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
QUESTIONS 1 of 3 1 2 3 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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 Type & Select Correct Answer 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) M 11 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic