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HYPERTENSION - JNC VII The EMCREG Updates

HYPERTENSION - JNC VII The EMCREG Updates

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HYPERTENSION - JNC VII The EMCREG Updates

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    1. HYPERTENSION – JNC VII & The EMCREG Updates Abhinav Chandra & Sarah Stahmer August 2008 DUKE EM Conference

    2. A. Chandra & S. Stahmer, August 2008 JNC VII

    3. A. Chandra & S. Stahmer, August 2008 Goals Incidence Etiology Medications Scenerios Questions

    4. A. Chandra & S. Stahmer, August 2008 Incidence Hypertension affects: 25% of all adults 60% of all people older than 60 years in the US. 37 million O/P visits for HTN (#1 in 2004) Cecil Textbook of Medicine, 22nd ed; St. Louis: WB Saunders; 2004.

    5. A. Chandra & S. Stahmer, August 2008 Incidence Almost 30% of ED patients have elevated BP during their ED evaluations (>140/90) 20-70% of patients with BP in the ED have an elevated BP on follow-up

    6. A. Chandra & S. Stahmer, August 2008 What Is Hypertension 7th Report of the Joint National Committee Prevention, Detection, Evaluation and Treatment of High Blood Pressure – 2003 (JNC7)

    7. A. Chandra & S. Stahmer, August 2008 JNC 7 – What To Remember Systolic is MORE important than diastolic Risk of CV disease doubles for every 20/10 increase above 140/90 “PreHTN” emphasized Thiazide diuretics Goal BP <140/90 and <130/80 with DM/CKD Start with 2 meds if BP >20/10 above goal

    8. A. Chandra & S. Stahmer, August 2008 Etiology Essential – 90% Anxiety Pain Hypoxia Bladder Distention

    9. A. Chandra & S. Stahmer, August 2008 Etiology – Secondary Causes Renal Disease Endocrine (Pheo, Cushings, Aldos) Neurologic(Incr. ICP) Drugs Withdrawl Coarctation

    10. A. Chandra & S. Stahmer, August 2008 Sympathetic Hyperstimulation Autonomic imbalance Elderly population Diminished beta receptor sensitivity Systolic HTN, relative tachycardia Increased PVR Decreased Circulating blood volume CO Nitrous oxide production

    11. A. Chandra & S. Stahmer, August 2008 Renin-Angiotensin Axis Ang II increased BP by: Increasing PVR Stimulation of aldosterone synthesis Renal tubular sodium reabsorption Stimulation of thirst Release of ADH Cardiac and vascular hyperplasia through activation of AT1 receptors

    12. A. Chandra & S. Stahmer, August 2008 Modifiers Salt sensitivity Vascular reactivity Endothelial Dysfunction Increased arterial stiffness Reduced NO sensitivity/production

    13. A. Chandra & S. Stahmer, August 2008 EM Evaluation Goals Look for End-organ Damage Look for alternative etiologies Look at specific clinical features to aid treatment selection Our function in the ED Screen and refer Treat and refer Treat and hospitalize

    14. A. Chandra & S. Stahmer, August 2008 Does Tx Help? • YES !! • 35-40% decline in stroke • 25% decline in CAD/MI • >50% decline in HF

    15. A. Chandra & S. Stahmer, August 2008 Impact of Hypertension Slide 5 Studies show that a multitude of diseases are attributable to hypertension. They include: • Heart failure • Coronary heart disease • Myocardial infarction • Left ventricular hypertrophy and failure • Aortic aneurysm • Peripheral vascular disease • Retinopathy • Hypertensive encephalopathy • Chronic kidney failure • Cerebral hemorrhage • Stroke With so many diseases linked to hypertension, prompt and effective treatments have the potential to reduce many complications. Dustan HP, et al. Arch Intern Med 1996; 156:1926-1935.Slide 5 Studies show that a multitude of diseases are attributable to hypertension. They include: • Heart failure • Coronary heart disease • Myocardial infarction • Left ventricular hypertrophy and failure • Aortic aneurysm • Peripheral vascular disease • Retinopathy • Hypertensive encephalopathy • Chronic kidney failure • Cerebral hemorrhage • Stroke With so many diseases linked to hypertension, prompt and effective treatments have the potential to reduce many complications. Dustan HP, et al. Arch Intern Med 1996; 156:1926-1935.

    16. A. Chandra & S. Stahmer, August 2008 End Organ Damage Cerebral Infarction 24.5% Hypertensive Encephalopathy 16.3% Acute Heart Failure Syndrome 14.3% Acute Coronary Syndrome 12.0% Intracerebral/Subdural Bleed 4.5% Aortic Dissection 2.0%

    17. DRUGS Are Good

    18. A. Chandra & S. Stahmer, August 2008 Vasodilatation

    19. A. Chandra & S. Stahmer, August 2008 Vasodilatation

    20. A. Chandra & S. Stahmer, August 2008 Nitroglycerin Useful in managing BP in patients with angina or pulmonary edema At lower doses, works primarily by ?ing preload Affects venous system predominantly Reduces myocardial oxygen demand At higher doses, works primarily by ?ing afterload Affects arterioles and coronary arteries predominantly

    21. A. Chandra & S. Stahmer, August 2008 Nitroglycerin Nitroglycerin Watch out for Viagra and Cialis—Enhances nitric oxide release and has a half-life of 8 hrs Tolerance may occur Paste contains 7.5 mg / 0.5 inch Inhibitors ** Stahmler

    22. A. Chandra & S. Stahmer, August 2008 Nitroprusside Affects both peripheral arteries and veins as well as the coronary arteries Indications: Anytime, but specifically AD & CHF Rapid off, rapid on (5 min) Caution in those with ? ICP Adv Effect: Cyanide toxicity (in light) Prolonged infusion, high dose, renal or hepatic insufficency Clues: Metabolic acidosis, air hunger, bright red venous blood Dose: Start at 0.3 mcg/kg/min, average effective dose is 3 mcg/kg/min, with the max of 10 mcg/kg/min

    23. A. Chandra & S. Stahmer, August 2008 Hydralazine Vasodilator, Arteriole > Venule dilator (dbp > sbp) Indication: Pregnancy (preeclampsia & eclampsia) ? CO and HR Adverse Effects SLE like syndrome (> 6 months of use), tachycardia, headache Reflex compensatory mxns ? Cause tachycardia, increase in CO & renin release - increased aldosterone - Na+ & water retention (combine with diuretic) Induced-angina may be precipitated due to increased cardiac work

    24. A. Chandra & S. Stahmer, August 2008 Fenoldopam Selective dopamine-1 receptor agonist, ?ing PVR while ?ing RBF, natriuresis, and diuresis 6x more potent than dopamine in producing renal vasodilation Given IV and titrated; onset of action 10 min and effects persist for an hour after d/c May cause T-wave flattening, angina, atrial fib/flutter, and reflex tachycardia

    25. A. Chandra & S. Stahmer, August 2008 Calcium Channel Blockers 2 Classes Dihydropyridines ? Nifedipine, amlodipine, felodipine, nicardipine Effect on vascular calcium channels, Nondihydropyridine ? Diltiazem, verapamil Effect on the cardiac(*) and vascular channels Avoid CHF

    26. A. Chandra & S. Stahmer, August 2008 Calcium Channel Blockers

    27. A. Chandra & S. Stahmer, August 2008 Nicardipine As a CCB, relaxes arteriolar smooth muscle and ?s PVR Onset to effect is about 10min, and lasts 2-6h after d/c Abrupt withdrawal can cause rebound angina and hypertension Still, in at least one head-to-head trial, better tolerated than Nitroprusside

    28. A. Chandra & S. Stahmer, August 2008 Angiotensin Inhibitors

    29. A. Chandra & S. Stahmer, August 2008 Diuretics Thiazides – Increased Uric Acid, decreased Na, Cl, K, incr hyperglycemia, Thiazides – Increased Uric Acid, decreased Na, Cl, K, incr hyperglycemia,

    30. A. Chandra & S. Stahmer, August 2008 Thiazides Proven to impact M/M, good first line and commonly combined ALLHAT Study 40,000 comparing to ACEI and CCB ? CVA & ? CHF with HCTZ of 50mg or less Mxn: Reduce BP by decreasing blood volume and CO. Some SVR reduction (? Ca ++ sensitivity). SE: Kidney Stones, hypokalemia, elevated lipids and homocysteine, some impotence Caution: To be avoided in Sulfa Allergy

    31. A. Chandra & S. Stahmer, August 2008 Beta-Blockers MXN: Including ? HR and ? CO, blocking renin release, and blocking the production of angiotensin II and aldosterone Indications: ACS, Preeclampsia SE: Dizziness, orthostatic hypotension, nausea and fatigue Contraindications: RAD, decompensated CHF, 2nd or higher heart block, severe bradycardia, or hypotension

    32. A. Chandra & S. Stahmer, August 2008 Esmolol Blocks ß-1 receptors of heart and vasculature Given IV, onset of action is 6-10min after bolus, and activity persists 20min after infusion d/c’d; must be carefully titrated Symptoms may occur after abrupt withdrawal

    33. A. Chandra & S. Stahmer, August 2008 Labetalol ?s PVR by blocking a-1 receptors and prevents reflex tachycardia by blocking ß-1 receptors, resulting in a ?BP Optimally used when a gradual ? in BP is needed with minimal effects on HR, and in CVA (labetolol has minimal effects on CBF) 0.5 – 2 mg/min infusion 10-20 mg IV bolus every 10 -15 minutes Should be avoided in significant asthma/COPD; may cause bradycardia, AV block, hypotension

    34. A. Chandra & S. Stahmer, August 2008 Clonidine Reduces central sympathetic outflow, thereby increasing vagal tone, reducing PVR and HR Only available orally; onset of effect is 1-3h May cause orthostasis (especially in volume-depleted patients, bradycardia, and AV block; associated with withdrawal in patients taking more than 0.3mg/d

    35. A. Chandra & S. Stahmer, August 2008 Medication Summary

    36. Hypertension Scenarios

    37. A. Chandra & S. Stahmer, August 2008 42 yo assaulted by “ the dude with the bat” VS BP 165/90 Significant soft tissue injury to arms, back No prior PMH HTN issues?

    38. A. Chandra & S. Stahmer, August 2008 EMCREG Recommendations for Asymptomatic HTN without End-Organ Damage Blood Pressure Recommendations 140-159/90-99 Confirm w/in 2 months and follow-up 160-179/100-109 Confirm and Tx w/in 1 month 180-209/110-119 Confirm and Tx w/in 1 week 210+/120+ Confirm, evaluate, Start Tx and refer

    39. A. Chandra & S. Stahmer, August 2008 First Line Therapy – Without Compelling Indications

    40. A. Chandra & S. Stahmer, August 2008 African-Americans Diuretics agents of first choice Then CCB and alpha-blockers Decreased responsiveness to Beta blockers or ACE I as monotherapy ACE I angioedema 2-4x more frequent

    41. A. Chandra & S. Stahmer, August 2008 Isolated Systolic HTN-Elderly

    42. A. Chandra & S. Stahmer, August 2008 DM with Nephropathy First line therapy:

    43. A. Chandra & S. Stahmer, August 2008 Renal Insufficency Creat 1.5, GFR <60, or albuminuria > 300mg ACE/ARB with non-diabetic renal disease– Ra Creatinine can increase 35% above baseline with ACE I and ARB OK, unless increased K develops With advanced renal disease, creat 2.5, GFR < 30 Add a loop diuretic to ACE as well

    44. A. Chandra & S. Stahmer, August 2008 24 yo f w/ 30 week gestation Vomiting, abdominal pain BP 160/100 Swollen belly and ankles HTN issues?

    45. A. Chandra & S. Stahmer, August 2008 Pregnancy & HTN

    46. A. Chandra & S. Stahmer, August 2008 Pregnancy -- Preeclampsia 25% of women with chronic HTN

    47. A. Chandra & S. Stahmer, August 2008 35 yo with chest pain after “smokin” VS 160/90 HR 118 Exam normal except for agitation and sweats ECG: ST, no active ischemia HTN issues?

    48. A. Chandra & S. Stahmer, August 2008 Sympathomimetic Induced HTN Aymptomatic: Observe as drugs have short half-life Symptomatic: BDZ, BDZ, BDZ NTG, Phentolamine, CCB Avoid Beta-blockers

    49. A. Chandra & S. Stahmer, August 2008 55 yo with inability to move arm VS 190/95 HR 118 Exam: Unable to move left leg and arm ECG: ST, no active ischemia HTN issues?

    50. A. Chandra & S. Stahmer, August 2008 Spectrum of CNS Damage

    51. A. Chandra & S. Stahmer, August 2008 HTN & Ischemic CVA Reflection of the body’s attempt to maintain a cerebral perfusion pressure ? BP may further CVA damage Zone No agreement, but AHA suggest tx if: SBP > 220 DBP > 140 MAP > 130 If plan to give TPA, ? BP below 185/105

    52. A. Chandra & S. Stahmer, August 2008 ICH & SAH HTN may worsen bleed Goal is to maintain CPP (MAP-ICP) at 60-70 mm HG Goal for SBP is 140-160 mm Hg Provide fluids as needed due to salt wasting issues in hemorrhages Nitroprusside, nicardipine, labetolol

    53. A. Chandra & S. Stahmer, August 2008 EMCREG Recommendations Ischemic CVA Only Tx if to give Lytics Goal SBP<185 and DBP<105 for 24 hours If other indication to tx, use labetolol or nicardipine Hemorrhagic CVA – Goal Preserve CPP 1st 24 hours – MAP < 130 or SBP < 180 If ? ICP, MAP < 110 or SBP < 160 for 24 hrs

    54. A. Chandra & S. Stahmer, August 2008 HTN & Ischemic CVA Treatment Labetolol – 10-20 mg IV q 10 minutes (max 300 mg) Nicardipine 5mg/hr IV (Max 15mg/hr) Avoid Hydralazine, NTG or Nitroprusside as ? ICP Some studies suggest using pressors to INCREASE CPP (Not recommended)

    55. A. Chandra & S. Stahmer, August 2008 EMCREG Recommendations Subarachnoid Hemorrhage Direct correlation with rebleed and SBP>160 Tx when MAP > 130 and goal is SBP < 160 Tx with pain meds, sedation, and recheck BP If still up, labetolol or nicardipine/clevedipine

    56. A. Chandra & S. Stahmer, August 2008 Hypertensive Emergency Why not aim for 120/80? This may decrease cerebral blood flow in a patient who is chronically hypertensive who likely has impaired cerebral autoregulation

    57. A. Chandra & S. Stahmer, August 2008 56 yo w/ HTN now with abdominal pain VS 180/90, HR 112 Has been vomiting, and has not taken his meds Abd: distended, soft, decreased BS HTN issues?

    58. A. Chandra & S. Stahmer, August 2008

    59. A. Chandra & S. Stahmer, August 2008 Aortic Dissection Goal SBP 100-120 mm Hg Decrease Cardiac Contractility Drugs Nitroprusside (Given with a Beta blocker only) Labetolol Esmolol NTG Opiates With acute aortic dissection, the stresses that damage the vessel wall are related to the mean pressure, the width of the pulse pressure, and the maximal rate of rise of the pressure (dp/dt). Drugs that diminish dp/dt are the optimal agents to treat a dissection [5]. The initial aim of medical therapy in such patients is to decrease both the systemic BP (to a systolic pressure of 100 to 120 mmHg if tolerated) and cardiac contractility. These combined goals are usually achieved by the combination of nitroprusside and an intravenous beta blocker such as propranolol or labetalol. Nitroprusside should not be given without a beta blocker. With acute aortic dissection, the stresses that damage the vessel wall are related to the mean pressure, the width of the pulse pressure, and the maximal rate of rise of the pressure (dp/dt). Drugs that diminish dp/dt are the optimal agents to treat a dissection [5]. The initial aim of medical therapy in such patients is to decrease both the systemic BP (to a systolic pressure of 100 to 120 mmHg if tolerated) and cardiac contractility. These combined goals are usually achieved by the combination of nitroprusside and an intravenous beta blocker such as propranolol or labetalol. Nitroprusside should not be given without a beta blocker.

    60. A. Chandra & S. Stahmer, August 2008 35 yo w/ ESRD,chest pain and SOB VS 200/110 HR 90 Agitated, tearful Chest:Basilar rales HTN issues?

    61. A. Chandra & S. Stahmer, August 2008

    62. A. Chandra & S. Stahmer, August 2008 Pulmonary Edema Systolic Dysfunction Vasodilators – NTG or Nitroprusside Loop Diuretics IV Ace Inhibitors Avoid: Hydralazine as increases cardiac work load Avoid: Beta Blockers Diastolic Dysfunction (45-50%) Afterload Reduction – ACEI, Arterial Vasodilators Acute pulmonary edema — Hypertension in patients with acute left ventricular failure due to systolic dysfunction should be principally treated with vasodilators. Nitroprusside or nitroglycerin with a loop diuretic is the regimen of choice for this problem. Drugs that increase cardiac work (hydralazine) or decrease cardiac contractility (labetalol or other beta blocker) should be avoided Acute pulmonary edema — Hypertension in patients with acute left ventricular failure due to systolic dysfunction should be principally treated with vasodilators. Nitroprusside or nitroglycerin with a loop diuretic is the regimen of choice for this problem. Drugs that increase cardiac work (hydralazine) or decrease cardiac contractility (labetalol or other beta blocker) should be avoided

    63. A. Chandra & S. Stahmer, August 2008 Chronic CHF + HTN Stage A—No LV dysf, ACEI Stage B—NYHA 1 – LV Dysfxn Stage C– NYHA 2-3 – LV Dysf and sx’s Stade D – NYHA 4 – LVD and advanced careStage A—No LV dysf, ACEI Stage B—NYHA 1 – LV Dysfxn Stage C– NYHA 2-3 – LV Dysf and sx’s Stade D – NYHA 4 – LVD and advanced care

    64. A. Chandra & S. Stahmer, August 2008 86 yo w/ HTN & altered MS VS: BP 180/110 HR 80 Temp 101.8 Somnolent Chest : Clear Abd: soft, ND, NT Urine “cloudy” HTN issues?

    65. A. Chandra & S. Stahmer, August 2008

    66. A. Chandra & S. Stahmer, August 2008 Hypertensive Encephalopathy The ? MAP overwhelms the brain’s ability to autoregulate cerebral blood flow BBB integrity disrupted, bleed may occur CT often is normal May show white-matter edema of the occipital lobes and other posterior structures Tx should ? MAP by 25% in 1st hour*, use IV meds

    67. A. Chandra & S. Stahmer, August 2008 65 yo ETOH dependent f Presents with abdominal pain and vomiting VS BP 180/110 HR 120 Abd: Diffusely tender HTN issues?

    68. A. Chandra & S. Stahmer, August 2008 23 yo with HA Rotund, well appearing BP 160/100 HR 70 Alert Nonfocal exam except for…

    69. A. Chandra & S. Stahmer, August 2008 33 yo with nausea and fatigue No prior medical history BP 190/120 Tired Chest: clear Cor: Extra heart sound HTN issues?

    70. A. Chandra & S. Stahmer, August 2008 Coronary Artery Disease MI/Unstable Angina Beta Blocker, ACEI, Vasodilators Use Beat blockers* with NTG/Nitroprusside Labetolol offers alpha/beta blockade Acute coronary insufficiency frequently increases the systemic blood pressure. Intravenous parenteral vasodilators, principally nitroprusside and nitroglycerin, are effective and reduce mortality in patients with acute myocardial infarction, with or without hypertension [4]. Labetalol is also effective in this setting. Drugs that increase cardiac work (hydralazine) are contraindicated Acute coronary insufficiency frequently increases the systemic blood pressure. Intravenous parenteral vasodilators, principally nitroprusside and nitroglycerin, are effective and reduce mortality in patients with acute myocardial infarction, with or without hypertension [4]. Labetalol is also effective in this setting. Drugs that increase cardiac work (hydralazine) are contraindicated

    71. A. Chandra & S. Stahmer, August 2008 CAD-Recent MI or LV Dysfunction 1st Line is BB, and then add CCB1st Line is BB, and then add CCB

    72. A. Chandra & S. Stahmer, August 2008 CAD - Chronic Angina

    73. Re-Cap

    74. A. Chandra & S. Stahmer, August 2008 Hypertension Categories Transient hypertension Severe hypertension Hypertensive emergency Hypertensive urgency

    75. A. Chandra & S. Stahmer, August 2008 Transient Hypertension Causes Anxiety Acutely painful conditions Alcohol withdrawal Exogenous catecholamines Treatment Treat the underlying condition BP will usually normalize

    76. A. Chandra & S. Stahmer, August 2008 Severe Hypertension Elevated BP that is not causing acute end organ damage Rx: Elderly, CHF, essential HTN: HCTZ Angina/post MI: Beta-blockers CHF/Diabetes: ACE inhibitors

    77. A. Chandra & S. Stahmer, August 2008 Hypertensive Syndromes Using JNC 7 nomenclature, “hypertensive crisis” is an acute, severe, stage 2 (160/100) elevation in blood pressure Crisis is then differentiated into: Hypertensive “emergencies” (involving some end-organ damage) Hypertensive “urgencies” (no end-organ damage

    78. A. Chandra & S. Stahmer, August 2008 Hypertensive Emergencies Definition: situations requiring immediate BP reduction to prevent or limit target organ damage hypertensive encephalopathy intracranial hemorrhage unstable angina, acute MI, CHF dissecting aortic aneurysm Eclampsia Renal Failure The treatment goal is blood pressure reduction by 10% in the first hour with an additional 15% reduction in the next 2-3 hours.

    79. A. Chandra & S. Stahmer, August 2008 Hypertensive Emergency Treatment Options (IV) Nitroprusside Esmolol Labetolol Nicardipine Fenoldopam NO ORAL AGENTS

    80. A. Chandra & S. Stahmer, August 2008 Hypertensive Urgencies Definition: Stage 2 blood pressure without acute end organ damage Goal: Managed with oral medications and requires BP lowering over 24-48 hours Important to prevent too-rapid lowering due to autoregulation of flow by pressure in brain, heart, and kidneys Quan AP. Insufficient reliable evidence about treating hypertensive emergencies. Evidence-based Cardiovascular Medicine 2003;7: 150-152.

    81. A. Chandra & S. Stahmer, August 2008 Hypertensive Urgency Tx

    82. A. Chandra & S. Stahmer, August 2008 Hypertensive Urgencies Avoid use of Nifedipine SL… serious AEs have been reported c/ use MI CVA inability to control the rate or degree of fall in BP makes this medication unacceptable!!

    83. A. Chandra & S. Stahmer, August 2008 Hypertension Treatment To date no outcome data corroborate that acutely lowering blood pressure other than in a hypertensive emergency improves short-term prognosis. Bakris GL, Mensah GA. Pathogenesis and clinical physiology of hypertension. Cardiol Clin 2002;20:195-206

    84. A. Chandra & S. Stahmer, August 2008 Algorithm for Tx of HTN

    85. A. Chandra & S. Stahmer, August 2008 Care With Antihypertensives Bronchospasm--Beta blocker Depression--Central alpha-agonist, reserpine Gout--thiazides Heart block, CHF--Beta blocker, non DHP CA

    86. A. Chandra & S. Stahmer, August 2008 Treatment Recommendations

    87. Questions

    88. A. Chandra & S. Stahmer, August 2008 Q’s Which of the following statements is true regarding a hypertensive emergency? A. Immediate blood pressure reduction to the normal range is indicated in all cases. B. Eclampsia is not considered a hypertensive emergency. C. Oral agents are preferred in the treatment of hypertensive emergency. D. The treatment goal is blood pressure reduction by 10% in the first hour with an additional 15% reduction in the next 2-3 hours. E. Nitroprusside is contraindicated in pregnancy due to the risk of cyanide toxicity. DD

    89. A. Chandra & S. Stahmer, August 2008 Q’s Which of the following statements is true regarding hypertensive encephalopathy? A. It is a common condition in hypertensive patients. B. It usually is associated with intracranial hemorrhage. C. The brain CT often is normal but may show white matter edema of the posterior brain structures. D. Treatment with oral antihypertensive agents is acceptable. E. Normal blood pressure should be obtained rapidly. CC

    90. A. Chandra & S. Stahmer, August 2008 Q’s In which of the following patients is invasive blood pressure monitoring indicated? A. Patients who require continuous infusions of antihypertensive medications B. Patients with very high blood pressure C. Patients with very low blood pressure D. Patients in whom accurate blood pressures cannot be obtained, such as obese patients E. All of the above EE

    91. A. Chandra & S. Stahmer, August 2008 Q’s Which of the following drugs does not have vasodilation as a main mechanism of action? A. Labetalol B. Minoxidil C. Hydralazine D. Nitroprusside E. Fenoldopam EE

    92. A. Chandra & S. Stahmer, August 2008 Q’s Regarding hypertension and stroke, which of the following statements is false? There is a firm consensus on the management of elevated blood pressure associated with acute stroke. Hypertension associated with acute stroke is probably due to a physiologic response to maintain perfusion to the ischemic penumbra. The recommended blood pressure cutoff for using TPA in stroke is 185/110 mmHg. Vasodilators should be avoided as they may increase intracranial pressure. If the blood pressure needs to be treated, useful agents include labetalol. AA

    93. A. Chandra & S. Stahmer, August 2008 Q’s A 56-year-old male who hasn’t seen a doctor in “years” presents to the ED for a laceration on his leg. His blood pressure was noted to be 190/85 on initial presentation and 186/92 on repeat measurement. His only complaint is the laceration, and the remainder of the physical examination is normal. Which of the following choices describes an unnecessary management option? Immediately medicate with an antihypertensive agent and admit the patient for observation. Treat the patient with a low-dose oral agent in the ED and discharge him with a prescription and instructions for close follow-up. Provide no treatment, educate the patient, and instruct him to follow up within a week. All choices are medically indicated CC

    94. A. Chandra & S. Stahmer, August 2008 Q’s At which of the following diastolic blood pressures should you administer parenteral antihypertensive medications in an asymptomatic patient? a. 70 d. 110 b. 90 e. None of the above c. 100 EE

    95. A. Chandra & S. Stahmer, August 2008 Q’s The most common end organ affected by hypertensive emergencies is: a. Brain c. Kidney b. Heart d. Liver AA

    96. A. Chandra & S. Stahmer, August 2008 Q’s Which of the following is contraindicated in a patient intoxicated with cocaine and having chest pain with hypertension? a. A beta antagonist b. A thiazide diuretic c. An angiotensin converting enzyme inhibitor d. Nitroglycerin e. A benzodiazepine AA

    97. A. Chandra & S. Stahmer, August 2008 Q’s For a patients with a blood pressure of 170/105,ACEP Practice Guidelines recommend initiation of antihypertensive medications in the ED only when there are signs of acute end organ damage, or the patient is known to already carry the diagnosis of hypertension. a. True b. False AA

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