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Hypertensive Emergency & Urgency

Hypertensive Emergency & Urgency

When encountering a patient with significantly elevated blood pressure (often above 180/110 mmHg), it's crucial to distinguish between hypertensive emergency and urgency by assessing for target organ damage.

Evaluation for Hypertensive Emergency vs Urgency

  1. Symptoms Assessment:

  • Look for signs of target organ damage which may include headache, visual changes, chest pain, fatigue, numbness, weakness, altered mental status.

  • History: Ask about pre-existing hypertension, onset, duration of symptoms.

  • Elicit causes: Inquire about medication adherence, lifestyle changes, physical or psychological stress, pain, insomnia, and the use of medications like decongestants, NSAIDs, steroids, sympathomimetics, cocaine, etc.

  1. Physical Examination:

  • Vital Signs: Measure blood pressure in all four extremities.

  • Perform a cardiovascular and neurological exam, fundoscopy for retinal changes, and a 12-lead EKG.

  1. Investigations:

  • Basic labs: Complete Blood Count (CBC), fibrinogen, Creatinine (Cr), Electrolytes (Elyte), Lactate Dehydrogenase (LDH), Urinalysis (UA), Urine Pregnancy Test (UPT).

  • Additional tests based on suspicion: Troponin (for Acute Coronary Syndrome, Heart Failure), Chest X-Ray (CXR for volume overload), Echocardiogram (for Aortic Dissection, ACS, Heart Failure), CT/MRI (for CNS involvement), CT Angiography (for Aortic Dissection), Renal Ultrasound (for renal artery stenosis), and Urine drug screen (for methamphetamine/cocaine use).

Management of Hypertensive Emergency & Urgency

  • Hypertensive Emergency: Requires immediate BP reduction to prevent or limit target organ damage. This often involves IV antihypertensive therapy and close monitoring in an intensive care setting.

  • Hypertensive Urgency: Elevated BP without acute target organ damage. This can usually be managed with oral antihypertensives and does not typically require hospital admission.

The key in managing these conditions is the careful evaluation of target organ damage and the urgency of intervention required. The treatment approach should be individualized based on the patient's overall clinical presentation and underlying causes.


 

Hypertensive Emergency Definition: Elevated BP (unclear numbers, in some places uses BP≥180/110) but must have target organ damage (retina, brain, heart, large arteries, kidneys, uterus).

  • Important: Immediate BP reduction is necessary using IV anti-hypertensives, depending on the target organ damage (TOD) found.

Clinical Presentation of TOD, Findings, First-line Treatment (Alternative), Target BP, Timeline:

  • Malignant HT: Extremely high BP (often >200/120) with bilateral retinopathy, HF, DIC, TMA, Acute renal failure. Treat with Labetalol, Nicardipine (Nitroprusside). Aim to ↓MAP by 20-25% within a few hours.

  • Hypertensive Encephalopathy: Extremely high BP with seizures, stupor, cortical blindness, coma. Treat with Labetalol, Nicardipine (Nitroprusside). Aim to ↓MAP by 20-25% immediately.

  • Acute Ischemic Stroke with BP >220/120 mmHg (or >185/110mmHg if requiring thrombolytic): Sudden neurological deficit, AOC. Treat with Labetalol, Nicardipine (Nitroprusside). Aim to ↓MAP by 15% within 1 hour.

  • Acute Hemorrhagic Stroke with SBP >180 mmHg: Sudden neurological deficit, AOC. Treat with Labetalol, Nicardipine. Target SBP 130-180 mmHg immediately.

  • Acute Coronary Syndrome: Chest pain, EKG shows ischemic change, elevated Troponin. Treat with NTG, Labetalol. Target SBP <140 mmHg immediately.

  • Acute Cardiogenic Pulmonary Edema: Orthopnea, PND, crepitation. Treat with Nitroprusside, NTG (with loop diuretic). Target SBP <140 mmHg immediately.

  • Acute Aortic Dissection: Chest pain radiating to the back, Differential BP, pulse deficit. Treat with Esmolol + Nitroprusside / NTG / Nicardipine. Target SBP <120mmHg and HR <60bpm immediately.

  • Eclampsia and Severe Pre-eclampsia/HELLP: Pregnancy GA >20 weeks with proteinuria. Treat with Labetalol, Nicardipine, MgSO4. Target SBP <160mmHg and DBP <105mmHg immediately.

Note on Bilateral Retinopathy: Found through funduscopic exam, includes hemorrhage, cotton wool spots, papilledema.

Note on Thrombotic Microangiopathy (TMA): Found through tests indicating hemolysis, thrombocytopenia, and MAHA in PBS.

IV Anti-Hypertensive Drug Doses:

  • Nitroprusside: 0.25-10 mcg/kg/min IV infusion (can titrate up by 0.5 mcg/kg/min until target BP is reached). Onset: Immediate. Duration: 1-2 min. Contraindication: Second/third-degree AV block, systolic HF, asthma, bradycardia.

  • Nitroglycerin: 5-200 mcg/min IV infusion (can titrate up by 0.5 mcg/kg/min until target BP is reached). Onset: 1-5 min. Duration: 3-5 min. Side Effects: Headache, reflex tachycardia.

  • Nicardipine: 5-15 mg/hr IV, starting at 5 mg/hr and increasing by 2.5 mg/hr every 15-30 min until target BP is reached, then reduce to 3 mg/hr. Onset: 5-15 min. Duration: 30-40 min. Side Effects: Headache, reflex tachycardia.

  • Labetalol: 0.25-0.5 mg/kg IV bolus, 2-4 mg/min infusion until target BP is reached, then maintain at 5-20 mg/hr. Onset: 5-10 min. Duration: 3-6 hr. Contraindications: Bronchoconstriction, fetal bradycardia.


 

Hypertensive Urgency Definition: BP >180/110–120 without target organ involvement.

Management:

  • For patients with symptoms not as severe as a hypertensive emergency, such as headache, atypical chest pain, or epistaxis, administer fast-acting medication: Repeat medication as needed when BP is above 180/110 and symptoms persist until BP is lower than 180/110 without symptoms.

  • Labetalol: 200-800 mg every 2-3 hours, Onset: 30-120 minutes, Duration: 6-12 hours.

  • Captopril: 12.5-25 mg every 8 hours, Onset: 15-30 minutes, Duration: 4-6 hours.

  • Losartan: 50 mg, Onset: 60 minutes, Duration: 12-24 hours.

  • Hydralazine: 10-75 mg, Onset: 10-20 minutes, Duration: 2-6 hours.

  • Labetalol: 10-80 mg (max 300mg/day), Onset: 2-5 minutes, Duration: 3-6 hours.

  • For asymptomatic patients, allow rest in a quiet room for 30 minutes and recheck blood pressure. If ineffective, start antihypertensive medication with long-acting effects. Choose a medication type based on existing chronic diseases. Close monitoring of blood pressure is not necessary.

  • Patients must be evaluated for factors contributing to uncontrolled blood pressure, such as drug adherence, lifestyle changes, physical/psychological stress, pain, insomnia, and medication usage (e.g., Decongestants, NSAIDs, steroids, sympathomimetics, cocaine, etc.), and receive appropriate management.

  • For inpatients, adjust and increase antihypertensive medication accordingly. For outpatients, adjust and increase antihypertensive medication or start antihypertensive treatment if the patient has not previously been on medication. Schedule a follow-up within 1-7 days.

This overview provides guidance for managing hypertensive urgency, emphasizing quick intervention and follow-up to prevent the development of more severe conditions.

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