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 100-105

over 2-6 hours; max initial fall not to exceed 25%

If

More aggressive decrease can lead to ischemic stroke and

myocardial ischemia

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 antihypertensives 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!