Updated: 3/22/2020

Hypertensive Urgency And Emergency

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Snapshot
  • A 56-year-old woman with a history of poorly controlled hypertension presents to the emergency room with a severe headache, blurry vision, and proteinuria. Her blood pressure is 238/122 mmHg. Funduscopic exam demonstrates arteriolar narrowing and arteriovenous nicking. His neurological examination is unremarkable and his CT head without contrast does not demonstrate evidence of an intracranial hemorrhage or ischemic stroke. The patient is given intravenous labetalol.
Introduction
  • Overview
    • hypertensive urgency
      • severely elevated blood pressure (either systolic BP of ≥ 180 mmHg and/or diastolic BP of ≥ 120 mmHg)
        • no evidence of end-organ damage
    • hypertensive emergency
      • severely elevated blood pressure (either ≥ systolic BP of 180 mmHg and/or diastolic BP of 120 mmHg)
        • evidence of end-organ damage
  • Epidemiology
    • incidence
      • approximately 4-5 cases per 1,000 emergency department visits
        • 25% of these are hypertensive emergencies
        • some patients will present without a known history of hypertension
    • risk factors
      • poorly controlled hypertension
      • medication noncompliance
      • sedentary lifestyle
  • Pathophysiology
    • blood pressure values
      • normal BP
        • ≤ 120/80 mmHg
      • elevated BP
        • 120-129 / < 80 mmHg
      • stage 1 hypertension
        • 130-139 / 80-89 mmHg
      • stage 2 hypertension
        • 140-159 / > 90mmHg
      • hypertensive crisis
        • >180 / 120 mmHg
    • pathophysiologic mechanisms
      • failure of autoregulatory mechanisms in the vascular supply
        • inappropriately increased vascular resistance 
          • can lead to endothelial damage
      • activation of the renin-angiotensin-aldosterone system
        • increases peripheral vasoconstriction
  • Prognosis
    • prognostic variable
      • unfavorable
        • elevated troponin levels
    • survival with treatment
      • < 10% overall
      • survival is better in patients with hypertensive urgency compared to those with hypertensive emergency
Presentation
  • Symptoms
    • can be asymptomatic, especially in those with hypertensive urgency
    • common symptoms
      • headache (most common complaint)
      • chest pain
      • dyspnea
      • focal neurologic deficits
      • altered mental status
      • delirium
      • seizures
      • nausea/vomiting
  • Physical exam 
    • BP > 180/120 mmHg, multiple measurements aid in making the diagnosis
    • funduscopic exam 
      • papilledema
      • flame hemorrhages
      • cotton wool spots
    • neurologic exam 
      • weakness
      • paralysis
      • paresthesias
      • visual field changes
      • cranial nerve deficits
    • cardiac exam
      • S3
      • jugular venous distention
    • pulmonary exam
      • crackles
      • dullness at lung bases
Studies
  • Diagnostic testing decisions should be guided by the findings on history and physical exam, as well as the presence or absence of risk factors 
    • no symptoms and low risk
      • urinalysis to screen for proteinuria
    • no symptoms and moderate to high risk
      • urinalysis to screen for proteinuria
      • basic metabolic panel to screen for changes in creatinine levels
    • presence of chest pain, arrhythmias, or shortness of breath
      • electrocardiogram (ECG)
      • troponin and CK-MB, if ECG is abnormal or changed from prior ECGs
    • presence of focal neurologic changes
      • non-contrast computerized tomography (CT) scan of the head
Differential
  • Acute ischemic stroke
    • differentiating factor
      • patients may have evidence of infarction on CT head (e.g., hypodensity, loss of gray-white differentiation, or evidence of a hyperdense vessel)
  • Hemorrhagic stroke
    • differentiating factor
      • hyperdensity on CT head 
Treatment
  • Treatment goals
    • reduce BP by 10-20% within the first hour and another 5-15% within the next 24 hours 
      • more rapid BP reduction may lead to stroke from a decrease in cerebral perfusion 
      • exceptions to gradual BP reduction
        • acute ischemic stroke
          • BP only treated if above 185/110 mmHg in patients who are candidates for reperfusion therapy and 220/120 mmHg in those who are not candidates for reperfusion therapy
        • aortic dissection
          • SBP target 100-120 mmHg within 20 minutes 
  • Conservative
    • antihypertensive agents
      • indications
        • all patients in hypertensive crisis should receive antihypertensive agents to lower BP
      • intravenous agents can be used if oral medications are ineffective
        • β-blockers
          • labetalol is commonly used due to non-selective β-antagonism and α1-antagonism 
          • esmolol (rapid onset/offset) 
        • calcium channel blocker
          • nicardipine
          • clevidipine
        • nitrates
          • nitroprusside
          • nitroglycerin
Complications
  • Death
  • Sequelae of end-organ damage
    • blindness
    • stroke
    • acute kidney injury
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.CV.15.42) A 57-year-old woman presents to the emergency room with complaints of severe headache, vomiting, neck stiffness, and chest pain that have developed over the last several hours. Her past medical history is notable for diabetes, hypertension, and dyslipidemia. Her temperature is 99.0°F (37.2°C), blood pressure is 197/124 mm Hg, pulse is 120/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical examination is significant for papilledema. Urinalysis reveals gross hematuria and proteinuria. Which of the following is the next best step in management for this patient? Review Topic | Tested Concept

QID: 103333
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Esmolol

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Hydralazine

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Lisinopril

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Nitroprusside

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Propranolol

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