▪️Acute End-organ damages:
• Brain (stroke, ICH, posterior reversible encephalopathy syndrome).
• Retina (hemorrhage, exudates, papilledema).
• Heart (ACS, ADHF)
• Large vessels (aortic dissection)
• Kidneys (AKI)
• Microvasscular (microangiopathic hemolytic anemia)
❗️Hypertensive emergencies are uncommon.
▪️︎The history and physical examination in patients presenting with a severely elevated BP (or an acute rise in blood pressure over a previously normal baseline, even if the presenting pressure is <180/120 mmHg) should raise suspicion about end-organ damage:
•Acute head injury or trauma▫️Other tests to evaluate the presence of organ damage:
•Generalized neurologic symptoms, such as agitation, delirium, stupor, seizures, or visual disturbances
•Focal neurologic symptoms that could be due to an ischemic or hemorrhagic stroke .
•Fresh flame hemorrhages, exudates (cotton-wool spots), or papilledema when direct funduscopy is performed.
•Nausea and vomiting, which may be a sign of increased ICP
•Chest discomfort or pain, which may be due to MI or aortic dissection
•Acute, severe back pain, which may be due to aortic dissection
•Dyspnea, which may be due to pulmonary edema
•Pregnancy, as such patients with severe hypertension could have preeclampsia
•Use of drugs that can produce a hyperadrenergic state, such as cocaine, amphetamine(s), phencyclidine, or recent discontinuation of clonidine.
•ECG
•CXR
•Urinalysis, urine pregnancy test (if appropriate)
•Serum electrolytes and serum creatinine
•Cardiac biomarkers (if ACS suspected)
•Brain CT or MRI(if head injury, neurologic symptoms, hypertensive retinopathy, nausea, or vomiting)
•Contrast-enhanced CT or MRI of the chest or TEE (if aortic dissection is suspected, although rapid blood pressure lowering need not be delayed in such patients while awaiting the results of imaging).
▪️︎Goal of the treatment:(NEJM)
For most hypertensive emergencies, mean arterial pressure should be reduced gradually by approximately 10 to 20 percent in the first hour and by a further 5 to 15 percent over the next 23 hours. This often results in a target blood pressure of <180/<120 mmHg for the first hour and <160/<110 mmHg for the next 23 hours.
▫️The major exceptions to gradual BP lowering over the first day are:
• Acute phase of an ischemic stroke – The blood pressure is usually not lowered unless it is ≥185/110 mmHg in patients who are candidates for reperfusion therapy or ≥220/120 mmHg in patients who are not candidates for reperfusion (thrombolytic) therapy.
•Acute aortic dissection – systolic should be rapidly lowered to a target of 100
to 120 mmHg (to be attained in 20 minutes) to reduce aortic shearin forces.
• ICH
▪️︎Treatment
e.g.
Labetolol: Initial bolus of 20 mg IV followed by 20 to 80 mg IV bolus every 10 min (maximum 300 mg)
or
0.5 to 2 mg/minute as IV loading infusion following an initial 20 mg IV bolus (max 300 mg).
✅ Hypertensive urgency (severe asymptomatic hypertension)
Most patients with significantly elevated blood pressure (systolic pressure ≥180 mmHg and/or
diastolic pressure ≥120 mmHg) have no acute, end-organ injury.These patients might have a mild headache, but no signs or symptoms of acute end-organ damage.
💡NEJM:
Patients without target-organ damage are usually asymptomatic.Symptoms, when present, may include headache, atypical chest pain, dyspnea, dizziness, lightheadedness, and epistaxis.
▪️When lowered over a period of hours:
Patients judged to be at high risk for imminent cardiovascular events due to severe hypertension, including those with known aortic or intracranial aneurysms.
▪️︎Short-term goal of treatment:
Reduce the blood pressure to ≤160/≤100 mmHg. However, the MAP should not be lowered by more than 25 to 30 percent over the first several hours.
▪️︎Treatment of severe asymptomatic hypertension:
Oral captopril: (if the patient is not volume overloaded)
12.5-25 mg PO; may repeat PRN
💡Nonadherence to medication is the important triger for a hypertensive crisis.
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