Emergency or urgency? How to effectively manage a hypertensive crisis

Kishore Kuppasani, MS, MPA, PA-C, Alluru S. Reddi, MD, PhD

August 03, 2010

PDF of CME Hypertensive 0810

Emergency or urgency? How to effectively manage a hypertensive crisis

RELATED TOPICS

Acute evaluation and management of the anterior shoulder dislocation

Hypertensive emergency The patient should be admitted to the ICU for continuous BP monitoring. Once a hypertensive emergency is identified, IV administration of an appropriate drug should be started in the ED. The initial goal is to lower BP by 25% of the mean arterial BP within minutes to 1 hour and stabilize BP to approximately 160/100 to 110 mm Hg over the next 2 to 6 hours.⁹ Rapid BP reduction below this level may precipitate renal, coronary, or cerebral ischemia. If the patient is stable and tolerates a BP of 160/100 to 110 mm Hg, further reduction to near normal can be attempted over 24 to 48 hours. However, normal BP levels should not be achieved in the patient with ischemic stroke. SBP should be lowered to less than 120 mm Hg in the patient with aortic dissection.⁹ Table 4 describes the signs and symptoms, preferred agent(s), and agents to be avoided when treating a patient in a hypertensive emergency. Suggested target BP levels are also listed. 

Hypertensive urgency Patients will not have sustained target organ damage; therefore, their BP can be followed and treated with short-acting oral agents after eliminating any triggering factors, such as pain. If the patient does not have any triggering factors and severe hypertension persists, the patient is considered to have chronic hypertension. Parenteral drugs are not needed, nor is a rapid reduction of BP, as there is no evidence to suggest that these patients experience immediate (from hours to a few days) target organ damage if left untreated. BP will fall by 6% within 1 hour even before antihypertensive drugs are started.⁸ Thus, parenteral use of antihypertensive agents should be avoided in the uncomplicated patient with severe hypertension.  

Some clinicians hesitate to treat hypertensive urgency in the ED. Oral agents should be considered if the patient's BP is higher than 180/110 mm Hg and are indicated when the patient's BP is higher than 220/120 mm Hg.^10,11 BP should be reduced to approximately 160/110 mm Hg over a period of 12 to 24 hours after triggering factors are corrected to avoid myocardial, cerebral, and renal ischemia.  

Follow-up within 2 to 4 days after the ED visit is extremely important. Patients should be instructed to schedule a follow-up appointment with a primary care physician or an outpatient clinic as soon as possible.  

Prognosis Patient prognosis after a hypertensive crisis is poor. A 30-year follow-up of 315 patients with hypertensive emergency showed a 5-year survival of 74%.¹² The most common causes of death were renal failure (40%), stroke (24%), MI (11%), and heart failure (10%).  

CONCLUSION 

The most important task for the ED clinician is to identify whether the patient's condition is a hypertensive emergency or urgency. The goal is to avoid overaggressive treatment of the nonemergent patient while initiating the most appropriate treatment. Effective management  of hypertensive crises improves both morbidity and  mortality. JAAPA 

Kishore Kuppasani is a hospitalist PA at the University Hospital, UMDNJ, Newark, New Jersey. Alluru Reddi is professor of medicine, Department of Medicine, Division of Nephrology and Hypertension, UMDNJ-New Jersey Medical School, Newark. The authors have indicated no relationships to disclose relating to the content of this article. 

IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read Acute evaluation and management of the anterior shoulder dislocation; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to www.aapa.org and searching for keyword JAAPA post-tests. All others may complete and submit the post-test online at no charge at www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.

REFERENCES 

1. Kinkaid-Smith P, McMichael J, Murphy EA. The clinical course and pathology of hypertension with papilloedema (malignant hypertension). Quart J Med. 1958;27(105):117-153.  

2. Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P. Hypertensive urgencies and emergencies: prevalence and clinical presentation. Hypertension. 1996;27(1):144-147.  

3. Patel HP, Mitsnefes M. Advances in the pathogenesis and management of hypertensive crisis. Curr Opin Pediatr. 2005;17(2):210-214. 

4. Kitiyakara C, Guzman NJ. Malignant hypertension and hypertensive emergencies. J Am Soc Nephrol. 1998;9(1):133-142. 

5. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000;356(9227):411-417. 

6. Aggarwal M, Khan IA. Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin. 2006;24(1):135-146. 

7. Marik PE, Varon J. Hypertensive crises: challenges and management. Chest. 2007;131(6):1949-1962. 

8. Nolan CR, Linas SL. Malignant hypertension and other hypertensive crises. In: Schrier RW, ed. Diseases of the Kidney & Urinary Tract. 8th ed. Philadelphia, PA: Wolters Kluwer/Lippincott, Williams & Wilkins; 2007:1370-1436. 

9. Chobanian AV, Bakris GL, Black HR, Cushman WC, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252. 

10. Shayne P. Against routine initiation of antihypertensive therapy in the emergency department. Ann Emerg Med. 2009;54(6):792-793. 

11. Slovis CM, Reddi AS. Increased blood pressure without evidence of acute end organ damage. Ann Emerg Med. 2008;51(3S):S7-S9. 

12. Lip GY, Beevers M, Beevers DG. Complications and survival of 315 patients with malignant-phase hypertension. J Hypertens. 1995;13(8):915-924. 

13. Rosei EA, Salvetti M, Farsang C. European Society of Hypertension Scientific Newsletter: treatment of hypertensive urgencies and emergencies. J Hypertens. 2006;24(12):2482-2485. 