12-phase flow (10)

1. 1FRAME
   Obesity + OSA hypertensive crisis = resistant-HTN phenotype crossed crisis threshold. Pathophys: chronic intermittent hypoxemia + arousals → sympathetic + RAAS + endothelial overdrive; ~30% of resistant HTN explained by OSA. Acute: standard HTN-emergency (nicardipine, labetalol). Specialty value: identify + treat OSA acutely (CPAP) + plan long-term resistant-HTN ladder (MRA + thiazide-like + RDN consideration).
   inputs: sbp, dbp, bmi, osa_features_history
   advance: phenotype framed; resistant-HTN + OSA combo confirmed by med list + history
2. 2ENTRY
   Recognize obesity + OSA + resistant-HTN crisis; IV access; cardiac monitor; nicardipine IV bridge; address airway (CPAP for documented OSA OR HFNC if hypoxemic; AVOID supine if severe OSA — elevate head ≥30°)
   inputs: age, sbp, spo2
   advance: IV access + monitor + nicardipine started + airway/positioning addressed
3. 3CONTEXT
   Comprehensive med rec including ALL antihypertensives + diuretic class + MRA presence; STOP-BANG screen if no prior OSA dx; CPAP adherence history (hours/night, mask fit, AHI on therapy); weight history + BMI trajectory; obesity-related comorbidities (T2DM, NAFLD, OHS, metabolic syndrome); cardiac comorbidities (HFpEF, AFib enriched in obesity-OSA); endocrine screen (PA, Cushing, thyroid)
   inputs: age, bmi, antihypertensive_med_list
   advance: med list + STOP-BANG + CPAP history + comorbidities documented
4. 4RED_FLAGS
   Cor pulmonale with RV strain (severe untreated OSA → pulmonary HTN → RV failure → cardiogenic shock variant); concurrent OHS with hypercapnic respiratory failure (avoid sedatives, bridge with NIV); flash pulmonary edema (LV failure from sympathetic + RAAS overdrive); aortic dissection (chronic HTN + obesity raises risk); ICH (severe HTN + sympathetic surge); pheochromocytoma masquerade (paroxysmal HTN + tachy + sweating overlaps with OSA arousals); semaglutide-induced GI events if recently initiated (pancreatitis, gastroparesis)
   inputs: sbp, spo2, heart_rate
   actions: htn_emergency
   advance: RED flags screened + life-threats addressed + RV/OHS/ACS/dissection/ICH ruled in/out
5. 5INITIAL_WORKUP
   ECG + troponin + BMP + Mg + CBC + UA + ABG if hypoxemic (OHS rule-out — pCO2 ≥45); CXR (pulm edema, cardiomegaly); bedside echo (LVH, diastolic dysfunction, RV strain, EF); aldosterone-renin ratio + 24-h urinary metanephrines (PA + pheo screen given resistant phenotype); thyroid (TSH); renal Doppler if RAS suspected (renovascular); urinary protein-to-creatinine for nephropathy; CT head if neuro deficit
   inputs: ecg_12_lead, troponin, creatinine, echo_lv_function, spo2
   actions: panel.cardiac, panel.renal
   advance: workup documented + secondary HTN screens initiated
6. 6BRANCHING_WORKUP
   OSA confirmation: HSAT (high pre-test probability) OR in-lab PSG (suspect OHS, central apnea, comorbid arrhythmia); if PA screen positive (ARR ≥30 + aldo ≥15) → endocrinology + saline-suppression + adrenal CT; if pheo positive (metanephrines >2x ULN) → adrenal imaging + endocrine workup; if RAS → CT/MR angiography or duplex Doppler; bariatric surgery evaluation if BMI ≥40 with refractory HTN; renal denervation evaluation (SPYRAL) if BP refractory after lifestyle + ≥4 agents + secondary causes excluded
   inputs: home_sleep_apnea_test_or_polysomnography
   advance: OSA confirmed + secondary causes branched + long-term plan structured
7. 7TREATMENT
   STEP 1 ACUTE: Nicardipine IV (5 mg/h titrate q5-15 min by 2.5 mg/h, max 15 mg/h) — first-line per AHA 2025 HTN emergency for non-aortic-dissection adults; gradual reduction MAP ↓ ≤25% in first hour. STEP 2: Labetalol IV (10-20 mg q10 min OR 0.5-2 mg/min infusion) as alternative or add-on (mixed α/β safe in this phenotype; β-blockade additionally helpful for sympathetic-overdrive component). STEP 3: NTG IV (5-200 mcg/min) if pulmonary edema overlay. STEP 4: Initiate or restart CPAP within first 12-24 h of admission for documented or strongly-suspected OSA (auto-CPAP acceptable while titrating); for OHS overlap → BiPAP/NIV. STEP 5 LONG-TERM resistant-HTN ladder (PATHWAY-2): ensure MRA (spironolactone 25-50 mg daily, K-sparing) + thiazide-like (chlorthalidone 12.5-25 mg or indapamide 1.25-2.5 mg) + ACEi/ARB + CCB (amlodipine 5-10 mg); add α-blocker (doxazosin) or central agonist (clonidine) as 5th-line; consider renal denervation per SPYRAL if BP refractory. STEP 6 WEIGHT MANAGEMENT: GLP-1 RA semaglutide 2.4 mg SC weekly (STEP-1 PMID 33567185 + STEP-HFpEF PMID 37877559) — target ≥10% body-weight reduction; tirzepatide alternative; bariatric surgery (RYGB or sleeve) for BMI ≥40 with refractory HTN.
   inputs: sbp, dbp, creatinine
   advance: IV agents titrated to SBP <160; CPAP/BiPAP initiated if applicable; long-term ladder structured
8. 8DISPOSITION
   ICU/step-down for q15-30 min BP, telemetry, CPAP/BiPAP titration; nocturnal pulse-ox + capnography if OHS suspected; sleep-medicine consult during admission for HSAT/PSG arrangement; ENT/sleep evaluation for upper-airway pathology; weight-management referral pre-d/c
   advance: monitored bed assigned + sleep-medicine consult booked + CPAP titration initiated
9. 9MONITORING
   Continuous ECG + telemetry; q15-30 min BP × 24 h then q1-2h; serial troponin q3-6h × 2 if elevated; nocturnal SpO2 + capnography; CPAP adherence (hours/night via download); daily BMP for K (MRA) + Cr; weight daily; agitation/somnolence assessment for OHS
   inputs: sbp, heart_rate, spo2
   actions: panel.cardiac
   advance: BP at target + CPAP adherence ≥4 h/night during inpatient stay + electrolytes stable + symptoms improved
10. 10FOLLOWUP
    Sleep medicine 2-4 weeks post-d/c for CPAP titration + adherence verification; cardiology + nephrology for resistant HTN; endocrine if PA/pheo positive; nutrition + bariatric medicine for weight management (semaglutide titration over 16 weeks; bariatric surgery referral if BMI ≥40 refractory); home BP monitoring (target <130/80 if standard, <125/75 if CKD/DM); CPAP adherence target ≥4 h/night ≥70% of nights with AHI <5 on therapy; weight loss target 5-10% in 6-12 months → reassess HTN regimen; renal denervation referral if BP refractory after maximal medical + lifestyle therapy + secondary causes excluded
    advance: CPAP adherence on track + weight management plan active + 4-week PCP/cardiology booked + sleep-medicine follow-up scheduled