Hypertension Crisis

What is the main requirement for Hypertension Emergency?

Target Organ Damage

What is the BP of a Hypertensive Emergency patient?

>180/120

How should medication be administered in a hypertensive emergency?

IV

When should medication be administered in a hypertensive emergency situation?

Immediately

BP of a Hypertensive Urgency Patient

>180/120

Is Hypertensive Urgency Life threatening?

No

How should medication be administered in a hypertensive Urgent patient?

PO

What is the goal of treatment for a Hypertensive urgent patient

Low the BP of the course of days

What should be Initial evaluated for a hypertensive crisis patient?

• Mental Status

• Continuous Monitoring (every 5 minutes)

• EKG

• Medical History

• Determine if the patient is adherent to med regimen

Good Evaluation questions to consider in a hypertensive crisis?

• What is the HR and BP

• Have taken BP manually

• Is the cuff correct size

• Do they have symptoms

What should be treated before BP in hypertensive crsis

Extreme Anxiety and Pain

What are secondary causes of Hypertension

• Amphetamines

• Corticosteroids

• Decongestants

• Estrogen-containing oral contraceptives

• NSAIDS

What drugs and food can cause secondary hypertension?

• Nicotine and withdraw

• Ergot containing herbal products

• Sodium filled foods

• Alcohol

• Black licorice

What three conditions do we watch for in a Hypertensive emergency?

• aortic dissection

• Severe Preeclampsia or eclampsia

• Pheochromocytoma crisis

If there is one of the three conditions is the plan of treatment in a hypertensive emergency

Reduce SBP to under 140 during the first hour

If aortic dissection reduce to under 120

Plan of action in a patient without one of the three conditions in a hypertensive emergency?

Reduce BP by a max of 25% within the first hour the to 160/100 over the next 2-6 hours then to normal over the next 1-2 days

Signs of TOD in hypertension emergency in the heart

• Aortic dissection

• AHF

• Acute pulmonary edema

• MI/unstable angina

Signs of TOD in hypertension emergency in Renal

• ARD

• Decrease urine output

• Hematuria

Signs of TOD in hypertension emergency in the Neurologic region of the body

• Cerebral vascular accident

• Intracerebral hemorrhage

• Severe headache

• confusion

• Visual lost

Signs of TOD in hypertension emergency in the Optic region

retinopathy

Test to determine TOD?

• EKG

• Chest X-ray

• Urinalysis

• Serum electrolytes and serum creatinine

• Cardiac Enzymes

Timeline for reevaluation in Hypertensive urgent patents

Max is 7 days

• Prefer 1-3 days

Why do we not want to treat hypertensive urgent patients fast?

Can cause CVA,MI,AKI

Sodium Nitroprusside MOA

Direct venous and arterial vasodilation via NO release

Sodium Nitroprusside Black box warning

Cyanide toxicity

Nitroglycerin MOA

Vasodilator effect on most the peripheral veins by forming NO

Nitroglycerin Side effect

Headache

What should nitroglycerin be prepared in?

Glass bottle

Main therapeutic usage of Nitroglycerin?

Cardiac Ischemia

Why is the use of Hydralazine discouraged in hypertensive emergency?

Unpredictable and prolonged antihypertensive effects

Hydralazine Side effect

Reflex Tach

Hydralazine Contraindication

Aortic Dissection

Enalaprilat MOA

ACE inhibitor

Fenoldopam MOA

Postsynaptic dopamine agonist and decreases TPR w/ increase renal BF

Fenoldopam Side Effects

• Flushing

• Headache

• Nausea

fenoldopam Contraindication

Glaucoma

Nicardipine MOA

CCB (dihydropyridine)

Nicardipine indication

Arterial hypertension in acute ischemic stroke

Clevidipine MOA

CCB

How is Clevidipine formulated

Lipid Emulsion

Esmolol MOA

Selective Beta blocker

Labetalol MOA

alpha and beta Blocker

Labetalol indication

Stroke and CAD

Phentolamine MOA

Non-selective Alpha 1 blocker

Phentolamine Usage

Counteract catecholamine excess

• Catecholamine is NE,Epi, and Dopa

  • Occurs in pheochromocytoma and MOI

DOC for Acute aortic Dissection

• Labetalol or Esmolol alone or in combo with nicardipine, clevipine or nitroprusside

DOC for AHF

• Nitroprusside, nitro, or ACE inhibitor in combo with a diuretic

What should you avoid in AHF

beta blocker

DOC for Acute intracerebral hemorrhage or acute ischemic stroke

• Labetalol, nicardipine

DOC in acute MI

Beta blocker in combo with nitro

• if HR is < 70 consider nicardipine or clevidpine

DOC in Acute Pulmonary edema

Nitroglycerin, nitroprusside

DOC in acute renal failure

Fenoldopam, nicardipine, and clevidipine

DOC in Eclampsia or preeclampsia

Labetalol, nicardipine, hydralazine

DOC in hypertensive encephalopathy

Nitroprusside, labetalol, nicardipine, fenoldopram

DOC in Perioperative hypertension

Clevidipine, esmolol, nicardipine, nitroglycerin, nitroprusside

DOC in Sympathetic crisis

Phentolamine, nicardipine, clevidipine, fenoldopam

Aortic stenosis cations

hard to treat. all drugs pose a risk

Aortic stenosis general rule

start with low doses and titrate slowly

Renal Artery Stenosis contraindicated

ACEI and ARB

When should you avoid treatment of hypertension in Ischemic Stroke

In the first 48-72 hours unless the BP is over 220/110

Treat of hypertension in Ischemic Stroke with someone’s BP at 220/110

Lower by 15% in the first 24 hours