Hypertension Management for Specific Emergencies

Aka: Hypertension Management for Specific Emergencies, Hypertensive Crisis, Malignant Hypertension, Severe Hypertension, Hypertensive Emergency, Hypertensive Urgency, Uncontrolled Hypertension, Acute Severe Hypertension-Related Target Organ Injury Findings

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II. Definitions

  1. Severe Hypertension
    1. Blood Pressure >180/110 mmHg
  2. Hypertensive Emergency (Hypertensive Crisis)
    1. Rapid and progressive decompensation of vital organ function secondary to Severe Hypertension
    2. Acute life-threatening complications due to Severe Hypertension (acute Myocardial Infarction, Hemorrhagic CVA)
  3. Hypertensive Urgency
    1. Progressive end-organ damage risk factors (pre-existing CHF, Unstable Angina, Chronic Kidney Disease)
    2. Unlike Hypertensive Emergency there is no evidence of new injury secondary to Severe Hypertension
  4. Severe Uncontrolled Hypertension (Severe Asymptomatic Hypertension)
    1. No criteria met for Hypertensive Emergency or urgency as described above
    2. Elevated Blood Pressure in an asymptomatic patient with no signs of end-organ dysfunction

III. Evaluation

  1. Hypertension Evaluation History
  2. Hypertension Evaluation Exam
  3. Hypertension Evaluation Labs

IV. Precautions

  1. Avoid rapidly lowering Blood Pressure in asymptomatic patients with Severe Hypertension
    1. Severe Hypertension typically increases over weeks to months (as opposed to abruptly)
    2. Avoid abruptly lowering Blood Pressure (e.g. Clonidine, Captopril, Nifedipine) in asymptomatic patients
    3. Emergency care is not required for asymptomatic Severe Hypertension
      1. (2013) Ann Emerg Med 62:59-68 [PubMed]
  2. Hypoperfusion may occur with acute Blood Pressure lowering >20-25%
    1. Risk of cerebral ischemia
    2. In asymptomatic patients, avoid intravenous or excessive Antihypertensive dosing
    3. Gradual Blood Pressure lowering of Severe Asymptomatic Hypertension over days to weeks is preferred
  3. Assess for sudden Hypertension Causes
    1. Consider non-compliance with Antihypertensive medications
    2. See Secondary Hypertension Causes
    3. See Resistant Hypertension
  4. Avoid delaying management of Severe Hypertension in patients on Anticoagulation, Antiplatelet Therapy
    1. Control Hypertension early in those on Anticoagulation, Antiplatelet Therapy to prevent Hemorrhagic CVA

V. History

  1. See Hypertension Evaluation History
    1. Includes predisposing factors and Secondary Hypertension risks
  2. Hypertension History
    1. Onset and treatment history
    2. Medication Compliance
  3. Past Medical History
    1. Coronary Artery Disease
    2. Peripheral Vascular Disease
    3. Congestive Heart Failure
    4. Cerebrovascular Disease
    5. Chronic Kidney Disease
    6. Diabetes Mellitus
    7. Obstructive Sleep Apnea
    8. Current pregnancy or postpartum
      1. Consider Preeclampsia if between 20 weeks gestation and 6 weeks postpartum
  4. Acute Contributing Factors
    1. See Medication Causes of Hypertension
    2. Stimulant Use (e.g. Cocaine)
    3. Abrupt cessation of drug or medication
      1. Alcohol Withdrawal
      2. Antihypertensive Withdrawal
    4. Newly added medication (esp. psychiatric medications)
      1. Serotonin Syndrome (esp. SSRI)
      2. Neuroleptic Malignant Syndrome (esp. Antipsychotics)
      3. Anticholinergic Syndrome

VI. Symptoms: End organ dysfunction related to Hypertension

  1. Red flag findings suggestive or target organ injury (Hypertensive Emergency or urgency)
    1. Contrast with the mild symptoms of Severe Asymptomatic Hypertension
  2. Cardiopulmonary Symptoms
    1. Chest Pain
    2. Shortness of Breath
    3. Orthopnea
    4. Syncope
    5. Edema
    6. Claudication (or cold distal extremities, weak distal pulses)
  3. Neurologic Symptoms
    1. Severe Headache
    2. Confusion or other Altered Level of Consciousness
    3. Vision Changes
    4. Extremity weakness
    5. Cranial Nerve deficit
    6. Incoordination
    7. Seizure
  4. Renal Symptoms
    1. Oliguria or Anuria

VII. Exam

  1. See Hypertension Evaluation Exam
  2. Cardiovascular Exam
    1. Arrhythmia
    2. Jugular Venous Distention
    3. Lower Extremity Pitting Edema
    4. Absent or diminished peripheral pulses (esp. Asymmetric Pulses)
    5. Abdominal bruit or pulsatile mass
  3. Respiratory Exam
    1. Hypoxia
    2. Rales
    3. Tachypnea
  4. Ophthalmologic Exam
    1. Retinal Hemorrhage
    2. Papilledema
  5. Neurologic Exam
    1. Altered Level of Consciousness
    2. Focal neurologic deficits

VIII. Signs: End organ dysfunction related to Hypertension

  1. Cardiac dysfunction
    1. Evaluate symptomatic patients (e.g. Angina, Dyspnea, Orthopnea, edema)
    2. Asymptomatic patients with Severe Hypertension are unlikely to benefit from Electrocardiogram or Chest XRay
    3. Karras (2008) Ann Emerg Med 51(3): 231-9 [PubMed]
  2. Renal dysfunction
    1. Serum Creatinine alone is unreliable as an acute marker of hypertensive injury
    2. Basic chemistry panel may be beneficial in acute Severe Hypertension
    3. Nishijima (2010) Am J Emerg Med 28(2): 235-42 [PubMed]
  3. Central Nervous System
    1. Subarachnoid Hemorrhage
    2. Hypertensive Encephalopathy
      1. Results from Hypertension induced cerebral edema and micro-Hemorrhages
      2. May present with Headache, Vomiting, Dizziness and very high Blood Pressure
      3. Clinical diagnosis (no imaging studies make a definitive diagnosis)
    3. Headache
      1. CT Head indicated in acute onset of Headache with Vomiting and Severe Hypertension
      2. Headache in the absence of red flags does not require brain imaging

IX. Differential Diagnosis

  1. See Resistant Hypertension
  2. Hypertensive Emergency (Hypertensive Crisis)
    1. Rapid and progressive decompensation of vital organ function secondary to severely elevated Blood Pressure
    2. Acute life-threatening complications due to Severe Hypertension (acute Myocardial Infarction, Hemorrhagic CVA)
  3. Hypertensive Urgency
    1. Progressive end-organ damage risk factors (pre-existing CHF, Unstable Angina, Chronic Kidney Disease)
    2. Unlike Hypertensive Emergency there is no evidence of new injury secondary to Severe Hypertension
  4. Secondary Hypertension (less common)
    1. See Secondary Hypertension Causes
    2. Primary Hyperaldosteronism
    3. Obstructive Sleep Apnea
    4. Renal Artery Stenosis
    5. Hyperthyroidism or Hypothyroidism
    6. Cushing's Disease
    7. Pheochromocytoma
    8. Preeclampsia (20 weeks gestation to 6 weeks postpartum)
    9. Cerebrovascular Accident
    10. Autonomic Dysreflexia
  5. Medication or Substance Induced
    1. See Medication Causes of Hypertension
    2. Antihypertensive Withdrawal
    3. Alcohol Withdrawal
    4. Cocaine or other stimulant
    5. Serotonin Syndrome
    6. Anticholinergic Syndrome
    7. Malignant Hyperthermia

X. Management: Severe Hypertension Presentations (all have Blood Pressure >180/110)

  1. Hypertensive Emergency (Hypertensive Crisis)
    1. Rapid and progressive decompensation of vital organ function secondary to severely elevated Blood Pressure
    2. Acute life-threatening complications due to Severe Hypertension (acute Myocardial Infarction, Hemorrhagic CVA)
    3. Requires emergent and careful lowering of Blood Pressure (condition specific protocols exist)
    4. Typically requires admission to the ICU
  2. Hypertensive Urgency
    1. Progressive end-organ damage risk factors (pre-existing CHF, Unstable Angina, Chronic Kidney Disease)
    2. Unlike Hypertensive Emergency there is no evidence of new injury secondary to Severe Hypertension
    3. Start oral Antihypertensive
    4. Consider admission in high risk cases
    5. Follow-up within 2 days with primary care
  3. Severe Uncontrolled Hypertension (Severe Asymptomatic Hypertension)
    1. No criteria met for Hypertensive Emergency or urgency as described above
    2. Elevated Blood Pressure in an asymptomatic patient with no signs of end-organ dysfunction
    3. Start oral Antihypertensive
    4. Follow-up within 7 days with primary care

XI. Management: Hypertensive Emergency (Hypertensive Crisis)

  1. Approach
    1. Agents used should be based on local hospital guidelines
    2. What constitutes ideal agent selection is controversial and varies between institutions
      1. Agents described here offer one of several possible protocols
      2. Agents listed as second-line may be considered first-line at many hospitals
    3. Blood Pressure goals
      1. General (unless otherwise specific goals or protocols): 20-30% overall drop in Blood Pressure
        1. First reduce Blood Pressure by 10-20% in first hour (typically <180/120 mmHg)
        2. Next reduce Blood Pressure 5-15% over the next 23 hours (typically <160/110 mmHg)
        3. Elliott and Varon (2018) Hypertensive Emergencies in Adults, UpToDate, Accessed 10/4/2018
      2. Specific Blood Pressure goals
        1. Subarachnoid Hemorrhage (SAH) SBP: <140 mmHg
        2. Intracerebral Hemorrhage (not SAH) SBP: <180 mmHg
        3. Closed Head Injury SBP: Maintain >120 mmHg
        4. Acute Ischemic Stroke SBP: <220 mmHg (<185 mmHg if using tPA)
          1. See CVA Blood Pressure Control
        5. Aortic Dissection: SBP 100-120 mmHg
          1. Also target Heart Rate 60-70 bpm
  2. First-line medications: No Heart Rate control needed
    1. Nicardipine
      1. Use as first line for most hypertensive emergencies
      2. Affects arterial vasodilation only (no effect on Heart Rate or Preload)
      3. Alternative: Clevidapine (new and improved, but more expensive version of Nicardipine)
        1. Clevidapine is now generic and effects rapidly dissipate within minutes of turning off infusion
  3. First-line medications: Heart Rate control needed
    1. Esmolol
      1. Use for Abdominal Aortic Aneurysm, Aortic Dissection or other conditions where rate control is needed
  4. Second-line medications
    1. Nitroprusside
      1. Difficult titration with resulting wide fluctuations in Blood Pressure effect
      2. Decreases Preload and causes reflex Tachycardia
    2. Labetalol
      1. Short acting and may not control Blood Pressure despite titration
      2. Use Nicardipine instead for most cases (however, Labetalol is preferred over Hydralazine and Clonidine)
    3. Nitroglycerin Drip
      1. Indicated in Acute Pulmonary Edema and Severe Hypertension where direct vasodilation would be beneficial
      2. May also be used in Acute Coronary Syndrome with Hypertensive Crisis
  5. Other measures
    1. Treat acute pain, which also raises Blood Pressure
  6. References
    1. Orman and Weingart in Majoewsky (2012) EM: RAP 12(2): 6-7

XII. Management: Historic indications for various Antihypertensives for Hypertensive Crisis

  1. Management described above uses preferred medications
    1. This version listed only for completeness
  2. Hemorrhagic Stroke
    1. Nitroprusside
    2. Trimethaphan
    3. Labetalol
    4. Nicardipine
  3. Left Ventricular Heart Failure
    1. Nitroprusside
    2. Trimethaphan
    3. Avoid Labetalol
  4. Myocardial Infarction or Myocardial Ischemia
    1. Nitroglycerin Drip
    2. Labetalol
  5. Aortic Dissection
    1. Trimethaphan
    2. Nitroprusside
    3. Propranolol
  6. Pheochromocytoma
    1. Phentolamine
    2. Avoid Beta Blockers
  7. Preeclampsia or Eclampsia
    1. Magnesium Sulfate
    2. Hydralazine

XIII. References

  1. Swaminathan and Mattu in Herbert (2020) EM:Rap 20(7): 9-10
  2. Swaminathan and Marcolini in Herbert (2018) EM:Rap 18(10): 7-9
  3. Orman and Rogers in Majoewsky (2012) EM:RAP 12(2): 5-6
  4. Flanigan (2006) Med Clin North Am 90(3): 439-51 [PubMed]
  5. Gauer (2017) Am Fam Physician 95(8): 492-500 [PubMed]
  6. Kessler (2010) Am Fam Physician 81(4): 470-6 [PubMed]
  7. Handler (2006) J Clin Hypertens 8(1): 61-4 [PubMed]
  8. Shayne (2003) Ann Emerg Med 41(4): 513-29 [PubMed]

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