USMLE Step 2 Review 18 06 Drugs of Choice Hypertensive Crisis Cont

USMLE Step 2 Review 18 06 Drugs of Choice Hypertensive Crisis Cont

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Let’s start our USMLE Review with Drugs of Choice from the Gold Standard USMLE Step 2 Audio Review program.

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Begin 18 06 Drugs of Choice Hypertensive Crisis Cont Transcription

Ok. We’re going to look at some other medications and indications in the treatment of hypertensive emergencies. What drug has chemical similarities to Nitroprusside, and is also an arterial and venous vasodilator?

  • Nitroglycerin.

In addition to arterial and venous vasodilation, what other major actions does nitroglycerin have but Nitroprusside does not?

  • Nitroglycerin is also a coronary artery vasodilator.

In the presence of a hypertensive emergency, what are the 3 indications for using nitroglycerin?

  • Unstable angina, acute MI, pulmonary edema.

There are 6 brand names for nitroglycerin. Let’s run though them quickly.

  • Tridil, Nitro-Dur, Nitrostat, Nitro-Bid, transderm, nitroglycerin.

What are 3 relatively minor side effects of using nitroglycerin in a hypertensive emergency?

  • Headache, nausea, vomiting.

And what should you particularly watch for giving nitroglycerin IV in a hypertensive emergency?

  • Just the opposite- causing hypotension.

Given the toxicity concerns with Nitroprusside from thiocyanate and cyanide, what 3 things should you consider in terms of hospitalization of the patient if you wish to use Nitroprusside/Nipride?

  • You should probably admit the patient to the ICU where they can have continuous cardiac and blood pressure monitoring, and where the ICU personnel can watch for hypotension and toxicity.

And what should you be careful about with the IV bag using Nitroprusside/Nipride?

  • You should keep the IV bag covered from light.


  • Because Nitroprusside/Nipride is unstable in ultraviolet light.

Finally, is Nitroprusside/Nipride safe in pregnancy?

  • No, it is not.

What are the 3 primary indications for using Nitroprusside/Nipride in the presence of a hypertensive emergency?

  • Hypertensive encephalopathy, malignant hypertension, and aortic dissection.

Now, if there is aortic dissection, what drug should be used first before you start the Nipride infusion?

  • A beta-blocker.

What are 2 beta blockers indicated for initiating treatment of aortic dissection?

  • Esmolol or trimethaphan.

Trade name for Esmolol?

  • Brevibloc.

Trade name for trimethaphan?

  • Arfonad.

And what sort of beta blocker is Esmolol/Brevibloc?

  • It’s a selective beta 1 blocker.

In addition to initiating treatment of aortic dissection, what are the 3 other indications for the use of Esmolol/Brevibloc?

  • Myocardial ischemia, IHSS, and pheochromocytoma.

And what type of blocker is Trimethaphan/Arfonad?

  • This is a ganglionic blocker.

And, in addition to initiating treatment of an aortic dissection in the presence of a hypertensive emergency, what is the other indication for Trimethaphan/Arfonad?

Pulmonary edema.

And what is an alternative to Nitroprusside/Nipride for treating an aortic dissection in the presence of a hypertensive emergency along with the beta blocker?

  • Nifedipine. Nifedipine may come to replace Nitroprusside as the drug of choice for treating aortic dissection in the presence of hypertension, keeping in mind that a beta-blocker should initiate the treatment.

What is the trade name for nifedipine?

  • Procardia.

And what are the 2 major actions of Nifedipine/Procardia?

  • Vasodilation of both coronary arteries and peripheral arteries.

What is the other indication for Nifedipine/Procardia in the emergency room?

  • Hypertensive urgencies.

How should the Nifedipine/Procardia pill be administered to the patient in the presence of a hypertensive urgency or emergency?

  • The pill should be punctured first and then the patient should bite on it, chew, and swallow.

What are the 2 diuretics often used in treating hypertension?

  • Furosemide or Bumetanide.

What is the trade name for Furosemide?

  • Lasix.

And the trade name for Bumetanide?

  • Bumex.

What is the major action for both Furosemide/Lasix or Bumetanide/Bumex?

  • They both inhibit sodium reabsorption in the ascending limb of Henle’s loop.

What are the 2 main indications for use?

  • Pulmonary edema and newly diagnosed hypertension.

What 2 potential problems do you have to watch for in using this type of diuretic?

  • Hypokalemia, hyperuricemia.

What is the class of drug used for hypertension that is known for having cough as its primary side effect?

  • These are the ACE Inhibitors.

And what is their major action?

  • They inhibit angiotensin-converting enzyme, which converts angiotensin I (which is inactive) into angiotensin II, which is active, and which activates the expression of endothelin from endothelial cells, causing vasoconstriction.

What are the 2 primary uses for the ACE Inhibitors in the emergency room?

  • Hypertensive urgencies, pulmonary edema.

And what sort of cardiac condition are the ACE Inhibitors beneficial for using with in treating hypertensive urgencies or pulmonary edema?

  • CHF- Congestive Heart Failure.

What cautions should be observed in terms of renal insufficiency?

  • Renal insufficiency can result in accumulation of the ACE Inhibitors in the blood, increasing plasma levels.

There are many different ACE Inhibitors and they probably all have about the same effectiveness, although there is substantial variation in their ability to bind to the endothelium and stay there.

What are 2 that are currently indicated and in common use for hypertensive urgencies and pulmonary edema?

  • Captopril and Enalapril.

What’s the brand name for Captopril?

  • Capoten.

And the brand name for Enalapril?

  • Vasotec.

Finally, what is the drug that is specifically indicated for syndromes of catecholamine excess, including pheochromocytoma and cocaine overdose, and is especially useful in narcotic withdrawal?

  • This is clonidine.

And the brand name?

  • Catapres.

And what is the major action of Clonidine/Catapres? It is a potent alpha-2 agonist and it is also what?

  • A centrally acting agent.

In addition to narcotic withdrawal, what other withdrawal is it indicated for?

  • Clonidine withdrawal. Sometimes patients on clonidine for other reasons will decide to stop taking it without informing their physicians, and then they can get into clonidine withdrawal, resulting in catecholamine excess.

What is the other indication for Clonidine/Catapres in terms of hypertension in the emergency room?

  • Hypertensive urgencies.

And in terms of side effect profile, what are 2 benefits of Clonidine/Catapres?

  • Postural hypotension is not seen, that’s not a problem, and Clonidine/Catapres is safe in renal failure.



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