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What is a hypertensive emergency? What are the symptoms of a hypertensive emergency? How does the doctor treat a hypertensive emergency? Hypertensive Urgency Hypertensive urgency occurs when blood pressure spikes but there is no damage to the body's organs. Blood pressure can be brought down safely within a few hours with blood pressure medication. Hypertensive Emergency What is a hypertensive emergency? A person with a hypertensive emergency has damage to the brain, heart, kidneys or eyes, caused by severely elevated blood pressure. In hypertensive urgency, the systolic blood pressure (top number) is over 220 or the diastolic blood pressure (bottom number) is over 115. Hypertensive emergency requires immediate treatment, before it causes permanent damage to the brain, heart, kidneys, or the retina of the eye. Hypertensive emergency means blood pressure is so high that organ damage can occur. Blood pressure must be reduced immediately to prevent imminent organ damage. This is done in an intensive care unit of a hospital. Organ damage associated with hypertensive emergency may include: Changes in mental status such as confusion Bleeding into the brain (stroke) Heart failure Chest pain (unstable angina) Fluid in the lungs (pulmonary edema) Heart attack Aneurysm (aortic dissection ) Eclampsia (occurs during pregnancy) Hypertensive emergency is rare. When it does occur, it is often when hypertension goes untreated, if the patient does not take his or her blood pressure medication, or he or she has taken an over-the-counter medication that exacerbates high blood pressure. Symptoms of Hypertensive Emergency Symptoms of a hypertensive emergency include: Headache or blurred vision Increasing confusion or level of consciousness Seizure Increasing chest pain Increasing shortness of breath Swelling or edema (fluid buildup in the tissues) Diagnosing Hypertensive Emergency To diagnose a hypertensive emergency, the health care provider will ask you several questions to get a better understanding of your medical history. He or she will also need to know all medications you are taking including nonprescription and recreational drugs. Also, be sure to tell them if you are taking any herbal or dietary supplements. Certain tests will be given to monitor blood pressure and assess organ damage, including: Regular monitoring of blood pressure Eye exam to look for swelling and bleeding Blood and urine testing What are the symptoms of a hypertensive emergency? Symptoms of a hypertensive emergency include a systolic blood pressure that is typically over 220 and a diastolic blood pressure that is over 120. Other symptoms include chest pain, severe headache, shortness of breath, poor balance or coordination, severe weakness, blurry vision, and loss of vision. How does the doctor treat a hypertensive emergency? What's the Treatment for Hypertensive Emergency and Associated Organ Damage? In a hypertensive emergency, the first goal is to bring down the blood pressure as quickly as possible with intravenous (IV) blood pressure medications to prevent further organ damage. Whatever organ damage that has occurred is treated with therapies specific to the organ that is damaged. A hypertensive emergency is severe hypertension with signs of damage to target organs (primarily the brain, cardiovascular system, and kidneys). Diagnosis is by BP measurement, ECG, urinalysis, and serum BUN and creatinine measurements. Treatment is immediate BP reduction with IV drugs (eg, nitroprusside, β - blockers, hydralazine). Target-organ damage includes hypertensive encephalopathy, preeclampsia and eclampsia, acute left ventricular failure with pulmonary edema, myocardial ischemia, acute aortic dissection, and renal failure. Damage is rapidly progressive and often fatal. Hypertensive encephalopathy may involve a failure of cerebral autoregulation of blood flow. Normally, as BP increases, cerebral vessels constrict to maintain constant cerebral perfusion. Above a mean arterial pressure (MAP) of about 160 mm Hg (lower for normotensive people whose BP suddenly increases), the cerebral vessels begin to dilate rather than remain constricted. As a result, the very high BP is transmitted directly to the capillary bed with transudation and exudation of plasma into the brain, causing cerebral edema, including papilledema. Pathophysiology of other target-organ manifestations is discussed elsewhere in The Manual. Although many patients with stroke and intracranial hemorrhage present with elevated BP, elevated BP is often a consequence rather than a cause of the condition. Whether rapidly lowering BP is beneficial in these conditions is unclear; it may even be harmful. Hypertensive urgencies: Very high blood pressure (eg, diastolic pressure > 120 to 130 mm Hg) without target-organ damage (except perhaps grades 1 to 3 retinopathy—see Hypertension: Diagnosis) may be considered a hypertensive urgency. BP at these levels often worries the physician; however, acute complications are unlikely, so immediate BP reduction is not required. However, patients should be started on a 2-drug oral combination (see Hypertension: Drugs for Hypertension), and close evaluation (with evaluation of treatment efficacy) should be continued on an outpatient basis. Symptoms and Signs BP is elevated, often markedly (diastolic pressure > 120 mm Hg). CNS symptoms include rapidly changing neurologic abnormalities (eg, confusion, transient cortical blindness, hemiparesis, hemisensory defects, seizures). Cardiovascular symptoms include chest pain and dyspnea. Renal involvement may be asymptomatic, although severe azotemia due to advanced renal failure may cause lethargy or nausea. Physical examination focuses on target organs, with neurologic examination, funduscopy, and cardiovascular examination. Global cerebral deficits (eg, confusion, obtundation, coma), with or without focal deficits, suggest encephalopathy; normal mental status with focal deficits suggests stroke. Severe retinopathy (sclerosis, cotton-wool spots, arteriolar narrowing, hemorrhage, papilledema) is usually present with hypertensive encephalopathy, and some degree of retinopathy is present in many other hypertensive emergencies. Jugular venous distention, basilar lung crackles, and a 3rd heart sound suggest pulmonary edema. Asymmetry of pulses between arms suggests aortic dissection. Diagnosis Very high BP Identify target-organ involvement: ECG, urinalysis, BUN, creatinine; if neurologic findings, head CT Testing typically includes ECG, urinalysis, and serum BUN and creatinine. Patients with neurologic findings require head CT to diagnose intracranial bleeding, edema, or infarction. Patients with chest pain or dyspnea require chest x-ray. ECG abnormalities suggesting target-organ damage include signs of left ventricular hypertrophy or acute ischemia. Urinalysis abnormalities typical of renal involvement include RBCs, RBC casts, and proteinuria. Diagnosis is based on the presence of a very high BP and findings of target-organ involvement. Treatment Admit to ICU Short-acting IV drug: nitrate, fenoldopam, labetalol Goal: 20 to 25% reduction MAP in 1 to 2 h Hypertensive emergencies are treated in an ICU; BP is progressively (although not abruptly) reduced using a short-acting, titratable IV drug. Choice of drug and speed and degree of reduction vary somewhat with the target organ involved, but generally a 20 to 25% reduction in MAP over an hour or so is appropriate, with further titration based on symptoms. Achieving “normal” BP urgently is not necessary. Which of the following drugs should not be used to treat hypertensive emergency? Sublingual Nifedipine Labetolol ACE Inhibitors Nicardipine 1 and 3 Which of the following drugs should be avoided in sympathetic crises with hypertensive emergency? Phentolamine Benzodiazepine Labetolol Nicardipine Fenoldopam |