Today we heard from Alexa Carlson, Assistant Clinical Pharmacy Professor at Northeastern University, on hypertensive crises and emergencies.
We started by defining hypertensive crisis (severe elevations in blood pressure without target organ dysfunction) and hypertensive emergency (severe elevations in blood pressure accompanied by target organ dysfunction).
After covering the clinical presentation and evaluation of hypertensive emergencies, we moved to treatments for hypertensive urgency and emergency. In urgency, Alexa recommended that providers give oral therapy to reduce blood pressure (options include clonidine, labetalol, and captopril). While technically not recommended because it has a longer duration of action, is a potent vasodilator and it isn't easy to titrate it to the blood pressure, many people are on Hydralazine. Labetalol is an alpha beta blocker and a potent blood pressure lowering agent. This could be an issue for patients with asthma/COPD because we worry about how we would impact beta 2 receptors in the lungs.
In emergency, patients should be admitted to an ICU for parenteral medication administration and continuous blood pressure monitoring. This requires immediate blood pressure reduction. How do we choose which medication to use? This is based on any comorbid indications and what type of end organ dysfunction we are having.
We then practiced with two cases:
Case I:
"I have a wicked headache." HPI: PB is a 67 year old male.
S/O:
PMH - HTN, COPD, NSTEMI (2007)
Home Medications: Tiotropium for COPD, Fluticasone/Salmeterol for COPD, ASA for the MI, lisinopril for HTN/MI
VS: BP 182/100, HR 102, RR 18
We think this is a hypertensive urgency because his only symptom is a headache. We know he has a wicked headache -- could he be taking an NSAID that would worsen his hypertension? Has he been taking his ACE inhibitor?
Given that this is an urgency and not an emergency, we recommend oral medications.
One person suggested clonidine, a centrally acting alpha 2 agonist. Dr. Molina said that this could be difficult, given that the patient is already on many medications. He also added that he might increase the lisinopril, or add calcium channel blockers. A resident noted that adding a diuretic could be useful, although that could take days. She also said that she would have him come back for a nursing visit the next week and would make sure that he had a blood pressure cuff at home.
Case II:
"I ran out of my meds."
HPI: LI is a 38 year old female with a past medical history significant for HTN for hte pas 3 years.
S/O:
PMH - HTN x 3 years
Home Medications - Clonidine
VS: BP 185/98, HR 98, RR 22
We would start by asking if she is pregnant as we do not use ACE inhibitors in pregnant women. We would also ask how long she has been off the medication - hours, weeks, days? We would start her back on the clonidine as it is fast acting drug, then taper it, and then switch her meds if getting the clonidine is going to be an issue in the future.
Dr. Molina added that we would like to explore why she was on clonidine in the first place, as this is an odd choice.
By Michal McDowell, MS I
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