The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7)
redefined chronic hypertension into three classifications: prehypertension, stage
1 hypertension, and stage 2 hypertension1 (Table 61-1).
61-1 JNC-7 Classification of Hypertension |Favorite Table|Download (.pdf)
61-1 JNC-7 Classification of Hypertension
|Class||Systolic BP (mm Hg)||Diastolic BP (mm Hg)|
These classifications are tied to diagnostic and treatment recommendations
in the report. The JNC-7 classification refers to blood pressure based
on the average of two or more properly measured blood pressure readings
taken in a seated patient on each of two or more office visits,
a specification that cannot be reproduced in the ED. However, knowledge of
the JNC-7 criteria helps emergency physicians to understand preferred
management of chronic hypertension, including the expected
intensity of medical therapy required to control an individual patient’s
blood pressure. For example, a patient meeting criteria for stage
2 hypertension can be expected to require at least two medications
to control blood pressure.1
Hypertensive emergency is an acute elevation
of blood pressure (≥180/120 mm Hg) associated with end-organ
damage, specifically, acute effects on the brain, heart, aorta,
kidneys, and/or eyes1 (Table
61-2; Figure 61-1). Epidemiologic studies
of this condition are hampered by the fact that no diagnostic code
exists to differentiate hypertensive emergency from less serious
clinical presentations associated with hypertension, despite the need
for such a code.2
Table 61-2 Hypertensive
Emergencies |Favorite Table|Download (.pdf)
Table 61-2 Hypertensive
|Diagnostic Category||Evidence of Acute End-Organ Damage|
|Acute aortic dissection||Abnormal findings on CT angiogram or transesophageal echocardiogram
of the aorta|
|Acute pulmonary edema||Interstitial edema on chest radiograph|
|Acute myocardial infarction||Changes on ECG and/or elevated levels of cardiac
|Acute coronary syndrome||Clinical diagnosis, and/or changes on ECG, and/or
elevated levels of cardiac biomarkers|
|Acute renal failure||Elevated serum creatinine level, proteinuria|
|Severe preeclampsia, HELLP syndrome, eclampsia||Proteinuria, hemolysis, elevated liver enzyme levels, low
platelet counts; seizures|
|Hypertensive retinopathy||Retinal hemorrhages and cotton-wool spots (Figure
61-1), hard exudates, and sausage-shaped veins|
|Hypertensive encephalopathy||Clinical diagnosis, including altered mental status associated
with elevated blood pressure (may see papilledema or arteriolar hemorrhage
or exudates on fundus examination, may note cerebral edema with
a predilection for the posterior white matter of the brain on MRI
after clinical diagnosis)...|
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