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) login to view 1 more bullet hypertensive emergency severely elevated blood pressure (either ≥ systolic BP of 180 mmHg and/or diastolic BP of 120 mmHg) login to view 1 more bullet 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 Etiology Pathophysiology blood pressure values normal BP login to view 1 more bullet elevated BP login to view 1 more bullet stage 1 hypertension login to view 1 more bullet stage 2 hypertension login to view 1 more bullet hypertensive crisis login to view 1 more bullet pathophysiologic mechanisms failure of autoregulatory mechanisms in the vascular supply login to view 2 more bullets activation of the renin-angiotensin-aldosterone system login to view 1 more bullet 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 login to view 6 more bullets 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 login to view 1 more bullet intravenous agents can be used if oral medications are ineffective login to view 9 more bullets Complications Death Sequelae of end-organ damage blindness stroke acute kidney injury 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