Clinical Notes : Cardiovascular Disease

3. Hypertensive Urgency and Emergency

Hypertensive emergency, a life-threatening complication of high blood pressure, may signify a patient's first presentation for hypertension.

In both GP practice and OOH settings, clinicians must be able to distinguish between hypertensive urgency and true hypertensive emergency, to decide on immediate management or referral .

The 2018 ESC/ESH Guidelines for the management of arterial hypertension are designed for adults with hypertension, i.e. aged ≥18 years.

 

 

New Terminology and Classification

 

The terms malignant hypertension, hypertensive crisis, and accelerated hypertension have been replaced by hypertensive urgency or hypertensive emergency. Hypertensive urgency and emergency are differentiated by the absence or presence of acute end-organ damage, respectively.

 

Hypertensive urgency is defined as a diastolic blood pressure of 110 mm Hg or greater without the acute signs of end-organ damage.(7)

 

Hypertensive emergency is defined as the presence of acute and rapidly evolving end-organ damage with severe hypertension (grade 3).

Preeclampsia and eclampsia are also considered manifestations of hypertensive end-organ damage (5,11)

 
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Most hypertensive urgencies or emergencies are preventable and are the result of inadequate treatment of mild to moderate hypertension or nonadherence to antihypertensive therapy (2,3)

 

The most common form of organ damage associated with hypertension is ischemic heart disease, in the form of either heart failure or acute coronary syndrome.(12)

 

Patients with chronically elevated blood pressures have a compensatory response that protects against end-organ damage. Acute changes in blood pressure are better tolerated in these patients because of their decreased propensity for hypoperfusion (4)

In contrast, normotensive patients who experience precipitous changes in blood pressure are at increased risk for organ hypoperfusion. The main concern regarding organ hypoperfusion is that it can lead to ischemia (4)

The most common emergency symptoms will depend of the organs affected but may include headache, visual disturbances, chest
pain, dyspnoea, dizziness, and other neurological deficits.

In patients with hypertensive encephalopathy, the presence of somnolence, lethargy, tonic clonic seizures, and cortical blindness may precede a loss of consciousness; however, focal neurological lesions are rare and should raise the suspicion of stroke (19).

 

History

 

Ask about :

  • normal blood pressure range

  • medication compliance

    • rebound hypertension can be seen in patients who abruptly discontinue medications such as clonidine or β-blockers (9,15)

  • OTC medications and other drug use

    • including cocaine, methamphetamines, phencyclidine, and alcohol (1,4 11,16)

  • monoamine oxidase inhibitors (MAOIs)

    • should avoid other antidepressants, as this can lead to a hypertensive reaction, but also to serotonin syndrome (1,17)

    • should avoid tyramine-containing foods and herbal supplements (including, but not limited to, St. John's wort, ginseng, and yohimbine).(1, 15,18)

  • medical conditions predisposing to hypertensive crisis

    • preeclampsia or eclampsia in pregnant women

    • pheochromocytoma

    • primary aldosteronism

    • glucocorticoid excess (Cushing syndrome)

    • central nervous system disorders (eg, cerebrovascular accident, head trauma, brain tumors)​​

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Physical Examination

 

Confirm hypertension :

  • repeat the blood pressure measurement after 2 minutes

  • confirm the value obtained in the opposite arm from where the initial reading was taken

 

The purpose of the physical examination is to determine whether end-organ damage is present (1,11)

 

is wise to specifically look for and record the presence or absence of :

  • Fundoscopic exam

    • papilledema is a sign of increased intracranial pressure (ICP) (7)

    • flame hemorrhages, cotton wool spots or arteriovenous nicking suggest a long-standing history of uncontrolled hypertension or diabetes (9)

  • Neck

    • jugular venous distention, may be elevated in decompensated heart failure or pulmonary edema (11)

  • Cardiac exam

    • look for irregular rate and rhythm, displaced apical pulse, gallop or murmur (9)

  • Pulmonary exam

    • look for pulmonary edema (15)

  • Abdominal exam

    • auscultate for renal artery bruit (1)

  • Neurologic exam

    • altered mental status, possibly indicating hypertensive encephalopathy (9)

    • focal findings, if the patient has had an underlying ischemic or hemorrhagic event (9)

Laboratory studies and imaging

 

  • Urinalysis

    • Proteinuria, possibly indicating renal damage (4,9,15)

In OOH setting, refer to A+E :

  • suspected renal damage, for serum chemistry panel (4)

  • chest pain, for serial cardiac enzymes (15)

  • shortness of breath and/or chest pain, for CXR (4,15)

  • headache with neurologic abnormalities, for CT head (15)

  • suspected illicit drug use, for drug screening (12)

 
 

Treatment

 

Elevated blood pressure may be a reaction to pain or stress and may be best treated alternatively.

Consider a brief period of rest in the OOH service, with review of BP when calm and settled, before considering medication.

 

Generally the aim of treatment is for

  • reduction in mean arterial blood pressure of no more than 10% to 25% within the first hour

  • goal blood pressure of 160/90 mm Hg within the first 8 hours

  • normalization of blood pressure over 8 to 24 hours (12)

 
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Treatment : hypertensive urgency

 

Although elevated blood pressures can be alarming to the patient, hypertensive urgency usually develops over days to weeks (8)

In this setting, it is not necessary to lower blood pressure acutely (12)

A rapid decrease in blood pressure can actually cause symptomatic hypotension, resulting in hypoperfusion to the brain (5,6,8) and other organs, escalating the condition to hypertensive emergency.

 

The most commonly used oral agents include captopril, clonidine and labetalol (14)

Where capotopril is not available, consider furosemide.

  • Captopril (12,5-25mg)

    • an angiotensin-converting enzyme inhibitor

    • well tolerated

    • given by mouth, captopril is usually effective within 15-30 minutes and may be repeated in 1-2 hours depending upon the response (13)

    • administered sublingually, the onset of action may occur within 10-20 minutes, with the maximal effect reached within 1 hour.

    • administration may lead to acute renal failure in patients with bilateral renal artery stenosis, and reflex tachycardia may be observed.

    • responsiveness can be enhanced by the administration of a loop diuretic, such as furosemide

  • Clonidine

    • drowsiness affect up to 45% of patients

    • dry mouth and light-headedness also common

    • contraindicated in pts with sinus bradycardia, sick sinus synd., or heart block

    • requires ECG prior to administration and cardiac monitoring during administration

    • best avoided in GP led OOH service

  • Labetalol

    • like any b blocking agent, it has the potential to induce heart block and to worsen symptoms of bronchospasm

    • adverse effects: bradycardia

    • requires cardiac monitoring during administration

    • best avoided in GP led OOH service

  • Furosemide (20-40mg PO)

    • do not administer IV in the OOH setting

 

 

Treatment : hypertensive emergency

 

Refer all cases to A+E for evaluation and management.

A+E treatment of hypertensive emergency is tailored to the specific underlying end organ damage (5,11).

 
 
 
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journals.png
 

1.  Marik PE, Varon J.

Hypertensive crises: challenges and management.

Chest. 2007;131(6): 1949-1962.

View/access

2.  Ferguson RK, Vlasses PH.

How urgent is "urgent" hypertension? [editorial].

Arch Intern Med. 1989;149:257-258.Cardiol. 2012;60(7):599-606.

 

3.  Zeller KR, Kunert LV, Matthews C.

Rapid reduction of severe asymptomatic hypertension; a prospective, controlled trial.

Arch Intern Med. 1989;149:2186-2189.

 

4.  Aggarwal M, Khan I.A.

Hypertensive crisis: hypertensive emergencies and urgencies.

Cardiol Clin. 2006;24(1):135-146.

View/access

5.  Chobanian AV, Bakris GL, Black HR, et al.

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

JAMA. 2003;289(19):2560-2572.

View/access

6.  National High Blood Pressure Education Program Coordinating Committee, National Heart Lung and Blood Institute, NIH. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Hypertension. 2003 Dec;42(6):1206-52.

View/access

7.  Houston M.

 Hypertensive emergencies and urgencies: pathophysiology and clinical aspects.

Am Heart J. 1986;111(1):205-210.

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8.  Kessler CS, Joudeh Y.

Evaluation and treatment of severe asymptomatic hypertension.

Am Fam Physician. 2010;81(4):470-476.

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9.  Vaidya CK, Ouellette J.R.

Hypertensive urgency and emergency.

Hosp Physician. Mar 2007:43-50.

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10.  Perez MI, Musini V.M.

Pharmacological interventions for hypertensive emergencies: a Cochrane systematic review.

J Hum Hypertens. 2008;22(9):596-607.

View/access

11.  Vaughan CJ, Delanty N.

Hypertensive emergencies.

Lancet. 2000;356(9227):411-417.

View/access

12.  Stewart DL, Feinstein SE, Colgan R.

Hypertensive urgencies and emergencies.

Prim Care. 2006; 33(3):613-623.

 

13.  Biollaz J, Waeber B, Brunner HR.

Hypertensive crisis treated with orally administered captopril.

Eur J Clin Pharmacol. 1983;25:145-149.

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14.  Varon J.

Treatment of acute severe hypertension: current and newer agents.

Drugs. 2008;68(3): 283-297.

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15.  Haas AR, Marik PE.

Current diagnosis and management of hypertensive emergency.

Semin Dial. 2006;19(6):502-512.

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16.  Hebert CJ, Vidt DG.

Hypertensive crises.

Prim Care. 2008;35(3):475-487.

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17.  Shulman KI, Fischer HD, Herrmann N, et al.

Current prescription patterns and safety profile of irreversible monoamine oxidase inhibitors: a population-based cohort study of older adults.

J Clin Psychiatry. 2009;70(12):1681-1696.

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18.  Musso NR, Vergassola C, Pende A, Lotti G.

Yohimbine effects on blood pressure and plasma catecholamines in human hypertension.

Am J Hypertens. 1995;8(6):565-571.

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19. Bryan Williams et al

2018 ESC/ESH Guidelines for the management of arterial hypertension,

European Heart Journal, Volume 39, Issue 33,

1 September 2018, Pages 3021–3104

View/access

Ireland notes.png

The following are available in Ireland :

captopril (Aceomel, Capoten, Captor)

clonidine (Catapres, Dixarit)

labetalol (Trandate)

furosemide (Lasix)

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