic BP goals

HTN Emergency Follow Up

+ Hourly checks while inpatient

+ 1-7 days at PCP office

+ Evaluation and treatment of secondary causes of HTN emergency

+ Continue to adjust meds over weeks and months to meet chronic BP goals

HTN Urgency

+ BP (mmHg)

+ End organ damage?

+ S/S

+ Rate of BP lowering

+ Medication formulation

+ Treatment setting

+ Follow-up

+ BP (mmHg) > 180/120

+ End organ damage? No

+ S/S

- Asymptomatic

+ Rate of BP lowering

- Gradual

+ Medication formulation

- Oral

+ Treatment setting

- Outpatient

+ Follow-up

- 1-2 days at PCP

HTN Emergency

+ BP (mmHg)

+ End organ damage?

+ S/S

+ Rate of BP lowering

+ Medication formulation

+ Treatment setting

+ Follow-up

+ BP (mmHg) > 180/120

+ End organ damage? Yes

+ S/S

- Present

+ Rate of BP lowering

- Rapid

+ Medication formulation

- IV

+ Treatment setting

- Inpatient

+ Follow-up

- Continuous