Hypertension Emergency vs Urgency

What constitute a hypertensive urgency?
Significant rise in BP
No acute end organ damage and no pending complications

What is a hypertensive emergency?
Severe rise in BP (usually DBP >120)
Impending or progressive EOD

End Organ Damage in Eyes:
Retinopathy
Papilledema

End of Organ Damage in CNS:
Intracerebral hemorrhage
CVA
Hypertensive encephalopathy
Eclampsia

Does Headache Equal EOD?
NO! Urgency but NOT Emergency

End of Organ Damage in Heart:
Aortic dissections
Acute left ventricular failure
Acute pulmonary edema
MI

End of Organ Damage in Kidneys
Acute renal failure

Etiology
Inadequate BP control
Drug withdrawal – Clonidine or BB
Drug interactions
Illicit drug use
Renovascular disorders
Endocrine disorders

Present with non-specific symptoms
Severe headache
Shortness of breath
Epistaxis
Anxiety

Matched suspected symptoms with possible EOD:
Eyes: Visual change
CNS: HA, AMS, seizure
Heart: angina and SOB
Kidneys: oliguria and hematuria

Treatment goal: HTN Urgency:
Prevent EOD
Establish therapy that can be better control BP

Treatment goal: HTN Emergency
Reverse or arrest EOD
Establish therapy that can better control BP

Treatment for Urgency
Admit to med floor
Control with PO meds
Decrease BP gradually over 24- 48 hrs

Agent used in Urgency
Clonidine
– Useful for clonidine withdrawal or stimulant induced HTN
– May affect mental status that complicates neurological assessment

Captopril
– Beneficial in patients with history of CVD
– Avoid in pregnant paitents
– Avoid in patients with ARF or renal artery stenosis

Labatalol
-Does not cross the placenta which makes it the drug of choice in pregnancy patient with urgency
– Avoid in CHF, bradycardia, 2nd or 3rd degree heart block, and uncontrolled asthma

Oral or SL Nifedipine
– DO NOT USE! risk of fall

What to avoid in treating patient with Captopril
Pregnancy
Avoid in patients with ARF

Drug of Choice in Urgency:
Preeclampsia
Labetalol

Drug of Choice in Urgency:
Clonidine withdrawal
Clonidine, Labetalol

Drug of Choice in Urgency:
BB withdrawal
Labetalol

Drug of Choice in Urgency:
Stimulant use
Clonidine, labetalol

Drug of Choice in Urgency:
Catecholamine excess
Clonidine, labetalol

Drug of Choice in Urgency:
Chronic renal insufficiency
labetalol, clonidine

Drug of Choice in Urgency:
HF or MI
Captopril

Drug of Choice in Urgency:
Asthma or COPD
Captopril

Uncontrolled HTN
Captopril

Drug of Choice in HTN Emergency
Nitroprusside
– Potent arterial and venous vasodilator
– Higher doses and longer duration increase the risk for thiocynate and cyanide toxicities
– Avoid in patients with renal or hepatic impairment

Labetalol
– Same

Esmolol
– Useful if HR increased
– Indicated for acute MI, BB withdrawal, and aortic dissection
– Avoid in clonidine withdrawal or stimulate induced HTN because of B1 selectivity
– Avoid in HF, Bradycardia, uncontrolled asthma

Fenoldopam
– Has been shown to improve creatinine clearance and urine flow rates
– Beneficial in patients with renal impairment

Nicardipine
– Adverse effect include reflex tachycardia and headache
– Indicated in most situations, except in HF and AMI

Phentolamine
– Use for pheochromocytoma or catecholamine induced hypertension

Drug of Choice in Emergency:
Acute pulmonary edema or HF
Nitroprusside + nitroglycerin

Avoid nicardipine, labetalol, esmolol

Drug of Choice in Emergency:
Acute MI
labetalol/ esmolol + nitroglycerin

Avoid nicardipine

Drug of Choice in Emergency:
Hypertensive encephalopathy
Nitroprusside or labetalol

Drug of Choice in Emergency:
Acute aortic dissection
Nitroprusside or Labetalol

Drug of Choice in Emergency:
Acute renal insufficiency
Fenoldopam or nicardipine

Avoid ACEI/ ARBs or prolonged treatment with nitroprusside

Drug of Choice in Emergency:
Eclampsia
Labetalol or hydralazine

Avoid ACEI/ ARBs

Drug of Choice in Emergency:
Sympathetic crisis/ cocaine overdose
Labetalol or phentolamine

Avoid Esmolol

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