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HYPERTENSIVE EMERGENCIES:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3
DECEMBER 2008 volume 3 Emergency Medicine Cardiac Research and Education Group
not have a hypertensive emergency (HE).6 Patients target organ dysfunction include, but are not limited to,
often present to the ED for unrelated issues, only to be encephalopathy, acute hemorrhagic or ischemic stroke,
found to have severely elevated BP. Other patients acute papilledema, acute pulmonary edema, aortic
present with complaints clearly associated with a dissection, acute renal failure with or without hematuria,
BP derangement. The incidence of hypertensive and eclampsia. It is essential to realize that most patients
emergency is disproportionately higher in the elderly, who present to the ED with severe hypertension do not
male, and African-American populations.7,8 Rapid have a hypertensive emergency.
recognition, evaluation, and treatment of hypertensive
emergencies are necessary to prevent permanent or Hypertensive urgency is defined as “those situations
worsened target organ damage. There are essentially associated with severe elevations in BP without
no evidence-based guidelines for treating hypertensive progressive target organ dysfunction.”4 Some authors use
emergencies in general, although there are guidelines the term hypertensive crisis to include both hypertensive
for the management of BP in stroke, aortic dissection, emergencies and hypertensive urgencies. This may not
and eclampsia. The most recent periodic review by the be fruitful as the term “crisis” is often used to justify an
Joint National Committee (JNC) on Prevention, Detection, acute intervention, which is not always necessary in the
Evaluation, and Treatment of High Blood Pressure (JNC ED when severe hypertension is detected.
7, 2003) offers little in the form of evidence-based
Another important term in this discussion is autoregulation.
guidance on the management of hypertensive urgencies,
In normotensive people, there is ordinarily a broad range
defined as severe elevations of BP without target organ
of pressures through which arteries and arterioles can
damage, or emergencies in general.4
dilate and constrict to maintain normal and consistent
perfusion. Chronic hypertension causes arterial walls
to accommodate chronically excessive pressures. This
Definitions autoregulation limits the vessels’ ability to respond
The JNC 7 describes hypertension using a baseline BP of appropriately to acute decreases or increases in BP.
115/75 mm Hg, reporting that the risk of cardiovascular When BP abruptly increases, regardless of stimulus,
disease (CVD) doubles with each incremental increase larger arteries reflexively vasoconstrict in an effort to
of 20/10 mm Hg. JNC 7 defines blood pressure and limit pressure reaching the tissues, which would interfere
hypertension categories as follows: with normal cellular activity. In this situation, an acute
lowering of BP by a clinician seeking to re-achieve a
Normal: <120/80 mm Hg
“normal” BP will reduce the blood flow to tissue without
Pre-hypertension: 120-139/80-89 mm Hg
prompt compensatory vessel dilation, which can lead to
Hypertension: Stage 1: 140-159/90-99 mm Hg
ischemia of end-organ tissue. Therefore, it is important
Hypertension: Stage 2: > 160/100 mm Hg
when treating hypertensive emergencies, to not decrease
BP either too rapidly or by too great of an amount.
Hypertensive emergencies almost always fall into stage 2,
although some patients, especially younger individuals,
can have hypertensive emergencies at much lower BP Causes of Hypertensive Emergencies
levels than those with chronic hypertension. The JNC 7
The most common origin of hypertensive emergency is an
publication defines hypertensive emergency as “a severe
abrupt increase in BP in patients with chronic hypertension,
elevation in blood pressure (usually >180/120 mm Hg)
most often as a result of medication noncompliance.3
complicated by evidence of impending or progressive
Other relatively common causes of hypertensive
target organ dysfunction.”4 Clinical manifestations of
emergency include stimulant intoxication, including
target organ damage usually involve derangements
cocaine, methamphetamine, and phencyclidine as well as
in the neurologic, cardiac, or renal systems. While
withdrawal syndromes from the anti-hypertensives such as
the myocardium is the most common target organ
clonidine and beta blockers. Less common causes include
damaged by hypertension with a clinical manifestation
pheochromocytoma and adverse drug interactions with
as acute coronary syndrome (ACS)3, other examples of
monoamine oxidase inhibitors (MAO-I).
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Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research and Education Group DECEMBER 2008 volume 3
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Hypertensive Emergencies:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3 Emergency Medicine Cardiac Research and Education Group
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Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research and Education Group DECEMBER 2008 volume 3
Studied in post-operative
hypertension, post-cardiac surgery,
and emergency department
treatment of HE. Potentially
useful for all types of HE syndromes.
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Hypertensive Emergencies:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3 Emergency Medicine Cardiac Research and Education Group
Specific Parenteral Agents for Treatment Labetalol is a combined α and β-adrenergic receptor
of Hypertensive Emergencies inhibitor (α:β activity ratio, 1:3 to 1:7). It controls reflex
tachycardia as BP drops. It does not affect cerebral blood
Choosing an appropriate agent for use in the ED is flow, does not decrease cardiac blood flow or reduce
difficult, and too often not based on objective criteria, cardiac output, or have any appreciable effect on renal
but on institutional and individual experiences. Often, function. The effect can persist 2-4 hours after stopping the
“resource” issues take precedence over “medical” issues infusion. Labetalol can be given as repeated IV boluses,
in choosing an agent. The ideal agent for use in the or as a short-term IV infusion. It is especially useful in
ED would be one that had a very quick onset of action aortic dissection, in combination with a vasodilator. The
matched by an equally quick offset of effect when the most recent American Heart Association/ American
infusion is stopped. Offset of effect is very important in Stroke Association guidelines specifically recommend
the ED, as overshoot of target BP does occur and can be labetalol or nicardipine for patients with hypertension
associated with poor outcomes if persistent. An ideal who are candidates for r-tPA or other acute reperfusion
agent would also be easy to administer, not requiring strategies.11 ED Bottom Line for labetalol: mixed alpha/
central venous access, intra-arterial monitoring, or special beta receptor blocker; rapid onset of action; repeated
set-up and delivery systems, and therefore may differ from bolus or titrated infusion dosing; activity may persist up to
the model agent for the intensive care unit or surgical four hours after cessation of infusion; particularly useful in
suite. Given the incomplete histories and complex stroke and aortic dissection patients.
comorbidities of many ED patients, an agent should also
have a limited side-effect profile and broad applicability, Nicardipine is a dihydropyridine calcium channel
with limited renal, hepatic, or cardiac contraindications blocker. It selectively blocks L-type, voltage-sensitive
or adverse impact. calcium channels of the heart, thereby dilating coronary
arteries and causing relaxation of peripheral arteriolar
Esmolol is a beta-adrenergic blocker that selectively smooth muscle and reduced peripheral vascular resistance.
inhibits beta-1 receptors in the heart and peripheral Abrupt withdrawal can cause rebound angina and
vasculature. It is short acting, with an onset of action of hypertension. ED Bottom Line for nicardipine: calcium
6-20 minutes after bolus, and a maximal effect occurring channel antagonist; rapid onset of action; infusion
about 5 minutes after bolus. Activity may persist for up dosing; coronary artery-friendly; activity may persist up
to 20 minutes after discontinuing the infusion. Dosing is to six hours after cessation of infusion; caution in hepatic
reviewed in Table 2. ED Bottom Line for esmolol: beta- and renal patients.
1 receptor blocker; rapid onset of action; bolus/infusion
dosing; activity may persist up to 20 minutes after Nitroprusside is a direct venous and arterial
cessation of infusion; caution in renal patients. vasodilator. Due to its combined venous and arterial
effects, nitroprusside decreases both preload and
Fenoldopam is a peripheral dopamine-1 receptor afterload. Its use often results in a reflex tachycardia due
agonist. It causes selective vasodilation predominately to activation of baroreceptors. In comparison to the other
in the renal, cardiac, and splanchnic vascular beds. agents discussed so far, it has the quickest onset of action
This causes decreased peripheral vascular resistance, and the shortest half-life. It is therefore easily titratable
increased renal blood flow, and inhibition of sodium and reversible. No type of hypertension is refractory to
reabsorption; the latter results in natriuresis and diuresis. nitroprusside.
Fenoldopam lowers BP but also improves creatinine
clearance and urine flow. It is short-acting with an onset of Use of nitroprusside, however, is problematic for many
action of about 10 minutes and a half-life of 7-9 minutes. reasons. It can cause precipitous drops in BP, leading
ED Bottom Line for fenoldopam: dopamine-1 receptor to overshoot of the target BP and tissue perfusion
blocker; rapid onset of action; titrated infusion dosing; compromise because of autoregulation. It is difficult
activity may persist up to 60 minutes after cessation to administer, as in most institutions it requires BP
of infusion; may be especially useful in renal patients; monitoring with an intra-arterial line. Furthermore, the
contraindicated in glaucoma patients. drug is inactivated by light, so the infusion bag and all IV
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Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research and Education Group DECEMBER 2008 volume 3
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Hypertensive Emergencies:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3 Emergency Medicine Cardiac Research and Education Group
Clevidipine has a very rapid onset of action, with a half- more of the agents previously discussed. As soon as the
life of less than 1 minute. The usual dose is 2 µg/kg/min, pressure begins to respond to therapy, plans should be
with upward doubling titration to effect. Blood pressure initiated for transitioning the patient to oral therapy. If
control is often achieved within 5 minutes of starting the patient is already on BP medications and has been
an infusion. It is rapidly cleared within 10 minutes. noncompliant, then those medications are often the
Clevidipine is metabolized to an inactive metabolite by best choice at least for reinstitution of oral therapy. If
esterases in blood and extravascular tissue, independent the diagnosis of hypertension is new, then a reasonable
of renal or hepatic function. It is logistically simple to oral agent might be chosen from the same class as the
use, being given through a peripheral IV line and with intravenous (IV) agent employed such as a calcium
BP cuff monitoring instead of intra-arterial access. It has channel antagonist if clevidipine or nicardipine controlled
a non-weight-based dosing regimen and no associated the BP, or an oral beta-blocker if labetalol or esmolol was
myocardial depression, sino-atrial (SA) node suppression, used.1 The choice of oral agent may also be impacted by
or atrio-ventricular (AV) node suppression. the nature of new or reinstituted therapy for the end-organ
damage sustained by the patient.
Clevidipine was shown to be safe and effective for the
treatment of acute hypertension during an 18-hour infusion The overall management of acute hypertension was
in a recent clinical trial performed in the ED. VELOCITY summarized in a recent supplement to Annals of
was a Phase-III, open-label, single-arm study to confirm Emergency Medicine.16 This work is a handy reference
the safety and efficacy of IV clevidipine for patients with for the emergency physician and ED nursing personnel.
acute hypertension requiring parenteral treatment for at
least 18 hours. Patients were enrolled in the trial if they Observation or “clinical decision” units (CDUs) may be
had acute hypertension (SBP >180 mm Hg or DBP >115 suitable for the short-term monitoring and management
mm Hg) on 2 successive occasions 15 minutes apart and of hypertensive urgency. Ordinarily, initiation of IV
had evidence of acute or chronic end-organ damage, antihypertensive therapy is associated with the need for
were 18 years of age or older, and could provide written, admission to an intensive care unit bed. On occasion,
informed consent. Ninety percent (104/117) of patients when the suspected end-organ damage is avoided or
reached their target BP within 30 minutes (median for all excluded in a short-term stay, such as the patient with
patients, 10.9 minutes). No clinical hypotensive events angina and severe hypertension who does not have
related to clevidipine were reported throughout the study, elevated serial cardiac biomarkers, the total hypertensive
and there was no excessive reflex tachycardia. Transition emergency management might be effected in a CDU.
to oral therapy was successful in 91.3% of patients.15
ED Bottom Line for clevidipine: Rapid onset and offset Conclusion
of effect, limited side-effect profile, broadly applicable
without renal or hepatic issues, limited-to-no reflex Treatment of hypertensive emergencies, especially in an
tachycardia, easy to administer as requires no central ED, can be challenging and resource-intensive. Many
access or monitoring. agents are available, but most are limited by side effects,
pharmacologic and physiologic barriers, or resource-
ED Management Strategies based barriers. Clevidipine, a new ultrashort-acting
dihydripyridine calcium channel blocker appears to be
Hypertensive urgencies can and should ordinarily be an important new addition to the armamentarium of the
managed with oral antihypertensives only. Because the clinician. It has been shown to be safe, effective, and
diagnosis confirms that no end-organ damage is ongoing or easy to administer in an ED setting. Labetalol continues
incipient, most patients with hypertensive urgencies have had to enjoy wide applicability in the ED. Newer, safer, and
their BP control deteriorate over days to weeks to months, easier-to-use agents may begin to replace nitroprusside.
and urgent correction is neither necessary nor advisable.1 In the case of patients with limited comorbidities,
management in a CDU without formal hospital admission
Hypertensive emergencies, again by definition with end
may be possible, especially in hypertensive urgencies.
organ damage, require parenteral therapy using one or
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Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research and Education Group DECEMBER 2008 volume 3
References
1. Aggarwal M, Khan IA. Hypertensive crises: hypertensive 12. Pollack CV, Varon J, Garrison NA, et al. Clevidipine, an
emergencies and urgencies. Cardiology clinics intravenous dihydropyridine calcium channel blocker, is
2006;24:135-46. safe and effective for the treatment of patients with acute
severe hypertension. Ann Emerg Med 2008 E-pub ahead
2. Marik PE, Varon J. Hypertensive crises: challenges and
of print Jun 4.
management. Chest 2007;131:1949-62.
13. Mann T, Cohn RF, Holman LB, Green LH, Markis
3. Stewart DL, Feinstein SE, Colgan R. Hypertensive
JE, Phillips DA. Effect of nitroprusside on regional
urgencies and emergencies. Primary Care: Clinics in
myocardial blood flow in coronary artery disease.
Office Practice 2006;33: 613-23.
Results in 25 patients and comparison with nitroglycerin.
4. National Heart, Lung, and Blood Institute. Seventh report Circulation 1978;57:732-38.
of the Joint National Committee on prevention, detection,
14. Cohn JN, Franciosa JA, Francis GS, et al. Effect of short-
evaluation, and treatment of high blood pressure (JNC-7)
term infusion of sodium nitroprusside on mortality rate in
2003. Publication No. NIH 03-5233. Bethesda (MD): NIH;
acute myocardial infarction complicated by left ventricular
2003.
failure: results of a Veterans Administration cooperative
5. Zampaglione B, Pascale C, Marchisio M, et al. study. NEJM 1982;306:1129-35.
Hypertensive urgencies and emergencies: prevalence and
15. Walker JJ. Severe pre-eclampsia and eclampsia. Bailleres
clinical presentations. Hypertension 1996;27:144-47.
Best Prac Res Clin Obstet Gynaecol 2000;14:57.
6. Karras DJ, Ufberg JW, Harrigan RA, et al. Lack of
16. Hoekstra J, Qureshi A. Management of hypertension
relationship between hypertension-associated symptoms
and hypertensive emergencies in the emergency
and blood pressure in hypertensive ED patients. Am J
department: The EMCREG-International Consensus Panel
Emerg Med 2005;23:106-10.
Recommendations. Ann Emerg Med 2008;51 Suppl 3.
7. Bennett NM, Shea S. Hypertensive emergency: case
17. Flanigan JS, Vitberg D. Hypertensive emergencies and
criteria, sociodemographic profile, and previous care of
severe hypertension: what to treat, who to treat, and how
100 cases. Am J Public Health 1988;78:636-40.
to treat. Med Clin N Am 2006;90:439-51.
8. Potter JF. Malignant hypertension in the elderly. Q J Med
18. Amin A. Parenteral medication for hypertension with
1995;88:641-47.
symptoms. Ann Em Med 2008;51(Suppl):S1-S15.
9. Lavin P. Management of hypertension in patients with
19. Elliott, WJ. Clinical features in the management of
acute stroke. Arch Int Med 1986;146:66-68.
selected hypertensive emergencies. Prog Cardiovasc Dis
10. Gilmore RM, Miller SJ, Stead LG. Severe hypertension in 2006;48:316-25.
the emergency department patient. Emerg Med Clin N
Am 2005;23:1141-58.
11. Adams HP Jr., delZoppo G, Alberts MJ, et al. Guidelines
for the early management of adults with ischemic stroke:
a guideline from the American Heart Association/
American Stroke Association, Clinical Cardiology council,
Cerebrovascular Radiology and Intervention Council,
and the Atherosclerotic Peripheral Vascular Disease and
Quality of Care Outcomes in Research Interdisciplinary
Working Groups. Stroke 2007;38:1655-1722.
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Hypertensive Emergencies:
Acute Care Evaluation and Management
DECEMBER 2008 volume 3 Emergency Medicine Cardiac Research and Education Group
Support: This monograph is supported in part by an unrestricted bioMérieux, Bristol-Myers Squibb, Heartscape Technologies,
educational grant from The Medicines Company. Inovise, The Medicines Company, Millennium Pharmaceuticals,
PDL BioPharma, Roche Diagnostics, Sanofi-Aventis, Schering-
Author Disclosures
Plough, and Scios (Significant).
In accordance with the ACCME Standards for Commercial
Support of CME, the author has disclosed relevant relationships CME Accreditation
with pharmaceutical and device manufacturers. The University of Cincinnati designates this educational activity
Dr. Pollack – Speaker’s Bureau, The Medicines Company. for a maximum of (1) AMA PRA Category 1 credit(s)™. Physicians
Dr. Rees – No disclosures. should only claim credit commensurate with the extent of their
participation in the activity. The University of Cincinnati College
EMCREG Disclosures
of Medicine is accredited by the Accreditation Council for
EMCREG-International has disclosed relevant relationships with
Continuing Medical Education (ACCME) to sponsor continuing
pharmaceutical and device manufacturers. EMCREG-International,
medical education for physicians.
a medical education company, provides non-biased, high
quality educational newsletters, monographs and symposia for Disclaimer
emergency physicians and other health care providers providing This document is to be used as a summary and clinical reference tool
emergency care. The EMCREG website (www.emcreg.org) and NOT as a substitute for reading the valuable and original source
provides further detail regarding our policy on sponsors and documents. EMCREG-International will not be liable to you or anyone
disclosures as well as disclosures for other EMCREG members. else for any decision made or action taken or not taken by you in
EMCREG-International has received unrestricted educational reliance on these materials. This document does not replace
grants from Abbott POC/i-STAT, ArgiNOx, Biosite, BRAHMS/ individual physician clinical judgment.
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Hypertensive Emergencies:
Acute Care Evaluation and Management
Emergency Medicine Cardiac Research and Education Group DECEMBER 2008 volume 3
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