Hypertensive Cases

Explanation
(A) is the correct answer here. Let's follow this systematically.

Even if it doesn't seem relevant, look for age and gender: 58 year old male. He has a blood pressure of 200/130. To even be considered as a hypertensive crisis, you have to have a systolic blood pressure of at least 180 OR a diastolic blood pressure of at least 110.

The key part here is distinguishing between "urgency" and "emergency". The difference is that hypertensive urgency is WITHOUT end organ damage. If organ damage had been present, you would have seen statements such as "retinal damage" and "serum creatinine". These indicate dysfunction with an organ, which is NOT the case here, so this is a hypertensive urgency.

In a hypertensive urgency, you still want to act fast, but you have a little leeway in time. Emergencies would obviously require swift action since organs are failing, but an urgency buys you some time. This is why you "only" need to lower the blood pressure to

Explanation
(B) is the correct answer here. Let's think about it.

As stated before, this is going to be a hypertensive urgency. Action is needed but it does NOT need to be as extreme as an emergency. That is, the therapy required for a hypertensive urgency revolves around ORAL medications. During an emergency, blood pressure must be dropped down to prevent more organ damage and thus IV would be appropriate. Since this is an urgency, oral medications will suffice.

(A), (C), and (D) are viable IV options for emergencies. As we will soon see, they each have their benefits and risks that must be weighed carefully before use. But that is for later.

It must be noted that one of the goals is NOT to reduce blood pressure rapidly. Although that might intuitively seem like a good idea, it is very risky. Organs acclimate to the higher blood pressure and immediately dropping the pressure to a "goal" will lead to HYPOprofusion of the organ and may lead to organ failure that way. Organs need blood flow no matter what, even if it means artificially raising the blood pressure to do so.

Explanation
(E) is the correct answer here. This is an important concept so let's check each answer choice.

(A) is true, believe it or not. If someone had hypertension and they weren't treated for it, blood pressure would spiral out of control. Not taking blood pressure medications is similar. You can pick the best therapy and have the best plan, but if the patient doesn't understand or simply can't do it, all that means nothing. So checking to see if the patient is correctly taking the lisinopril and HCTZ is a crucial first step. HCTZ should be taken in the morning, because it makes patients urinate more and they won't want to wake up in the middle of the night to do so.

(B) is also correct. As with any level of hypertension, restriction of sodium is always a good option. Recall that the reabsorption of sodium is important for the body. It is so important that it will excrete potassium to do so. With sodium comes water and that will increase the volume of the extracellular fluid and increase the pressure. It's a safety mechanism introduced for when we used to have low sodium in our diets. Obviously, that is not the case today.

(C) is correct. Chances are, you'd want to increase the dose, but that answer would depend on numerous factors (adherence, patient preference, etc.). This hypertensive urgency may have been a simple result of the dose just being too low and it wasn't working well enough. If that were the case, we would want to increase the dose. Why not lisinopril? That is also an option, but HCTZ is a relatively safe option nonetheless.

(D) is also true. We can do all this work now but we need to see how TA will be later on. TA would need to go back to his PCP in a week for evaluation. If the blood pressure didn't stay at goal for long, then there would be a need to further inquire as to why that is the case. Regardless of the reason, he must be seen again in a week so we can check him out.

Explanation
(C) is the correct answer here. Again, let's take a look at this systematically.

So this is a 60 year old woman who comes in with a very high blood pressure and symptoms that are conducive to an emergent situation. Classic symptoms are that she has decreased urine output and her headache. The real difference here between an urgency and an emergency is that she has lab values that are indicative of organ damage. BUN and SCr are those two values. BUN is normally around 18 and SCr should be less than 1. High values of both indicate some sort of dysfunction with the kidneys. Because of this, her situation is classified as hypertensive emergency and must be treated as such.

In a hypertensive emergency, it is important to reduce the blood pressure to prevent further damage to organs and this needs to happen relatively quickly. (A) and (B) are eliminated for the reason that it is not an urgency. Actually, (B) would be correct if the situation was a hypertensive urgency. (D) is not a correct goal because that may or may not be feasible since organs in her body may have acclimated to a higher blood pressure while she was taking her HCTZ. Therefore, a "good" blood pressure of 120/80 may be too low for some organs and they be HYPOprofused. (C) is correct.

Mean arterial blood pressure can be determined by the following [(2 x diastolic) + systolic] / 3. In this case, it would be [(2 x 130) + 200] / 3 = 153. The goal in an emergency is to lower this value by 20-25% in the next 1-2 hours. So a 20% reduction will drop the blood pressure to around 120, and that needs to be achieved at the latest of 2 hours. Alternatively, the diastolic blood pressure could be reduced by 10-15% (or to around 115 mmHg) in 30-60 minutes. This will really relieve some of the stress on the heart.

Once the patient is stable, the goal would then be to reduce the blood pressure to

Explanation
(D) is correct here and the following will explain why.

The true key difference here, which is done on purpose to make a point, is that in a hypertensive emergency, IV drugs must be used. This is a serious problem that requires immediate action, which makes it significantly different from hypertensive urgency. This is because organ damage is present (kidneys in this case). (A), (B), and (C) are all oral medications, which won't act fast enough to lower the blood pressure and relieve stress on the heart.

It must be noted that although the answer is "obvious", it is dependent on understanding that it was a hypertensive emergency. For a hypertensive emergency, there are numerous IV medications that can be given and that will be discussed later.

Explanation
(C) is the most correct answer here. Let's evaluate it one at a time.

Again, you want to look at the details. 57 year old male with a blood pressure of 220/140, which is very high. It is so high that the fundoscopy showed retinal damage. Fundoscopy is when a health professional will look into the eye and evaluate the health of the retina; it allows them to look into the back of the eye and look at the retina. In this case, the retina had tears, which is what we consider "organ damage". This means that this is a hypertensive emergency, eliminating (A).

Now that we know that, we must figure out a goal blood pressure. The mean arterial pressure is calculated by [(2 x diastolic) + systolic] / 3. So [(2 x 140) + 220] / 3 = 167. Our goal is to lower it 20-25% in 1-2 hours. So we want to shoot for 130 mmHg in 1-2 hours. (B) has the right pressure, but 3 hours is too long to wait to relieve workload on the heart. (D) has the right timeframe, but not the right goal blood pressure, which also won't relieve enough stress on the heart.

The alternative goal is to lower diastolic blood pressure by 10-15% in 30-60 minutes. A 10-15% reduction of the 140 mmHg diastolic blood pressure is around 120 mmHg. Indeed, (C) describes the goal diastolic blood pressure in the correct timeframe.

Explanation
(D) would be the most correct answer here. Let's find out why.

It is established that this is a hypertensive emergency; the fundoscopic exam revealed retinal damage. Because of this, the need to lower blood pressure to prevent further caustic damage to the organs must be the primary goal. Therefore, IV medications must be used, eliminating (A) and (C). The tough part is deciding between the two IV medications remaining.

(B) is nitroglycerin, which is a potent vasodilator in the nitrate class. It will help boost coronary perfusion to the heart, which is great, but it lower cerebral perfusion, which is a con and thus wouldn't be used in hypertension following a cerebrovascular accident. The main reason why this is not used is because the medications of JS include sildenafil 10 mg PRN. This is a phosphodiesterase type-5 inhibitor and nitrates are contraindicated with them. Granted, there is that chance that JS hasn't take one in a long time and so that isn't a problem, but until we know that for sure, it is best to stray away from nitroglycerin.

(D) is the best option for JD. Enalaprilat is an IV ACE inhibitor that is utilized for this purpose. It has an onset of action of 15 minutes, which is pretty good. It is contraindicated in pregnancy (which is obviously not a problem here) and it is unpredictable. It will most likely be accompanied by very strict monitoring in JS, but it is indeed the best option of the four here.

Explanation
(E) is the correct answer here. Either option will work. Let's find out why.

PL is a 64 year old woman and her blood pressure is very high. Once we accept it as greater than or equal to 180/110, we need to determine if this is an urgency or an emergency; end organ damage will tell us that. The fundoscopic exam shows no retinal damage, which is good. However, the lab values of BUN and SCr are telling. BUN is usually around 18 and SCr is generally less than 1.0. These values are very high values and indicate that there is some damage to the kidneys, thus making this case a hypertensive emergency, ruling out (A).

In a hypertensive emergency, there are two goals to have in mind: lower mean arterial pressure by 20-25% in 1-2 hours OR lower diastolic blood pressure by 10-15% in 30-60 minutes.

Mean arterial pressure = [(2 x diastolic) + systolic] / 3 = [(2 x 110) + 190] / 3 = 137. A reduction of 20-25% is about 105 mmHg in 1-2 hours. Therefore (B) is correct.

Diastolic blood pressure reduction should occur in 30-60 minutes. 10-15% of 110 mmHg is approximately 95 mmHg. (C) is also correct because the percentage reduction and the time-frame are accurate.

(D) is incorrect because we are not striving for "perfect" blood pressure. Again, the patient's organs may have already acclimated to the higher blood pressure, so too much reduction too quickly will not allow adequate perfusion to the organs and they may fail that way.

Explanation
(D) is the correct answer. There are some subtleties here that can affect the choices, so let's take a look.

First, this is classified as a hypertensive emergency. As a result, the blood pressure needs to be decreased to the appropriate goal as quickly and safely as possible. Therefore, IV medications must be used, thereby eliminating (B) and (C). Now you have to choose between sodium nitroprusside and labetalol.

Sodium nitroprusside is toxic. It contains 44% cyanide by weight, which can lead to cyanide toxicity. The liver will metabolize cyanide into thiocyanate, which isn't nearly as toxic as cyanide. It is then cleared by the kidneys. The problems arise when either the liver can't metabolize the cyanide OR the kidney can't eliminate the thiocyanate. As you can imagine, cyanide will just accumulate in the body and cause disastrous poisoning. Because of this, you shouldn't use this drug for long periods of time, so it should be limited to 24-48 hours.

PL has poor kidney function. This can be seen with the BUN and SCr values, which are elevated. This indicates some sort of acute kidney damage, which is a problem. Thiocyanate will not be cleared and cyanide will accumulate. Therefore, sodium nitroprusside should not be used in this patient. If you ever want to use this medicine, the patient MUST have good liver AND kidney functions.

As a result, labetalol, a non-selective beta-blocker, will be the best choice here.

Explanation
(C) is the correct answer here and the following discussion will explain why.

First, you have to determine if this is a hypertensive urgency or emergency. TS is a 31 year old female who is pregnant. Her blood pressure is 200/110. Remember to even be considered a hypertensive crisis, systolic blood pressure must be higher than or equal to 180 mmHg OR diastolic blood pressure must be higher than or equal to 110 mmHg. That is true in this case. The woman also has a fundoscopic exam that shows some retinal damage. This is a technical way of describing end organ damage and that means this is classified as a hypertensive emergency, which indicates that IV medications must be used, eliminating (A) and (B).

Enaliprilat is an IV ACE inhibitor, which is good if there is left ventricular failure (more on that later). Unfortunately, its use is contraindicated in pregnancy and should thus be avoided. In fact, answer choice (B), which is lisinopril, should also be avoided in pregnancy (Pregnancy Category D). As a result, labetalol would be the safest and most correct option.

Enalaprilat was purposefully placed as an answer choice to stress that pregnancy must also be taken into consideration for these cases. Hypertensive urgencies and emergencies are not limited to the elderly or those non-adherent to their hypertensive medications.

It may be tempting to assume labetalol is a safe choice almost every time. Indeed, it is safe to use in those with coronary artery disease and pregnancy. However, because it is a non-selective beta-blocker, it does have the ability to block beta-2 receptors in the bronchial smooth muscle. Because of this, it should be avoided in those with asthma and COPD.

Explanation
(B) is the right answer here. Let's discuss this.

Again, the first thing you want to do is determine whether this is a hypertensive urgency or emergency. The blood pressure is above 180/110. The BUN and SCr levels are elevated, indicating some damage to the kidney. Therefore, this is a hypertensive emergency, which requires IV medications and thus eliminating (A) and (C).

Now you have to choose between (B) and (D). There are a few reasons why enalaprilat would not be the best option. Firstly, in someone with renal failure, such as this, enalaprilat shouldn't be used. It doesn't mean an ACE inhibitor should NEVER be used, but it is not the best choice. Recall that ACE inhibitors work in the kidney, which is not something we want to truly alter in this situation.

In this case, a cocaine overdose would lead to what is called a "high adrenergic state". This means that there is a dramatic increase in serum catecholamine levels. These include epinephrine, norepinephrine, and dopamine and would ultimately lead to tachycardia and hypertension, as seen here. Ecstasy, caffeine, and methamphetamine overdoses would also do the same. Nicardipine is a 2nd generation dihydropyridine CCB. It is effective for most hypertensive emergencies AND high adrenergic states. Therefore, nicardipine would be the best answer.

Actually, prescription drugs can lead to a high adrenergic state. For instance, Adderall and Vyvanse, medications for ADHD, in very high doses, will block monoamine oxidase, an enzyme to metabolize catecholamines. With this enzyme knocked out, higher levels of catecholamines can produce pronounced effects (tachycardia, hypertension, etc.) and lead to this state. Tumors in the kidney can produce catecholamines to also bring to this state.

This question was the first that provided two "viable" options. The idea is to individualize treatment for the patient and assess the situation to ensure the correct medication and dose are selected. Enalaprilat could technically work, but the BEST option is the nicardipine. As we progress further, these subtleties will be highlighted to ensure the correct selections.

Explanation
(A) is the correct answer choice here and the following explanation will show why.

Once again, this is a hypertensive emergency for all the same reasons as before (at least 180/110 blood pressure and end organ damage with serum creatinine elevated). The treatment requires IV medications, thus eliminating (B) and (C). Now you have to choose between esmolol and hydralazine.

Esmolol is cardioselective beta-blocker that will decrease the rate and contractility of the heart. The other positive about this drug is that it is NOT affected by renal or hepatic function, which is ideal in this situation. The patient has renal failure and we want to try our best to avoid damaging the body more. Esmolol is ideal when the cardiac output, heart rate, and/or blood pressure are increased because of its cardioselectivity. It works quickly and has minimal side effects, thus making it the best option in this patient.

Hydralazine is a vasodilator that is useful in pregnancy, but does have the unfortunate qualities of reflex tachycardia and aggravation of angina. The patient already complains of chest pain so aggravating that will not be suitable. Therefore, (C) may not be the best for this patient.

This is where the subtleties come into play. Different drugs have different properties, which make them ideal in different situations. The goal is to understand and appreciate the differences and then select appropriately, which takes practice. If I had inputted nicardipine instead of hydralazine, would esmolol still be correct? The answer is yes. Nicardipine has high vascular selectivity. This is what I mean about subtleties and that is the "problem" with having so many medicines from which to choose. But because we spend so much time in our lives studying them, it would be expected that we know which one to pick, which takes practice.