James Rafael O.

Mendoza
University of Cebu Medical Center- Emergency Department
November 15-16, 2023

Hypertensive Crisis: Clinical Characteristics Of Patients With Hypertensive Urgency, Emergency

And Pseudo crisis At A Public Emergency Department

Introduction:
The World Health Organization highlights the significant impact of cardiovascular diseases, with
approximately 17 million annual deaths, of which 9.4 million result from complications related to
hypertension. This study focuses on hypertensive crisis, an acute complication leading to emergency
hospital admissions.
Classification and Characteristics:
Hypertensive crisis involves a sudden, severe increase in blood pressure, categorized as urgency or
emergency based on the presence or absence of end-organ damage. A less-discussed category,
hypertensive pseudo crisis, is transient and triggered by emotional or painful events.
Prevalence and Changes Over Time:
Examining the last four decades, the study notes changes in the prevalence and characteristics of
hypertensive crisis. Hypertensive urgency is more common, constituting 71.7% of cases, while
hypertensive emergency is less frequent but carries a higher risk of death.
Symptoms and Classification:
Headache emerges as a key symptom associated with hypertensive crisis, particularly in cases of urgency.
The study employs multinomial logistic regression to simultaneously analyze urgency, emergency, and
pseudo crisis, revealing age as a relevant factor.
Blood Pressure Levels and Treatment Efficacy:
Patients exhibit very high baseline blood pressure levels, aligning with the definition of hypertensive
crisis. Treatment leads to a notable reduction in blood pressure, indicating efficacy. Hypertensive pseudo
crisis, linked to emotional events, sees a similar reduction.
Clinical Manifestations and Associated Factors:
Pain and emotional problems are more strongly associated with hypertensive pseudo crisis, emphasizing
the importance of recognizing these symptoms for accurate diagnosis and treatment.
End-Organ Damage and Diagnostic Tests:
Neurological problems and dyspnea are prominent signs of hypertensive emergency, aligning with the
concept of end-organ damage. Specific tests, such as laboratory tests, electrocardiography, and computed
tomography, show significant associations.
Treatment Approaches and Patient Outcomes:
The study validates the use of hypotensive, analgesic, anti-inflammatory, and anticonvulsant drugs in
treating hypertensive crisis. Patients with pseudo crisis or urgency are more often discharged, while those
with emergency require hospitalization due to the imminent risk of life.
Limitations and Implications:
The study acknowledges limitations in data collection due to manual entry in a non-computerized system,
potentially impacting the accuracy of recorded variables. Nevertheless, insights into associated factors
and clinical profiles offer valuable information for refining screening and referral processes for
hypertensive crisis in healthcare services

Summary

Cardiovascular diseases account for 17 million deaths annually, with hypertension complications
accounting for 9.4 million. Hypertensive crisis, a major acute complications of hypertension, is a major
emergency admission. The prevalence and characteristics of patients with hypertensive crisis have
changed over the last four decades, but morbidity and mortality remain significant. Hypertensive crisis is
characterized by severe and abrupt elevation of blood pressure, usually defined by diastolic pressure
values above 120mmHg. It is classified as hypertensive urgency or hypertensive emergency when there is
a risk of death evidenced by end-organ damage. Brazilian literature is poor in studies on the
characteristics of patients with hypertensive crisis in emergency services and their associated factors. The
study found that six out of 1,000 patients seeking emergency services had hypertensive crises.
Hypertensive urgency had the highest prevalence, corresponding to 71.7%. Hypertensive pseudo crisis is
a transient elevation of blood pressure during emotional, painful, or uncomfortable events in patients with
headaches, chest pain, dyspnea, acute psychological stress, and panic syndrome. This category is less
frequent than hypertensive urgencies and emergencies. The study found that age was a relevant variable
in hypertensive crisis, as it reduced the probability of hypertensive pseudo crisis and hypertensive
urgency compared to hypertensive emergency patients. Headache was the most frequent clinical
manifestation associated with hypertensive crisis, with a higher frequency among patients with
hypertensive urgency. The study also found a reduction in blood pressure levels in patients with
hypertensive pseudo crisis, possibly due to its association with emotional or painful events. The findings
suggest that hypertensive pseudo crisis can be identified and treated based on symptoms, as it does not
present end-organ damage. The study found that pain and emotional problems were more frequently
associated with hypertensive pseudo crisis than hypertensive emergency patients. This association
remained after logistic regression analysis, corroborating the concept of hypertensive pseudo crisis. The
study also found that the most frequent signs and symptoms in patients with hypertensive emergency
were neurological problems (48.1%) and dyspnea (27.2%), suggesting end-organ damage. The study also
observed a close relation between medical diagnoses of stroke, acute lung edema, and myocardial
infarction in patients with hypertensive emergency. The study found that the choice of treatment depends
on the patient's clinical presentation, and the use of hypotensive, analgesic, anti-inflammatory, and
anticonvulsant drugs is consistent with the literature. Patients with hypertensive pseudo crisis and
hypertensive urgency were discharged more frequently, possibly due to not presenting end-organ damage.
The study's limitation is the lack of a computerized system in the emergency service, resulting in manual
entry of information. This may have led to underestimated prevalence’s. However, recognizing
hypertensive crisis factors and patient profiles can improve healthcare screening and referral processes.

Reference:
Pierin, Â. M. G., Flórido, C. F., & Santos, J. D. (2019). Hypertensive crisis: clinical characteristics of
patients with hypertensive urgency, emergency and pseudo crisis at a public emergency department.
Einstein (São Paulo), 17(4). https://doi.org/10.31744/einstein_journal/2019ao4685