Hypertensive Crisis
Definition
Severe elevation in blood pressure (SBP >=180mmHg or DBP >=120mmHg) with or without end-organ dysfunction
Categories
Hypertensive Urgency:
- BP elevation without end-organ dysfunction
- Can still be associated with headache, dyspnea, epistaxis, palpitations, anxiety
- Largely a consequence of inadequate HTN treatment or non-compliance
Hypertensive Emergency:
- BP elevation with end-organ dysfunction
- Evidence of damage to the retina, kidneys, heart, arteries and/or brain
Gestational Hypertensive Emergency:
- Severe HTN persisting >15mins plus end-organ dysfunction.
- Severe preeclampsia, eclampsia, hemolysis, elevated LFTs, low platelets (HELLP) syndrome
Pseudo Hypertensive Crisis:
- Transient BP elevations from external stimulus
- Pain, anxiety, stress, urinary retention, BP measurement errors
- NO end-organ dysfunction
- White-coat hypertension (see below)
Epidemiology
Most Affected Population:
- Elderly
- African Americans
- Men
- Patients with new or rapid BP elevation
- More susceptible to end-organ dysfunction at lower BPs because they haven't had chronic compensation/adaptation
Prevalence:
- 1-2% of general HTN patients
- Up to 11% of HTN patients admitted to hospital
- Up to 0.5% of all ED visits
- Pseudo-hypertensive crisis ~35% of inpatient HTN crisis, 91% outpatient HTN crisis
Etiology
Risk Factors for all HTN crisis:
- CHF, CAD, CKD, DLD, DM, Stroke, prior HTN
Causes:
- Primary HTN
- Medication non-compliance
- Inadequate treatment
- Secondary HTN
- Renal artery stenosis
- Arteritis
- Kidney pathology (think pre-renal, intra-renal, post-renal!)
- Endocrine
- Pheo
- Cushing
- Hyperaldo
- Renin tumour
- Hyperthyroid
- Carcinoid
- Obstructive Sleep Apnea
- Think hypoxia causing erythropoiesis, more RBCs in the blood raises BP
- Coarctation of the aorta
- Alcohol withdrawal
- Drugs!
- Medications (withdrawal from anti-HTN meds, especially beta-blockers)
- Recreational (cocaine, SSRI serotonin syndrome, etc.)
- Pregnancy
- Pre-eclampsia and eclampsia
- Neurogenic (head injury, infarction, hemorrhage, tumour)
- Acute stress
- trauma, burns
- Pain
- Guillian-Barre Syndrome
Clinical Presentation
Complaints:
- Pulmonary edema (23%)
- SOB, WOB, cough, orthopnea
- Heart failure (12%)
- Chest pain, dyspnea, palpitations
- Headache
- Neurological Deficit
- Seizures
- Asymptomatic (common)
Ask about:
- Duration of prior HTN
- Recent BP measurements
- Cardiovascular risk factors
- Comorbidities
- Neuro symptoms
- headache, nausea, vomiting, weakness, numbness, tingling
- visual disturbance!
- Cardio/resp symptoms
- SOB, orthopnea, cough, fatigue
- Sleep apnea
- Diaphoresis (pheo?)
- Dysphagia (Guillian-Barre?)
- Urinary hesitancy
- Red flag headache symptoms (SAH?)
- Sudden onset, worst headache ever
- Red flag chest pain (aortic dissection?)
- Sudden onset, severe pain radiating to the back
- Drug Use
- Prescription (e.g. anti-HTN, erectile dysfunction meds), OTC (e.g. NSAID), herbal, recreational (e.g. cocaine)
Physical Exam:
Step 1: Confirm BP yourself with properly fitting cuff! If a true crisis, inform SMR/staff ASAP!
Step 2: Assess for end-organ dysfunction
- Fundoscopy
- Retinopathy (above and left, compared to normal above and right), hemorrhages, exudate, papilledema
- Full neurological exam
- Unilateral signs uncommon without ischemic brain injury
- Mental status? Signs of encephalopathy?
- Vascular
- Pulses in all extremities vs. central
- Cardiac
- Rate and rhythm
- Murmurs
- Volume status and JVD
- PMI
- Is this patient in heart failure? (see below... keep in mind volume overload from other sources... nephrotic syndrome, cirrhosis, hypoalbuminemia, etc.)
- Abdomen
- Renal bruits?
- AAA?
- Head & Neck
- Carotid bruits?
- JVD?
- Head injury?
- Respiratory
- Wheezing?
- Crackles?
Diagnostic Testing
Blood Pressure & Heart Rate:
- >180/120 mmHg for hypertensive emergency and urgency
- Heart rate typically more elevated with hypertensive emergency
- This makes sense, compensation for dysfunctional perfusion of the end-organs that are being damaged!
- >160/110 mmHg for >15mins in pregnancy
End Organ Dysfunction:
- Physical exam!!
- ECG
- Myocardial ischemia
- Secondarily for getting a sense of LVH (chronicity, heart failure)
- BNP
- Heart failure
- CBC
- MAHA
- LFTs
- Liver dysfunction
- Chest x-ray or CT
- Pulmonary edema?
- Head CT
- Neuro ischemia
- Coagulation studies
- Liver dysfunction
- Also important for gauging risk of bleeding
- Creatinine
- Kidney dysfunction
Narrowing the Diagnosis:
- Urinalysis
- metanephrines (pheo)
- RBCs, protein, casts (renal dysfunction)
- Lytes
- Hyperaldosteronism?
- Bladder ultrasound
- Outlet obstruction
- Renal Ultrasound
- Artery stenosis (secondary HTN)?
- CT head
- Trauma? Ischemia? Hemorrhage?
- Echocardiogram
- Heart failure?
- Creatinine
Management
IV Fluids:
- ONLY if volume-depleted
- Give NS (0.9%) or Lactated Ringer's
- In order to avoid hypoperfusion or hypotension when anti-hypertensive therapy started
Anti-HTN Medication Principle:
- SLOW (high risk of hypoperfusion)
- <25% reduction in the first few hours (no more than 20% in the first hour)
- Exceptions!!
- Acute Aortic Dissection
- Target SBP <120mmHg within first hour and HR <60bpm
- This patient is bleeding from/into their largest artery and will die soon without aggressive treatment
- Ischemic stroke
- Consider TPA, management can be complicated
- Hypertensive encephalopathy
- Target MAP reduction of 20-25% immediately
- Acute cardiogenic pulmonary edema
- Immediately reduce SBP <140 mmHg
- Eclampsia, severe pre-eclampsia, HELLP
- Immediately reduce SBP to <160 mmHg and DBP to <105 mmHg
- Acute cardiogenic pulmonary edema
- Acute intracerebral hemorrhage (see below)?
- Acute Aortic Dissection
Hypertensive Urgency:
- Place patient supine for 30-45 minutes before drugs
- Oral anti-HTN commonly used to lower BP to <160/95 in the first 48 hours.
- Nicardipine 20-40mg po q8-12h
- Captopril 25-50mg po q8-12h
- Labetolol 200mg po, then 200-400mg po q6-12h
- Close monitoring!!
Hypertensive Emergency:
- This patient needs to be in the ICU
- IV anti-HTN
- Nicardipine 5mg/hr and titrating up
- Sodium nitroprussied 0.3-0.5mcg/kg/min titrating up
- Labetolol 0.3-1mg/kg slow injection then boluses
- Esmolol 500mcg/kg over 1 minute then continued infusions
- Consider arterial catheterization for accurate BP measurements
- Manage the end-organ damage!
- BP targets and meds change depending on concurrent ACS, perioperative HTN, renal failure, preeclampsia, etc.
- Transition to oral anti-HTN as soon as stable and tolerating PO meds
Prognosis
Overall mortality ~3.7%
- ~4.6% in HTN emergency
- ~0.8% in HTN urgency
Citation, and more information available at:
DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 -. Record No. T114059, Hypertensive Crisis; [updated 2018 Nov 30, cited 2020-Aug-05]. Available from https://www.dynamed.com/topics/dmp~AN~T114059. Registration and login required.
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