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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 ...

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