ESSENTIALS OF DIAGNOSIS
Emergency: Acute, ongoing target organ damage with very elevated blood pressure that should be lowered within minutes to hours.
Urgency: Absence of acute, ongoing target organ damage with very elevated blood pressure that should be lowered over one to several hours (controversial).
Many patients present to emergency departments or physician offices with very elevated blood pressures (BPs), but few of these constitute either hypertensive emergencies or urgencies. Hypertensive emergencies accounted for 167 of 100,000 emergency department visits across the United States in 2013, but developing nations, minority populations, economically challenged individuals, and those who are non-adherent to prescribed antihypertensive drugs have about a fourfold increased risk. The important principle to triage such patients appropriately is to identify symptoms or signs indicative of acute, ongoing target-organ damage. This usually involves examining or testing the central nervous system (including the optic fundi), cardiovascular system, kidneys, and/or uterus (see first 3 columns of Table 44–1). Patients with acute, ongoing target-organ damage are at very high risk of cardiovascular events, and generally should be treated within minutes in an intensively monitored setting with a short-acting intravenously delivered antihypertensive agent (typically sodium nitroprusside). Individuals who do not have acute, ongoing target-organ damage may be referred to a source of ongoing care for hypertension (if at low risk), or treated with orally administered antihypertensive agents (if at moderate risk), and the BP response observed.
Table 44–1.Common hypertensive emergencies with signs/symptoms and other findings. ||Download (.pdf) Table 44–1. Common hypertensive emergencies with signs/symptoms and other findings.
|Type of Emergency ||Signs & Symptoms ||Other Findings ||Recommended Drug(s) ||BP Target |
|Neurological emergencies |
|Hypertensive encephalopathy (typically a diagnosis of exclusion) ||Mental status changes, generally without focal neurological signs; Papilledema is common ||No other findings to explain mental status abnormalities ||Nitroprusside* ||25% reduction over 2–3 hours. |
|Acute ischemic stroke ||Focal neurological signs, headache ||CT or MRI may show infarcted or ischemic area ||Nitroprusside* (controversial) ||BP is generally not treated unless higher than 180–220/110–120 mm Hg |
|Intracranial hemorrhage ||Headache, focal neurological signs ||CT or MRI typically shows hemorrhagic area ||Nitroprusside* (controversial) ||0–25% reduction over 6–12 hours (controversial) |
|Subarachnoid hemorrhage ||Headache ||Lumbar puncture shows xanthochromia and/or blood ||Nimodipine ||Up to 25% reduction in previously hypertensive patients, 130–160 mm Hg systolic for normotensive patients |
|Acute head injury/trauma ||Headache, signs of external trauma ||CT or MRI may show area of traumatized brain ||Nitroprusside* ||0–25% reduction over 2–3 hours (controversial) |
|Cardiovascular emergencies |
|Acute myocardial infarction ||Chest discomfort, dyspnea, anxiety ||Electrocardiogram may show hyperacute T-wave elevation; troponin typically elevated ||Nitroglycerin ||Cessation of ischemia (typically only a 5–10% decrease is required) |
|Acute left ventricular failure/acute pulmonary edema ||Dyspnea, pulmonary rales ||Chest X-ray shows pulmonary vascular redistribution or worse ||Nitroprusside* or nitroglycerin ||Improvement in failure (typically only a 10–15% decrease is required) |
|Acute aortic dissection ||“Tearing” chest pain, pulse ...|