Stat Consult: Hypertensive emergency/ hypertensive urgency
- Hypertensive emergency is defined as BP >180/120 mm Hg with end-organ dysfunction.
- Hypertensive urgency is defined as severe BP elevation without evidence of end-organ dysfunction.
- Hypertensive crisis
- Malignant hypertension
- 401.0 malignant essential hypertension
- 405.0 malignant secondary hypertension
- 1%-2% of patients with hypertension
- More common in
- New onset or complication of essential or secondary hypertension
-- Medication nonadherence
-- Use of monoamine oxidase inhibitor
-- Recreational drug use
-- Acute postoperative hypertension
- Ineffective outpatient BP control
- Patient noncompliance with hypertension treatment
- Lack of primary-care provider
- End-organ damage may include
-- Intracerebral hemorrhage
-- Acute myocardial infarction
-- Unstable angina
-- Acute heart failure
-- Pulmonary edema
-- Dissecting aortic aneurysm
-- Acute renal failure
- Hypotension may be a complication of aggressive treatment.
- Patient may complain of
-- Chest pain
-- Neurologic deficit
- Most patients have persistently elevated BP for years before presenting with hypertensive emergency.
- Review medications, adherence, and time from last dose
- Ask about recreational drug use (e.g., amphetamines, cocaine, phencyclidine [PCP]).
- Confirm BP on both arms using a properly sized BP cuff.
- Check pulses in all extremities.
- Perform physical exam to evaluate for end-organ damage and to differentiate between hypertensive emergency and hypertensive urgency (no end-organ dysfunction).
-- Funduscopic exam (assess for arteriolar changes, hemorrhages, exudates, papilledema)
-- Cardiac exam (assess for murmurs and gallops)
-- Lung exam (assess for pulmonary edema)
-- Abdominal exam (assess for bruits, aortic aneurysm)
-- Neurologic exam (check mental status, lateralizing signs may suggest vascular event)
Making the diagnosis
- Hypertensive emergency—BP >180/120 mm Hg with evidence of end organ dysfunction
- Hypertensive urgency—severe BP elevation without evidence of end-organ dysfunction
- Subarachnoid hemorrhage—consider in patients with sudden onset of severe headache
- Stroke—consider if focal neurologic findings, especially lateralizing signs
Testing to consider
- Blood chemistries (electrolytes, blood urea nitrogen, creatinine)
- Complete blood count
- Consider cardiac biomarkers if cardiac ischemia suspected
- Consider toxicology screen
- Imaging based on clinical picture for specific conditions (e.g. chest x-ray, if dyspnea or chest pain)
- Hypertensive urgency (no evidence of end organ damage)
-- Observe for several hours following administration of antihypertensives
-- Medication options include
- Nicardipine 5 mg/hour orally, should be increased by 2 mg/hour every 15 minutes, maximum dose 15 mg/hour
- Captopril 25 mg orally two to three times daily
- Clonidine: Adults—initial dose 0.1-0.2 mg orally, then 0.05-0.2 mg every hour up to total dose of 0.5-0.7 mg as needed; Children aged 1-17 years—initial dose 0.05- 0.1 mg orally, repeat up to maximum 0.8 mg
- Labetalol dose options include: initial dose 20-80 mg IV, then additional 40- 80 mg dose (range 20-80 mg) at 10-minute intervals until desired BP achieved; initial dose 0.5-2 mg IV infusion, adjust as required; initial dose 200 mg oral, then additional 200- 400 mg dose after six to 12 hours as needed .
- Hypertensive emergency (end-organ damage)
- Admit to intensive care unit and treat with IV antihypertensives.
- Continuous BP monitoring (consider intra-arterial blood pressure monitoring)
- Give IV saline if volume depleted.
- In most cases, lower diastolic pressure by 10%-15% over the first hour.
- Choosing BP lowering medications and BP goal depends on target organ with dysfunction.
-- Acute aortic dissection
- Lower systolic pressure to <120 mm Hg rapidly (i.e., five to 10 minutes)
- Options include beta blockers (esmolol [Brevibloc], metoprolol [Lopressor, Toprol]) and vasodilators (nicardipine [Cardene], nitroprusside, fenoldopam [Corlopam])
-- Ischemic Stroke
- For thrombolysis candidates
- IV therapy is indicated for patients if systolic pressure is >185 mm Hg or diastolic pressure is >110 mm Hg.
- BP should be maintained at <180/105 mm Hg for at least first 24 hours after thrombolysis.
- Options include labetalol [Normodyne, Trandate], nicardipine, or nitroglycerin topical ointment.
- For patients not able to have thrombolysis
- Lowering BP (by 15%-25% in first 24 hours) is indicated if systolic pressure is >220 mm Hg or diastolic pressure is >120 mm Hg.
- Options include labetalol, nicardipine.
-- Acute hemorrhagic stroke
- The goal of BP lowering depends on how elevated BP is and whether there is elevated intracranial pressure.
- Options include enalaprilat [Vasotec], esmolol, hydralazine [Apresoline], labetalol, nitroglycerin, nicardipine.
-- Hypertensive encephalopathy
- Treat promptly, as delay can lead to seizures and neurologic deficits.
- Lower mean arterial pressure by 20%-25% in the first hour
- Targets are then systolic pressure of 160 mm Hg and diastolic pressure of 90-100 mm Hg.
- If patient is tolerating treatment, gradually lower BP further over next 24 hours.
- Options include IV labetalol or nicardipine.
- Avoid nitroprusside, which might increase intracranial pressure.
-- Acute myocardial ischemia
- Nitroglycerin drug of choice
- Treatment alternatives include labetalol, esmolol, clevidipine [Cleviprex], nicardipine.
-- Acute pulmonary edema
- Options include nitroglycerin, nitroprusside, furosemide [Delone, Furocot, Lasix, Lo-Aqua].
-- Acute renal failure
- Options include nicardipine, fenoldopam, clevidipine.
- Initiate antihypertensive treatment when diastolic blood pressure is ≥105-110 mm Hg.
- Maintain systolic BP 130-160 mm Hg and diastolic BP 80-110 mm Hg.
- Options include labetalol, hydralazine, nifedipine.
- Treatment usually also includes magnesium sulfate for seizure prevention.
-- Sympathetic crisis (e.g., cocaine overdose)
- Avoid beta-blockers, which might lead to increased BP.
- Options include nicardipine, diltiazem, phentolamine, verapamil [Calan, Covera, Isoptin, Verelan].
- Consider treatment with benzodiazepine in addition to antihypertensive medication.
-- Acute postoperative hypertension
- Usually starts less than two hours after surgery and lasts six hours or more.
- No consensus regarding treatment threshold (except cardiac surgery patients where treatment recommended for BP >140/90 mm Hg or MAP ≥105 mm Hg)
- Options include esmolol, nicardipine, clevidipine, labetalol, nitroprusside.
-- Transition to oral therapy as soon as possible after BP stabilization
Brian Randall, MD, is a clinical editor for DynaMed, a database of comprehensive updated summaries covering more than 3,200 clinical topics, and Assistant Clinical Professor of Family Medicine at Tufts University School of Medicine.