Cardiology Corner: Hypertensive Emergencies Part 1

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Ross B. -

This was a great segment. Thanks! Can you discuss hydralazine at all? The internal medicine folks seem to love this drug, and we generally don't use it much in the ED. Seems to be in the same class as "rapidly acting oral agents..."

Amal M., M.D. -

Ross, I agree, hydralazine is definitely more popular upstairs. We are not fans of hydralazine unless someone is already on it and missed their dose; in those patients, we might give it.
Hydralazine in general can cause reflex tachy (not good for cardiac patients) and can produce unexpected drops in BP that can last many hours! Many of us think of it as the modern-day version of SL procardia (which got blackboxed because of adverse effects).
IF someone wants to use it, I always advise starting really low, e.g. 5 mg, just to make sure the patient doesn't have profound response to it; and then 10 mg if they are ok. I'd be hesitant to ever use more than 10 mg doses at a time, because that's when I've seen, heard about, and read about adverse effects (strokes usually).

Mary C. -

Great discussion! Regarding microangiopathic hemolytic anemia (MAHA) in the context of hypertensive emergency, are you also inferring an underlying element of microthrombi? Not to get lost in the weeds, but I understand that MAHA doesn’t necessarily presuppose thrombotic microangiopathy (TMA)?

Amal M., M.D. -

No, not necessarily inferring microthrombi.

Karen A. Q., M.D. -

Hi
I am always impressed with EMRAP and the wise and wonderful Dr. Amal Mattu. It was music to my ears when he talked about “hypertensive emergencies” not being a real condition and stop doing all those *$ tests on asymptomatic patients. Love that. THANK YOU.

One teeny tiny point: he said that nitroglycerin ointment does not work. I think he quoted an unnamed cardiologist that it was “like spitting on a piece of tape”. Now I am a bit older than Dr. Mattu so maybe I just have more experience but NTG topically does work. Of course, I readily concede that there are better choices but saying it does not work is inaccurate. In fact, in studies >50% of people who get topical 2% nitroglycerin will get a headache. Impressively, when 0.4% nitro is used for anal fissures, headaches are seen in nearly 2/3 of people! It is also associated with hypotension in both concentrations and routes. So NTG ointment is absorbed and can work! Again, I am not a big fan of this option but it might be worth noting that NTG ointment is still an available, inexpensive option just not necessarily first-line.

Huge fan of all your work. Thanks for your attention.
Karen Quaday

Stephen J. -

Is there a BP that despite the patient being asymptomatic, the patient should be admitted?

Preston W., M.D. -

I am a bit late to this one. I am doing my New Years eve CME catchup. I missed this earlier. Although I agree in principle and in theory. I have read most of this literature. In practice if someone presents with a BP 190-210/100-120 (which I have seen often working in urban E.D.s) and you do nothing, No workup at all. Then before they get to followup have an untoward cardiovascular event. Will a "good history and physical" protect you from the evil men in the suits across that long cherry-wood table? Will the jury understand? The patient had an elevated blood pressure..one did nothing...they left with an elevated blood pressure. What will they think? I part with an anecdote. I was working in an ED in New York State (the nanny state) a patient with chronic back pain left with a blood pressure of 162/90. Instructed to followup with pain management and his primary care physician within 2-3 days. We were sanctioned by the STATE OF NEW YORK HEALTH DEPARTMENT for failing to (adequately) address their blood pressure. Nothing untoward happened to the patient. The patient complained to the state complaint that he did not receive "proper pain control" (ie narcotics) I shudder to think what they would do if a patient with a BP of 190/110 had an untoward event. With no workup..

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