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

Whats 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 100105 over 2-6 hours; max initial fall not to exceed
25%
More aggressive decrease can lead to ischemic stroke
and myocardial ischemia

If focal neurological sx presentobtain 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

anti-hypertensives 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

Whats 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
Dont forget to start Oral antihypertensives
and follow-up closely!