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HTN-Hypertensive Crisis

Hypertensive Urgency
   An SBP > 180 or DBP > 120 with no end-organ damage

Herpertensive Emergency
   An increase in BP causing acute end-organ ischemia and damage.

Neuro: Encephalopathy, Stroke (hemorrhagic / ischemic), papilledema 1 1 2 3
CVS: ACS, HF/pulmonary edema, Ao dissection
Renal: Proteinuria, Hematuria, ARF, scleroderma renal crisis
            MAHA, pre-eclampsia, eclampsia

Pathophysiology

   Progression of essential hypertension.
   Progression of renovascular disease.
       Acute Glomerulonephritis
       Scleroderma
       Pre-Eclampsia

   Endo: Cushing's disease, Pheochromocytoma.
   Meds: Cocaine, Amphetamines, MAOi + tyramine.

 Treatment     
   Monitor: UOP, Cr, mental status - deterioration my indicate higher GOAL BP.
  
Hypertensive Emergency:
        Step 1:  Within 2 hrs or faster if tolerated: Decrease MAP by 25%
        Step 2:  In 2-6 hours attain a GOAL: DBP < 110
    Hypertensive Urgency:
        Step 1: Within a few hours decrease BP with oral meds.
        Step 2: Attain GOAL: 1 - 2 days.
   IV Agents: Nitroprusside (*cyanide), Nitroglycerin, Labetolol, Hydralazine,                     Esmolol, Fenoldopam, Nicardipine, Phentolamine
   PO Agents: Captopril, Labetolol, Clonidine, Hydralazine
   
   Cerebral Injury:  Treat BP only in the following circumstances:
      Thrombolysis, BP > 220/120, Ao dissection, Active ischemia, CHF
  
                                Relevant Board Questions


African Americans:
Monotherapy for hypertension in African-American patients is more likely to consist of diuretics or calcium channel blockers than β-blockers or ACE inhibitors.  It has been suggested that hypertension in African-Americans is not as angiotensin II-dependent as it appears to be in Caucasians.


Ref: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National High Blood Pressure Education Program, 2004, NIH Publication No. 04-5230, p 39.  2) Rao S, Cherukuri M, Mayo HG: Clinical inquiries. What is the best treatment for hypertension in African-Americans? J Fam Pract 2007;56(2):149-151.  AAFP

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HCTZ at doses above 25 mg daily increases visceral fat accumulation. 2013 St Louis

JNC 7 guidelines suggest adding a loop diuretic if serum creatinine is >1.5 mg/dL in patients with resistant hypertension. REF