Hypertensive Crises

BP > 180/120 mmHg

Hypertensive urgency and hypertensive emergency

Severely elevated BP WITHOUT end organ damage

Severely elevated BP WITH 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)

A tear in inner blood vessel branching off the heart.

Occurs when a blood clot blocks or narrows an artery leading to the brain

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

Medication noncompliance, medication causes (withdrawal or introduction), patients >60 years, African American, and Male

BB: Metoprolol, alpha-2 agonists: clonidine, & CCB: amlodipine (occasionally)

Illicit drugs: stimulants (Meth, cocaine), Monoamine Oxidase Inhibitors (MAO-i) → used for CNS disorders in older patients, OTC medications (decongestants: pseudoephedrine)

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

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

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)

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)

Captopril, Clonidine, & Labetalol

ACE-i

Cough, acute kidney injury, hypotension, hyperkalemia, angioedema

Pregnancy and angioedema

alpha-2 agonist

bradycardia, dry mouth, drowsiness, hypotension

A weekly patch

Combined alpha and non-selective B-blocker

heart block, bronchospasm, bradycardia, hypotension

Contraindicated in acute liver failure; caution in obstructive or reactive airway; avoid in 2nd or 3rd degree heart block

Nicardipine, Clevidpine

Flushing, edema, N/V, dizziness, tachycardia, headache

Avoid in acute heart failure, contraindicated in advanced aortic stenosis (aorta is stiff → cannot contract)

Contains egg and soy, contraindicated in patients with defective lipid metabolism (comes in lipid emulsion), can only use for 3 days, and expensive

Nitroglycerin, Sodium Nitroprusside

Potent vasodilator (activates cGMP → smooth muscle relaxation); (vein > arteries)

flushing, tachycardia, headache, syncope (fainting), hypotension

Use for ACS (heart attack/chest pain) or pulmonary edema, tolerance with prolonged use; avoid with PDE-5 inhibitors (Sildenafil)

Potent vasodilator (veins=arteries)

Cyanide toxicity, chromaturia (red urine), erythema (red, itch, swell), flushing, sweating, and muscle twitching, elevate ICP

Avoid use in kidney/renal impairment (toxic metabolites → cyanide) and in ACS (higher mortality)

Hydralazine, Enalaprilat, Fenoldopam

Direct vasodilator

Caution: prolonged and unpredictable effect (can cause hypotension and hyperperfusion)

ACE-i

Cough

Contraindicated in pregnancy and angioedema, avoid in acute MI; rarely used

D1 agonist → decreases vascular resistance, increases renal blood flow, diuresis, and natriuresis

Elevates IOP and ICP

Contraindicated with increased IOP (glaucoma) or ICP (Increased cranial pressure); avoid with sulfa allergy

Esmolol, Labetalol, Metoprolol, Phentolamine

Cardio-selective B-blocker; class II antiarrhythmic

Contraindicated in acute heart failure or bradycardia; metabolized by red blood cells

Combined alpha, and non-selective B-blocker

Contraindicated in acute heart failure; caution in obstructive or reactive airway; avoid in 2nd or 3rd degree heart block

Cardio-selective B-blocker

Avoid in acute HF, bradycardia, and 2nd or 3rd degree heart block

Competitive blocker of alpha-adrenergic receptors; + inotrope & chronotrope

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)

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

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)

1-7 days at PCP office, continue to adjust meds over weeks and months to meet chronic BP goal

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