Hypertensive Emergency

Hypertensive Emergency
Terminology
End Organ Dysfunction (EOD) = Target Organ Damage (TOD)
Hypertensive emergency = Hypertensive crisis =Malignant Hypertension =
Accelerated hypertension
Hypertensive urgency = High Numbers = High Blood pressure = markedly elevated
BP
Pathogenesis:
The pathologic hallmark of malignant hypertension is fibrinoid necrosis of the
arterioles, which
occurs systemically, but specifically in the kidneys. These patients develop fatal
complications if
untreated.
Hypertensive emergencies
spectrum of clinical presentations in which uncontrolled blood
pressures
(BPs) lead to progressive or impending end-organ dysfunction. In
these conditions, the BP should be lowered aggressively over minutes
to hours.
TOD
- Brain ------
 Hypertensive encephalopathy
 cerebral vascular accident/cerebral infarction
 subarachnoid hemorrhage
 intracranial hemorrhage. [1]
TOD
- Heart -----
 myocardial ischemia/infarction
 acute left ventricular dysfunction
 acute pulmonary edema
 aortic dissection
TOD
- Kidney ---- Acute kidney injury / Failure
- Eye ---- Retinopathy

- Others: Eclampsia and microangiopathic hemolytic anemia
History and Examination:
Importantly:
ALWAYS Ask why Patient had high blood pressure??? Etiology
Keep patient calm for 10-20 minutes and repeat BP measurement
BP should in both the supine position and the standing position (assess
volume depletion)
BP should be measured in both arms (a significant difference may
suggest
aortic dissection).
The history and the physical examination are the corner stone
management
The history should focus on the presence of end-organ dysfunction to
differentiate
between Emergency and Urgency.
So, we will look for symptoms and signs according to TOD:
Neuro.:
- Acute Confusion or deterioration of Mental status
-Headache, vomiting
- Weakness, mouth deviation
- Speech problems like slurring or aphasia
- uncontrolled abnormal movements
- acute abnormal behavior
- FAST assessment for stroke patient
Cardiovascular:
-Acute chest pain, severe, tearing (hx to differentiate if significant symptom
or not)
-Breathing difficulty, sweating
-Orthopnea and irritability
- Jugular venous distention, crackles on auscultation, and peripheral edema.
- Abdominal masses or bruits may be noted.
Others:
-Confusion, decreased urine output and edema
- Impaired renal function, with hematuria
-Impaired vision and visual fields
- new retinal hemorrhages, exudates, or papilledema
-pregnant --- post-delivery (s&s of preeclampsia)
Evaluation of uncontrolled hypertension
Importantly: All work up should be according to findings in history and
Examination
 Electrolyte levels, (BUN) and creatinine levels to evaluate for renal
impairment.
 A dipstick urinalysis to detect hematuria or proteinuria and
microscopic
urinalysis to detect red blood cells (RBCs) or RBC casts should also be
performed.
 A complete blood cell (CBC) count.
 toxicology screen if the hx and examination were suggestive.
 pregnancy test, and endocrine testing may be obtained, as needed.
Imaging should be directed by the clinical presentation
- Chest X-Ray in case of pulmonary edema, Aortic Dissection
- Brain CT scan initially in case of neurological S&S
 Electrocardiography (ECG) if there is S&S of cardiac involvement
Cardiac work up if indicated, No Trop I for all patient.
 But please remember In ED patients with asymptomatic markedly
elevated BP, routine ED medical intervention and routine screening for
acute target-organ injury is not required.
Hypertensive urgencies
Referred as severe blood pressure (BP) elevations (>180/120 mm Hg) without
acute end-organ damage … AHA guidelines 2017 ---- “markedly elevated BP.”
do not mandate admission to a hospital

The goal of therapy is with these cases is to reduce BP within 24 hours or more,
which can be achieved on an outpatient basis.
Example during Covid vaccine many patients referred to ED for incidental high blood
pressure readings
Furthermore,
Overly aggressive treatment of severe uncomplicated hypertensive urgency
can lead to cumulative effects causing hypotension and vita tissues
hypoperfusion.
Acutely lowering BP in the ED for clinical situations other than those listed below
is controversial and generally should be avoided.
Treatment of Hypertensive Emergencies
Good percentage of hypertensive patients have at least 1 incidence of high
blood pressure.
- The fundamental principle in determining the necessary ED care of the
hypertensive patient is the presence or absence of end-organ dysfunction
- The primary goal of the emergency physician is to determine which patients
with acute hypertension are exhibiting symptoms of end-organ damage and
require immediate intravenous (IV) parenteral therapy.
- In contrast, patients presenting with acutely elevated BP (systolic BP [SBP]
>200 mm Hg or diastolic BP [DBP] >120 mm Hg) without symptoms and
whose BP stays significantly elevated to this level on discharge should
have initiation of medical therapy and close follow-up in the outpatient
setting, with BP reduction over hours or days.
Treatment of Hypertensive Emergencies
- Many patients present to the ED with elevated BPs; however, only a
small
proportion of patients will require emergency treatment.
- An important point to remember in the management of the patient with
any
degree of BP elevation is to "treat the patient and not the
number."
- Gradual lowering of the BP is crucial to preventing cerebral ischemia as
a
result of autoregulatory mechanisms. [7]
Pharmacotherapy
- Optimal pharmacotherapy is dependent upon the specific organ at risk.
- Admission to ICU and parenteral administration of appropriate agent when
there’s indications like:
 Aortic Dissection ----- <120
 Acute Coronary Syndrome --- glycerin
 Acute heart Failure, overloaded ---- Diuretic
 Severe pre-eclampsia and eclampsia (fit) ---- MGSO4
 Pheochromocytoma --- Selective alpha1 blocking agents, such as
prazosin -- unopposed alpha-adrenergic receptor stimulation can
precipitate a hypertensive crisis.
 Cerebral Hemorrhage --- Labetalol
 Hypertensive encephalopathy ---- Labetalol

 Acute ischemic stroke for thrombolytic therapy only ----- <180/105
Pharmacotherapy
- Other Cases with hypertensive emergency which not necessitate rapid
decrease in BP like in acute ischemic stroke or acute renal insufficiency.
Guidelines
- 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation,
and
Management of High Blood Pressure in Adults
- The European Society of Hypertension (ESH)/European Society of
Cardiology (ESC) guidelines
- American College of Emergency Physicians (ACEP)
Take home messages
 Early triage is required to determine which patients with acute
hypertension are exhibiting symptoms of end-organ damage and require
immediate intravenous parenteral antihypertensive therapy.
 In patients with asymptomatic markedly elevated BP, routine ED medical
intervention is not required.
 In ED patients with asymptomatic markedly elevated BP, routine screening
for acute target-organ injury (eg, serum creatinine, urinalysis,
electrocardiography [ECG]) is not required.
Take home messages
 In select patient populations (eg, those with poor follow-up), screening for
an
elevated serum creatinine level may identify kidney injury that affects
disposition.
 In select patient populations (eg, those with poor follow-up), emergency
physicians may treat markedly elevated BP in the ED and/or initiate therapy
for long-term control (consensus recommendation)
 Patients with asymptomatic markedly elevated BP should be referred for
outpatient follow-up (consensus recommendation)
References
1. Tintinallie’s Emergency Medicine comprehensive study guide.
2. Medscape.org
3. Arbe G, Pastor I, Franco J. Diagnostic and therapeutic approach to the hypertensive
crisis [English, Spanish]. Med Clin (Barc). 2017 Nov 24. [QxMD MEDLINE Link].
4. Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev. 2010 Mar-Apr.
18(2):102-7. [QxMD MEDLINE Link].
5. Amraoui F, Van Der Hoeven NV, Van Valkengoed IG, et al. Mortality and cardiovascular
risk in patients with a history of malignant hypertension: a case-control study. J Clin
Hypertens (Greenwich). 2014 Feb. 16(2):122-6. [QxMD MEDLINE Link].
References
1. Tintinallie’s Emergency Medicine comprehensive study guide.
2. Medscape.org
3. Arbe G, Pastor I, Franco J. Diagnostic and therapeutic approach to the hypertensive
crisis [English, Spanish]. Med Clin (Barc). 2017 Nov 24. [QxMD MEDLINE Link].
4. Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev. 2010 Mar-Apr.
18(2):102-7. [QxMD MEDLINE Link].
5. Amraoui F, Van Der Hoeven NV, Van Valkengoed IG, et al. Mortality and cardiovascular
risk in patients with a history of malignant hypertension: a case-control study. J Clin
Hypertens (Greenwich). 2014 Feb. 16(2):122-6. [QxMD MEDLINE Link].
References
6. Ipek E, Oktay AA, Krim SR. Hypertensive crisis: an update on clinical approach and
management. Curr Opin Cardiol. 2017 Jul. 32 (4):397-406. [QxMD MEDLINE Link].
7. Slovis CM, Reddi AS. Increased blood pressure without evidence of acute end organ
damage. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S7-9. [QxMD MEDLINE Link].
8. Misurac J, Nichols KR, Wilson AC. Pharmacologic management of pediatric
hypertension. Paediatr Drugs. 2016 Feb. 18 (1):31-43. [QxMD MEDLINE Link].
9. Stein DR, Ferguson MA. Evaluation and treatment of hypertensive crises in
children. Integr Blood Press Control. 2016 Mar 16. 9:49-58. [QxMD MEDLINE Link].
Image 1 stroke --- Yashoda hospital research center
MI ---- Apollo medics hospital

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Hypertensive Emergency

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Hypertensive Emergency

- Eye ---- Retinopathy

do not mandate admission to a hospital

 Hypertensive encephalopathy ---- Labetalol

Image 1 stroke --- Yashoda hospital research center

MI ---- Apollo medics hospital

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