Thammasat Medical Journal, Vol. 13 No.

1, January-March 2013

109

: , ,

22.indd 109

2/28/56 BE 10:18 AM

110

(hypertensive emergency)

(hypertensive emergency)
(target organ damage)-
/





(hypertensive encephalopathy)
(intracerebral hemorrhage)

(acute myocardial infarction),

(acute left ventricular
failure with pulmonary edema)
(unstable angina)
(aortic dissection)
(eclampsia)

(hypertensive
urgency) /







(TIA)



(severe asymptomatic hypertension)
/

22.indd 110

>/ .
>/ .

-







-

>/ .

2/28/56 BE 10:18 AM

Thammasat Medical Journal, Vol. 13 No. 1, January-March 2013

autoregulation



systemic vascular resistance

plasma

fibrinoid necrosis

hypertensive encephalopathy -

111

(diastolic blood pressure)

preeclampsia


cerebral autoregulation curve

autoregulation

(.)
cerebral autoregulation

Zampaglione

22.indd 111

Varon

2/28/56 BE 10:18 AM

112

(medication
noncompliance)
methamphetamine, cocaine phencyclidine
clonidine beta-blockers
pheochromocytoma
monoamine oxidase inhibitor

pheochromocytoma
hypertensive encephalopathy

22.indd 112

subarachnoid hemorrhage

acute coronary syndrome


aortic dissection







Guillain-Barr syndrome
,
(NSAIDs), cyclosporine, prednisolone monoamine oxidase inhibitors
tyramine

sympathomimetic drugs amphetamine cocaine









-

eye ground papilledema,
hypertensive exudates, hemorrhage
diastolic murmur aortic
dissection
(pulmonary edema) pulsatile mass
abdominal bruit

2/28/56 BE 10:18 AM

Thammasat Medical Journal, Vol. 13 No. 1, January-March 2013

aortic dissection




(cerebellar sign)


target organ damage
complete blood count (CBC)
microangiopathic hemolytic anemia
(blood urea nitrogen creatinine)
proteinuria hematuria

left ventricular hypertrophy
acute coronary syndrome
(cardiac biomarker)

widening mediastinum aortic
dissection

.
(hypertensive emergency)

(mean arterial blood pressure)
-

/-

22.indd 113

113

-

(ischemic stroke)

(intraarterial BP monitoring)

sodium nitroprusside, nicardipine, nitroglycerin, labetalol

sodium nitroprusside
cyanide
nifedipine, nitroglycerin, hydralazine first-line therapy
-

clevidipine
Deeks
sodium
nitroprusside, nitroglycerin
nicardipine

tachycardia

2/28/56 BE 10:18 AM

114

adrenergic crisis
preeclampsia/eclampsia

Labetalol, nicardipine
Labetalol, nicardipine
Esmolol, labetalol
sodium nitroprusside
Nitroglycerin labetalol
Sodium nitroprusside, nitroglycerin
Nicardipine, fenoldopram
Labetalol, nicardipine

Nifedipine
Sodium nitroprusside, nifedipine
Hydralazine
Sodium nitroprusside
beta blocker labetalol
beta blocker
Sodium nitroprusside
ACE inhibitor

ACE inhibitor = Angiotenisin converting enzyme inhibitor

Sodium nitroprusside .- ././

-





Nicardipine
- ./.
-
-








Nitroglycerin
- ./
-
-





Fenoldopram
.-. ././ <





Enalapriat
.- .
-
- .

.

Labetalol
- .
-
- .








- ././ -
-
Esmolol









- ././
Phentolamine
- .
-
-

22.indd 114

thiocyanate

high renin

acute
coronary
syndrome

adrenergic crisis

2/28/56 BE 10:18 AM

Thammasat Medical Journal, Vol. 13 No. 1, January-March 2013

(ischemic stroke)

American heart
association/American stroke association ..

/ .

(thrombolytic therapy)

115
/
/

(intravenous tPA)


(extracranial or intracranial stenoses)
-

(intracerebral hemorrhage)




-


(cerebral perfusion pressure)
-

American heart association

22.indd 115

(.)
.
(mean arterial blood pressure)
.

.
.

- .

.
.

.
/ .

2/28/56 BE 10:18 AM

116

labetalol

nicardipine sodium
nitroprusside

cyanide toxicity
sublingual
nifedipine

(aortic dissection)




-
-

beta-blocker esmolol



metoprolol combined alpha, beta blocker
labetalol


beta-blocker
calcium channel blocker nicardipine

nitroprusside hydralazine

cardiac tamponade
pericardiocentesis
inotropic agents

acute coronary syndrome

nitroglycerin
coronary perfusion

22.indd 116

beta blocker metoprolol

myocardial oxygen demand
beta blocker calcium channel
blocker ACE inhibitor

(thrombolytic agents)
/

sodium nitroprusside reflex tachycardia
myocardial oxygen demand

preload
sodium nitroprusside nitroglycerin
diuretics beta blocker
metoprolol
adrenergic crisis

sympathomimetic drugs nicardipine
benzodiazepine
alpha blocker phentolamine
combined alpha, beta blocker labetalol
clonidine
clonidine

adrenergic crisis
beta blocker
alpha receptor (unopposed alpha adrenergic activity)
severe preeclampsia/eclampsia


-

2/28/56 BE 10:18 AM

Thammasat Medical Journal, Vol. 13 No. 1, January-March 2013

-
-




/
-
-
hydralazine

-






-
-

labetalol
-

- -
- calcium channel
blocker sustended-release nifedipine
nicardipine
nicardipine

immediate release nifedipine

diazoxide

22.indd 117

117
Hennessy
diazoxide hydralazine
hydralazine

nitroprusside
cyanide

ACE inhibitors angiotensin II receptor blocker

.
(hypertensive urgency)



Vlcek
(hypertensive
urgency)



(severe asymptomatic hypertension)

-

, -



-

-


/ -

2/28/56 BE 10:18 AM

118

captopril . .
-



calcium channel blocker beta blocker ACE inhibitor




/
, , -
-

(hypertensive urgencies)

Captopril

Amlodipine

Prazosin

Labetalol

-

-

-

-

.- .

- .

- .

- .

.
(severe asymptomatic hypertension)

22.indd 118

bilateral
renal artery stenosis

Dieterle
/
-

2/28/56 BE 10:18 AM

Thammasat Medical Journal, Vol. 13 No. 1, January-March 2013

fundus sign hypertensive retinopathy
creatinine /


/

/

119
-

(electrolyte) (creatinine)

(.)

-

-

22.indd 119

(.)
-
-

2/28/56 BE 10:18 AM

120

</
</
</
</
</
</

(.)
-blocker or
-blocker
Diuretic with ACE inhibitor ACE inhibitor

Diuretic with

ACE inhibitor
ACE inhibitor

ACE inhibitor or ARB
or ARB
(first-line therapy)






-blocker
Aldosterone
ACE inhibitor,
-
Diuretic



antagonist
calcium channel
(second-line therapy)

blocker, or diuretic
ACE inhibitor = Angiotensin converting enzyme inhibitor
ARB = Angiotensin ll receptor blocker

.



.


.

.




.


.


.

22.indd 120

Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin

P. Hypertensive urgencies and emergencies.
Prevalence and clinical presentation. Hypertension
1996;27:144-7.
Vidt DG. Emergency room management of
hypertensive urgencies and emergencies. J Clin
Hypertens (Greenwich) 2001;3:158-64.
Kaplan NM. Management of hypertensive emergencies.
Lancet 1994;344:1335-8.
Chobanian AV, Bakris GL, Black HR, Cushman WC,
Green LA, Izzo JL, Jr., et al. The Seventh Report
of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood
Pressure: the JNC 7 report. JAMA 2003;289:2560-72.
Rosei EA, Salvetti M, Farsang C. Treatment of
hypertensive urgencies and emergencies. Blood
Press 2006;15:255-6.
Shayne PH, Pitts SR. Severely increased blood
pressure in the emergency department. Ann Emerg
Med 2003;41:513-29.
Hebert CJ, Vidt DG. Hypertensive crises. Prim Care
2008;35:475-87.

.


.


.

.

.




.

Strandgaard S, Paulson OB. Cerebral blood flow

and its pathophysiology in hypertension. Am J
Hypertens 1989;2:486-92.
Ault MJ, Ellrodt AG. Pathophysiological events
leading to the end-organ effects of acute hypertension.
Am J Emerg Med 1985;3:10-5.
Vaughan CJ, Delanty N. Hypertensive emergencies.
Lancet 2000;356:411-7.
Varon J, Marik PE. Clinical review: the management
of hypertensive crises. Crit Care 2003;7:374-84.
Rey E, LeLorier J, Burgess E, Lange IR, Leduc L.
Report of the Canadian Hypertension Society
Consensus Conference: 3. Pharmacologic
treatment of hypertensive disorders in pregnancy.
CMAJ 1997;157:1245-54.
Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves
J, Hill MN, et al. Recommendations for blood
pressure measurement in humans and experimental
animals: part 1: blood pressure measurement in
humans: a statement for professionals from the
Subcommittee of Professional and Public Education
of the American Heart Association Council on High
Blood Pressure Research. Circulation 2005;111:697-716.

2/28/56 BE 10:18 AM

Thammasat Medical Journal, Vol. 13 No. 1, January-March 2013

.

.

.

.

.


.




.











.


.

22.indd 121

Varon J, Marik PE. The diagnosis and management

of hypertensive crises. Chest 2000;118:214-27.
Varon J. The diagnosis and treatment of hypertensive
crises. Postgrad Med 2009;121:5-13.
Rodriguez MA, Kumar SK, De Caro M. Hypertensive
crisis. Cardiol Rev 2010;18:102-7.
Varon J. Treatment of acute severe hypertension:
current and newer agents. Drugs 2008;68:283-97.
Deeks ED, Keating GM, Keam SJ. Clevidipine: a
review of its use in the management of acute
hypertension. Am J Cardiovasc Drugs 2009;9:117-34.
Pollack CV, Varon J, Garrison NA, Ebrahimi R,
Dunbar L, Peacock WFt. Clevidipine, an intravenous
dihydropyridine calcium channel blocker, is safe and
effective for the treatment of patients with acute
severe hypertension. Ann Emerg Med 2009;53:329-38.
Adams HP, Jr., del Zoppo G, Alberts MJ, Bhatt
DL, Brass L, Furlan A, et al. Guidelines for the early
management of adults with ischemic stroke: a
guideline from the American Heart Association/American
Stroke Association Stroke Council, Clinical Cardiology
Council, Cardiovascular Radiology and Intervention
Council, and the Atherosclerotic Peripheral Vascular
Disease and Quality of Care Outcomes in Research
Interdisciplinary Working Groups: the American Academy
of Neurology affirms the value of this guideline as
an educational tool for neurologists. Stroke 2007;
38:1655-711.
Randomised, double-blind, placebo-controlled trial of
nimodipine in acute stroke. Trust Study Group.
Lancet 1990;336:1205-9.
Thrift AG, McNeil JJ, Forbes A, Donnan GA. Three
important subgroups of hypertensive persons at
greater risk of intracerebral hemorrhage. Melbourne
Risk Factor Study Group. Hypertension 1998;31:1223-9.

121
.








.


.

.



.



.


.



.

Broderick J, Connolly S, Feldmann E, Hanley D,

Kase C, Krieger D, et al. Guidelines for the
management of spontaneous intracerebral hemorrhage
in adults: 2007 update: a guideline from the American
Heart Association/American Stroke Association Stroke
Council, High Blood Pressure Research Council, and
the Quality of Care and Outcomes in Research
Interdisciplinary Working Group. Circulation 2007;
116:e391-413.
Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B,
Haverich A, et al. Diagnosis and management of
aortic dissection. Eur Heart J 2001;22:1642-81.
Tsai TT, Nienaber CA, Eagle KA. Acute aortic
syndromes. Circulation 2005;112:3802-13.
Isselbacher EM, Cigarroa JE, Eagle KA. Cardiac
tamponade complicating proximal aortic dissection.
Is pericardiocentesis harmful? Circulation 1994;
90:2375-8.
Lopez-Sendon J, Swedberg K, McMurray J, Tamargo
J, Maggioni AP, Dargie H, et al. Expert consensus
document on beta-adrenergic receptor blockers. Eur
Heart J 2004;25:1341-62.
Magee LA, Ornstein MP, von Dadelszen P.
Fortnightly review: management of hypertension in
pregnancy. BMJ 1999;318:1332-6.
Magee LA, Cham C, Waterman EJ, Ohlsson A, von
Dadelszen P. Hydralazine for treatment of severe
hypertension in pregnancy: meta-analysis. BMJ
2003;327:955-60.
Hennessy A, Thornton CE, Makris A, Ogle RF,
Henderson-Smart DJ, Gillin AG, et al. A randomised
comparison of hydralazine and mini-bolus diazoxide
for hypertensive emergencies in pregnancy: the
PIVOT trial. Aust N Z J Obstet Gynaecol 2007;
47:279-85.

2/28/56 BE 10:18 AM

122
.




.



.



.




.



.



.


.

.

22.indd 122

Vlcek M, Bur A, Woisetschlager C, Herkner H,

Laggner AN, Hirschl MM. Association between
hypertensive urgencies and subsequent cardiovascular
events in patients with hypertension. J Hypertens
2008;26:657-62.
O'Mailia JJ, Sander GE, Giles TD. Nifedipineassociated myocardial ischemia or infarction in the
treatment of hypertensive urgencies. Ann Intern
Med 1987;107:185-6.
Grossman E, Messerli FH, Grodzicki T, Kowey P.
Should a moratorium be placed on sublingual
nifedipine capsules given for hypertensive emergencies
and pseudoemergencies? JAMA 1996;276:1328-31.
Narotam PK, Puri V, Roberts JM, Taylon C, Vora
Y, Nathoo N. Management of hypertensive emergencies
in acute brain disease: evaluation of the treatment
effects of intravenous nicardipine on cerebral
oxygenation. J Neurosurg 2008;109:1065-74.
Zeller KR, Von Kuhnert L, Matthews C. Rapid
reduction of severe asymptomatic hypertension.
A prospective, controlled trial. Arch Intern Med
1989;149:2186-9.
Cherney D, Straus S. Management of patients with
hypertensive urgencies and emergencies: a
systematic review of the literature. J Gen Intern
Med 2002;17:937-45.
2003 European Society of Hypertension-European
Society of Cardiology guidelines for the management
of arterial hypertension. J Hypertens 2003;21:1011-53.
Handler J. Hypertensive urgency. J Clin Hypertens
(Greenwich) 2006;8:61-4.
Aggarwal M, Khan IA. Hypertensive crisis: hypertensive
emergencies and urgencies. Cardiol Clin 2006;24:
135-46.

.







.



.




.



.




.


.


.

.

Jamerson KA, Bakris GL, Wun CC, Dahlof B,

Lefkowitz M, Manfreda S, et al. Rationale and
design of the avoiding cardiovascular events through
combination therapy in patients living with systolic
hypertension (ACCOMPLISH) trial: the first randomized
controlled trial to compare the clinical outcome
effects of first-line combination therapies in hypertension.
Am J Hypertens 2004;17:793-801.
Bakris GL, Weir MR. Achieving goal blood pressure
in patients with type 2 diabetes: conventional
versus fixed-dose combination approaches. J Clin
Hypertens (Greenwich) 2003;5:202-9.
Tanabe P, Persell SD, Adams JG, McCormick JC,
Martinovich Z, Baker DW. Increased blood pressure
in the emergency department: pain, anxiety, or
undiagnosed hypertension? Ann Emerg Med 2008;
51:221-9.
Dieterle T, Schuurmans MM, Strobel W, Battegay
EJ, Martina B. Moderate-to-severe blood pressure
elevation at ED entry: hypertension or normotension?
Am J Emerg Med 2005;23:474-9.
Decker WW, Godwin SA, Hess EP, Lenamond CC,
Jagoda AS. Clinical policy: critical issues in the
evaluation and management of adult patients with
asymptomatic hypertension in the emergency
department. Ann Emerg Med 2006;47:237-49.
Kinsella K, Baraff LJ. Initiation of therapy for
asymptomatic hypertension in the emergency
department. Ann Emerg Med 2009;54:791-2.
Shayne P. Against routine initiation of antihypertensive
therapy in the emergency department. Ann Emerg
Med 2009;54:792-3.
Vidt DG. Hypertensive crises: emergencies and
urgencies. J Clin Hypertens (Greenwich). 2004;6:520-5.
Slovis CM, Reddi AS. Increased blood pressure
without evidence of acute end organ damage. Ann
Emerg Med 2008;51:S7-9.

2/28/56 BE 10:18 AM

Thammasat Medical Journal, Vol. 13 No. 1, January-March 2013

123

Abstract
Management of hypertension in emergency room
Intanon Imsuwan
Department of Emergency Medicine, Faculty of Medicine, Thammasat University

Hypertension in emergency room is an extremely common illness in clinical practice. This condition can be
classified as hypertensive emergencies, hypertensive urgencies and severe asymptomatic hypertension. Therefore, triage of
hypertensive patient is the cornerstone of the hypertensive patient management.

Hypertensive emergencies are unusual in clinical practice but its a severe life-threatening condition. These
patients should be rapidly treated with intravenous antihypertensive agent. The major target organ damage in hypertensive
emergencies are heart, brain and kidney. Chest pain is the most common symptom followed by dyspnea and neurologic
deficits. The choice of antihypertensive agents, level and duration of target blood pressure in each condition of hypertensive
emergencies are different.

Hypertensive urgencies are more common but less severe than hypertensive emergencies. Rapid-onset oral medication and short observation are the optimal management in the emergency room. Target blood pressure should be achieved
within 24 hours and follow up within 24-72 hours is recommended. However, medication that aggressive lowering blood
pressure is the cause in decrease blood supply to the brain and leads to ischemic events.

Management of high blood pressure in severe asymptomatic patient caused by anxiety or pain should be treated
according to the cause and antihypertensive agent is usually unnecessary. Blood pressure follow up should be done within
72 hours at out-patient department.
Key words: Management, Hypertension, Emergency room

22.indd 123

2/28/56 BE 10:18 AM