HTN Crisis

abrupt increase in vasoconstriction --> endothelial injury --> activation of coagulation necrosis --> renin-angiotensin system activation --> (+) inflammation --> volume depletion

• increased age
• Black
• Male
• diagnosed
• pregnancy
• lack of primary care physician
• non-compliance
• illicit drugs
• drugs
• renal parenchymal disease

• severe elevation in BP without progressive target organ dysfunction
• asymptomatic (may have general fatigue, malaise, etc)
• patient unaware until normal examination

• adjust current therapy by increasing dose or simplifying regimen and/or
• add short-acting ORAL therapeutic option

• Gradual reduction in BP
• goal = stage 1 HTN values which can be achieved over several hours/days
• don't be too aggressive with patients that have cerebrovascular accident, MI, or ARF

• captopril (Catpoten)
• clonidine (Catapres)
• labetalol (Trandate, Normodyne)
• nifedipine (Procardia, Adalat)

• Brand Name: Capoten
• Class: ACEI
• AEs: rash, pruritus, proteinuria, loss of taste, hypotension
• CI: renal aretery stenosis, hyperkalemia, dehydration, renal failure, pregnancy
• Dosing: 6.25-50 mg PO (25 mg normal dose q hr)
• OOA: 15 min (quick onset)
• DOA: 4-6 hrs (predictable duration)

• Brand Name: Catapres
• Class: alpha-2 agonist
• CI: altered mental status, severe cartoid artery stenosis
• Dosing: 0.2 mg PO initially, then 0.1 mg/hr (MDD = 0.8 mg) --> available in a patch, which takes longer for absorption
• OOA: 0.5-2 hours
• DOA: 6-8 hours

• Brand Name: Trandate, Normodyne
• Class: alpha- and beta- blocker
• CI: bronchial asthma, bradycardia, decompensated CHF
• Dosing: 200-400 mg PO q 2-3 hrs
• OOA: 0.5-2 hours
• DOA: 4 hours

• Brand Names: Procardia, Adalat
• Class: calcium channel blocker
• CI: GENERALLY AVOID (rapid decrease in blood pressure)
• Dosing: 10-20 mg PO
• OOA: 15-30 min
• DOA: 3-5 hrs

• patients should be observed (depending on severeity of in crease in BP), then followed in outpatient setting
• follow up is essential --> schedule for re-evaluation in 1 wk (ideally 1-3 days) and be preventative for the patient

• acute elevation in BP associatied with target organ damage
• signs/symptoms of acute target injury; severe chest pain, HA, anxiety, confusion, SOB

• immediate lowering of BP to prevent organ damage
• no blood pressure goal to begin with
• initial target = MAP greater than or equal to 25% within min-hrs
• if stable, reduce BP to 160/100-110 mmHg in next 2-6 hrs
• gradual reductions towards normal BP over next 24-48 hrs

• require PARENTERAL drug therapy
• Ideal drug should have the following:
• rapid OOA
• short DOA
• easily titratable
• require minimal dosage adjustments
• minimal risk of hypotension
• lack significant SEs
• mild reduction in myocardial contractility
• easy conversion to oral agents
• low cost (including drug and monitoring costs)

• nitroprusside (Nipride)
• nitroglycerin
• fenoldopam (Corlopam)
• hydralazine (apresoline)
• enalaprilat (Vastoec)
• nicardipine (Cardene)
• phentolamine (Regitine)
• esmolol (Brevibloc)
• labetolol (Trandate, Normodyne)
• clevidipine butyrate (Cleviprex)

• Brand Name: Nipride
• MOA: smooth muscle relaxer or arterial and venous vasodialtor that decreases both afterload and preload
• Indications: CHF, aortic dissection, syndromes of catecholamine excess
• CI: avoid prolonged use in patients with hepatic/renal impairment, acute MI
• Miscellaneous: thiocynate toxicity --> thiocynate > 60 mg/L = toxic, which will cause hallucinations, vomiting; careful with brain bleeds
• Dosing: lowest dose possible should be used for the shortest DOA; initial = 0.3 mcg/kg/min; 0.25-10 mcg/kg/min IV infusion; max = 10 mcg, which shouldn't be used for an extended period of time
• OOA: within seconds
• DOA: 2-3 min

• MOA: lowers blood pressure, reduces preload, decreases left ventricular filling pressure, and myocardial oxygen consumption
• Indication: unstable angina, acute MI, and acute left ventricular failure
• CI: cerebrovascular accident - head trauma/intracerebral hemorrhage
• Miscellaneous: must be in glass - NOT polyvinylchloride (PVC); can become tolerant of medication
• Dosing: 5-200 mcg/min IV infusion
• OOA: 2-5 min
• DOA: 5-10 min

• Brand Name: Corolopam
• Class: peripheral DA-1 agonist (no DA-2 activity)
• Indication: severe hypertension with renal insufficiency
• CI: glaucoma, sulfite allergy
• ADRs: HA, flushing, tachycardia, dizziness, increased IOP (dose related)
• Dosing: 0.1-1.6 mcg/kg/min IV infusion (titratable drug)
• OOA: 4-5 min
• DOA: 30 min

• Brand Name: Apresoline
• MOA: direct vasodilation (relaxes arteriole smooth muscle and decrease afterload)
• Use: limited to pre-eclampsia and eclampsia
• Drawbacks: prolonged and unpredictable BP lowering; inability to effectively titrate; can cause reflex tachycardia (not optimal for use)
• Dosing: 10-20 mg IV or IM bolus, repeat q 4-6 hrs PRN
• OOA: 10-20 min
• DOA: 1-4 hrs

• Brand Name: Vasotec
• MOA: ACEI
• Indication: HF
• CI: use with caution in patients with severe renal insufficiency, acute MI, pregnancy
• Miscellaneous: only IV ACEI
• Dosing: 1.25-5 mg IV q 6 hr (MDD = 20 mg/day); requires dose adjustments on diuretic and CLcr < 30 mL/min
• OOA: within 15 min
• DOA: longer DOA of 12-24 hrs

• Brand Name: Cardene
• Class: dihydropyridine (DHP) calcium channel blocker --> increases stroke volume --> increase in blood to brain
• Indication: hypertensive encephalopathy, acute renal failure
• AEs: tachycardia, flushing, HA, dizziness, hypotension, N/V
• Misc: advantageous to anything cerebral and no significant change in intracranial pressure; lots of vasoconstriction
• Dosing: 5 mg/hr, increase infusion rate by 2.5 mg/hr q 5min to max infusion rate 30 mg/hr; dosing independent of weight
• OOA: 5-15 min
• DOA: 4-6 hrs

• Brand Name: Regitine
• Class: alpha-AR blocker
• Indication: catecholamine excess
• CI: syndromes of coronary insufficiency
• Misc: often paired with beta blocker to offset reflex tachycardia
• Dosing: 5-20 mg IV, repeat as necssary
• OOA: 1-2 min
• DOA: 10-30 min

• Brand Name: Brevibloc
• MOA: beta-1 selective blocker --> rate control; often used in post-op HTN
• Indication: syndromes of coronary insufficiency
• CI: > 1st degree heart block, HF
• Miscellaneous: metabolized by rapid hydrolysis by RBCs; pay attention to dillution to avoid toxicity
• Dosing: 500-1000 mcg/kg over 1-4 min bolus, then 50-300 mcg/kg/min IV infusion
• OOA: 1-2 min
• DOA: 10-20 min

• Brand Name: Trandate, Normodyne
• MOA: alpha and beta blocker (more affinity for beta)
• Indications: hyperadrenergic syndromes, cerebrovascular events
• CI: 2nd or 3rd degree heart block, HF, bronchial asthma
• Dosing: 20-80 mg IV bolus q 10 min until BP controlled (MDD = 300 mg/day) or 2 mg/min IV infusion
• OOA: 2-5 min
• DOA: 2-4 hrs

• Brand Name: Cleviprex
• Class: 3rd generation DHP calcium channel blocker
• CI: acute HF and allergy to soybeans, soy products, eggs, or egg product
• Misc: lipid emulsion; undergoes rapid metabolism by arterial blood esterases; monitor TG; no renal/hepatic adjustments due to metabolism via arteriole esterases; no serious decrease in BP b/c it can lead to complications such as stroke, MI (especially quickly)
• OOA: 2-4 min (rapid)
• DOA: 5-15 min (rapid offset)

• excessive decreases can lead to complications
• special conditions to consider: ischemic stoke & stroke eligible for thromboylitc agents; aortic disscetion (bleeding into/along aorta)

• direct correlation of chronic level of BP and risk of stroke
• many acute stroke patients that have initial HTN may resolve spontaneously within 48 hrs
• Exception to tx for CA: TPA administration, other type of emergeny or intracerebral hemorrhage

• Signs: discrepancies b/t pulses, murmur of aortic insufficiency, and neurological defects
• requires rapid lowering of BP in 5-30 min
• tx of choice: beta-blocker & vasodialator
• critically ill patient - usually admitted to ICU, surgery like