Hypertensive Emergencies

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• Blood pressure > 180/120 mm Hg

• Symptoms and signs of encephalopathy, acute myocardial ischemia, stroke, pulmonary edema, or aortic dissection

GENERAL CONSIDERATIONS

• Hypertensive emergencies:

  • – Severely elevated blood pressure with symptoms and signs of damage to the heart, brain, kidneys, or vascular system.

  • – Can be the first presentation of hypertension or can occur in patients known to have hypertension

• Hypertensive urgencies are described as the same severely elevated blood pressure levels as in hypertensive emergencies and symptoms but without signs of target organ damage.

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Symptoms of the target organ problem, such as headache and lethargy with encephalopathy

PHYSICAL EXAM FINDINGS

• Blood pressure > 180/120 mm Hg

• Findings of the target organ problem, such as localizing neurologic findings in stroke

DIFFERENTIAL DIAGNOSIS

• Increased intracranial pressure—lowering blood pressure contraindicated

• Acute drug-induced pressure elevation (eg, cocaine)

DIAGNOSTIC EVALUATION

LABORATORY TESTS

• Serum catecholamines: to check for pheochromocytoma

• Toxic drug screen

• Target organ damage tests such as creatinine, troponin, B-type natriuretic peptide, D-dimer

ELECTROCARDIOGRAPHY

• ECG findings:

  • – Signs of acute myocardial ischemia or infarction

  • – Nonspecific ST-T–wave changes

  • – Left atrial and ventricular hypertrophy

IMAGING STUDIES

• As indicated for organ problem, such as echocardiography for heart failure

DIAGNOSTIC PROCEDURES

• As indicated for organ problem, such as coronary angiography for acute ST-segment elevation myocardial infarction

TREATMENT

CARDIOLOGY REFERRAL

• Myocardial infarction

• Heart failure

HOSPITALIZATION CRITERIA

• Encephalopathy

• Acute myocardial ischemia/infarction

• Heart failure

• Stroke

• Aortic dissection

MEDICATIONS

• Nitroprusside 0.25–1.0 μg/kg/min, increase by 0.5 μg/kg/min every 5 minutes until goal or until maximum dose of 10 μg/kg/min

• Fenoldopam 0.03–0.1 μg/kg/min; increase by 0.05 μg/kg/min up to 1.6 μg/kg/min

• Labetalol 20–40 mg IV every 10 minutes to 300 mg

• Esmolol 0.5–1.0 mg/kg over 1 minute, then 50–300 μg/kg/min

• Clevidipine 1–2 mg/hour, titrate to 32 mg/hour

• Nicardipine 5 mg/hour, increase by 2.5 mg/hour every 15–30 minutes until goal blood pressure or 15 mg/hour reached

• Phentolamine 1–5 mg, repeat after 5–15 minutes until goal blood pressure reached or 0.5–1.0 mg/hour continuous infusion

• Nitroglycerin 10–20 μg/min, increase by 5 μg/min every 5 minutes until goal blood pressure or 200 μg/min reached

THERAPEUTIC PROCEDURES

• For specific organ problems as indicated, such as angioplasty for acute ST-segment elevation myocardial infarction

SURGERY

• As indicated for organ problem, such as surgical repair of aortic dissection

MONITORING

• ECG and ...