Updated: 10/11/2020

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
    • hypertensive emergency
      • 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 
    • hypertensive urgency
      • no need to immediatley and rapidly lower blood pressure
      • more appropriate to give patient medications to chronically manage blood pressure (for example ACE inhibitors, beta blockers, or thiazide diuretics) 
  • 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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(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?

QID: 103333
1

Esmolol

100%

(1/1)

2

Hydralazine

0%

(0/1)

3

Lisinopril

0%

(0/1)

4

Nitroprusside

0%

(0/1)

5

Propranolol

0%

(0/1)

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