Hypertensive Crises: Urgencies and Emergencies

Approximately 74 million people in the United States have hypertension,     defined as a systolic blood pressure (BP) ≥140 mmHg or a diastolic BP ≥90 mmHg on at least two occasions.1,2 A severe, rapid elevation in BP is considered a hypertensive crisis. There are inconsistencies in the definition and the nomenclature of this condition. In addition, there is not an exact BP reading that constitutes a hypertensive crisis, although one report states that BP measurements >179/109 mmHg have been considered the threshold.3 It has been reported that approximately 27% of emergency room visits are due to hypertensive crises.4 This condition is divided into two categories based on the presence or absence of target organ damage.1 While end-organ damage occurs in a hypertensive emergency, a rapid and severe elevation in BP in the absence of organ injury is termed hypertensive urgency.

Clinical Presentation and Diagnosis
Patients presenting with hypertensive crisis typically have had either chronically elevated BP or may be completely unaware that they have hypertension. treatment regimens, and drug-induced etiologies have been attributed to its development.1,3,5,6 Being African American, elderly, male, and lacking a primary care physician have been identified as major risk factors for the development of hypertensive crisis.7,8 High grades of obesity, hypertensive heart disease, increased number of BP medications, and history of somatoform disorders have been identified as contributing factors; however, these factors should be studied further before concluding that they can increase the risk for development of a hypertensive crisis.5

Persons with hypertensive urgency may experience severe headache, shortness of breath, nosebleed, or anxiety.1 With hypertensive emergency, the clinical presentation will depend on the particular organ that is undergoing injury, in addition to other symptoms, such as headache.

A rapid but thorough assessment must be performed in order to differentiate between urgency and emergency. The clinician should inquire about use of all medications, including OTC and herbal therapies, and illicit drug use. Medication adherence, including time of last dose, should be evaluated in all patients previously diagnosed with hypertension. BP should be confirmed in both arms, using correct measurement techniques.9

Physical examination is an essential component of diagnosis. The examination should include assessment for signs indicative of heart failure, myocardial infarction, aortic dissection, hypertensive encephalopathy, cerebrovascular accident, renal failure, retinopathy, retinal hemorrhage, and papilledema.3 A CT scan, MRI, echocardiogram, or chest x-ray may also be necessary in assessing organ damage. Laboratory examination should include a metabolic panel, urinalysis, a complete blood count, and urine toxicology.

Treatment Approach: Hypertensive Urgency
Hypertensive urgencies may be treated in an outpatient facility with oral treatment consists of a slow lowering of BP over 24 to 48 hours.10 A reduction in BP of no more than 25% within the first 24 hours has been suggested.10 Adjusting current medication regimens to improve adherence or increasing the doses of current agents may be a sufficient management approach.11 However, additional agents may be necessary to attain desired results. Follow-up with the primary care provider within a week of the episode is necessary.11

First-line agents to use in hypertensive urgencies have not been clearly elucidated.11,12 Captopril, clonidine, and labetalol (TABLE 1) have predominantly been used in this condition. Although used in the past, sublingual or oral is no longer recommended due to its propensity to cause severe hypotension and organ ischemia.11


Treatment Approach: Hypertensive Emergency
Hypertensive emergency requires immediate medical attention, including admission to

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