HYPERTENSIVE
CRISES
Mini-Lecture
Objectives:
Define the various types of hypertensive
crises
 Recognize signs and symptoms
associated with hypertensive crises
 Treatment options

Clinical Vignette


65 y/o M with past medical history of Type II DM (on oral
hypoglycemics), presenting with headache, chest pain
and shortness of breath that developed after lunch the
day of admission; non-exertional; no alleviating factors.
Physical Exam:




Vitals: 37.3, 195/125, 92, 24, 93% on RA
HEENT: Decreased A:V on retinal exam (<25%)
Heart: S4 heard on exam, no m/r/g
Lungs: mild resp distress, otherwise clear to auscultation
What’s the diagnosis and next best step in management?
Definitions:

Hypertension:
 Stage
I: 140-159/90-99
 Stage II: >160/100

Hypertensive Urgency:
 Systolic
BP >180 or Diastolic BP >120 in the
absence of end-organ damage
Definitions Continued:

Hypertensive Emergencies:
 SBP
>180 OR DBP>120 in the presence of
end-organ damage
Malignant Hypertension: End-organ damage-eyes, kidneys, brain (hemorrhage/infarct) affected
 Hypertensive encephalopathy: Cerebral edema
leading to neurological symptoms

Signs and Symptoms:

Hypertensive Urgency:
 Can
be completely asymptomatic
 Some symptoms include:




Severe headache
Shortness of breath
Nosebleeds
Severe anxiety
 Signs:

Elevated BP on consecutive readings
S&S Continued

Hypertensive Emergencies
 Symptoms:
nausea, vomiting (cerebral edema)
 Chest Pain
 SOB
 Blurry vision
 Confusion
 Loss of consciousness


Signs:
 Retinal
hemorrhages, exudates, or papilledema
 Renal involvement (malignant nephrosclerosis) with
AKI, proteinuria, hematuria
 Cerebral edema  seizures and coma
 Pulmonary Edema
 Myocardial Infarction
 Hemorrhagic Stroke, lacunar infarcts
Treatment Options

Hypertensive Urgency:
 Goal:
Reduce BP to <160/100 over several
hours to day

Elderly at high risk of ischemia from rapid
reduction of BP, therefore slower reduction in BP in
this patient population
 Previously
treated hypertension:
Increase dose of existing med or add another med
 Reinstitution of med in non-compliant patients

Treatment continued

Hypertensive Urgency continued:
 Previously
untreated hypertension:
Slow reduction of BP (one to two days):
Amlodipine, Metoprolol XL, lisinopril (po antihypertensives usually enough)
 Experts recommend: Initiate two agents or a
combination agent (one being a thiazide diuretic)


Rationale: Most patients with BP >20/10 above goal will
require two agents to control their BP
Treatment Continued

Hypertensive Emergency:
 Goal:
Lower Diastolic BP to approximately 100-105
over 2-6 hours; max initial fall not to exceed 25%

 If
More aggressive decrease can lead to ischemic stroke and
myocardial ischemia
focal neurological sx presentobtain MRI to r/o
acute stroke (rapid BP correction contraindicated)
 Parenteral antihypertensives (IV Drip) recommended
over oral agents in hypertensive emergency
Treatment

Recommended parenteral
antihypertensive agents (IV drip) for
Hypertensive Emergencies and admission
to ICU
 Nitroprusside
(cautious about cyanide
toxicity), Nicardipine, and Labetalol.

Once BP controlled, switch to oral antihypertensives and follow-up closely
Clinical Vignette Revisited


65 y/o M with past medical history of Type II DM (on oral
hypoglycemics), presenting with headache, chest pain
and shortness of breath that developed after lunch the
day of admission; non-exertional; no alleviating factors.
Physical Exam:




Vitals: 37.3, 195/125, 92, 24, 93% on RA
HEENT: Decreased A:V on retinal exam (<25%)
Heart: S4 heard on exam, no m/r/g
Lungs: mild resp distress, otherwise clear to auscultation
What’s the diagnosis and next best step in management?
Summary





Hypertensive Crises are common
Differentiate Hypertensive Urgency from
Emergency on the basis of end-organ damage
Can treat hypertensive urgency with oral
antihypertensives, but parenteral medications
required for hypertensive emergencies
25% reduction in diastolic BP over 2-6 hours for
hypertensive emergencies
Don’t forget to start Oral antihypertensives and
follow-up closely!