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KEY FEATURES

Essentials of Diagnosis

  • The categories of uncontrolled hypertension and hypertensive emergency are based on the presence (hypertensive emergency) or absence (uncontrolled hypertension) of acute hypertension-mediated end-organ injury

  • These categories identify patients whose blood pressure (BP) must be controlled immediately from those whose BP control may safely be secured over hours to days

  • In a hypertensive emergency, the profile of organ injury will determine

    • The choice of anti-hypertensive agent

    • The rate at which BP should be reduced

    • The interval and final BP goal in response to therapy

General Considerations

  • Multiple terms have historically described acute hypertensive syndromes (eg. hypertensive crisis, accelerated hypertension, hypertensive emergency, and malignant hypertension)

  • Some expert guidelines have condensed the terms into two categories: uncontrolled hypertension and hypertensive emergency

  • Uncontrolled hypertension

    • Defined as acute elevation of BP in the absence of evidence of end-organ injury

  • Hypertensive emergency

    • Defined as significant hypertension (usually but not always exceeding 180/120 mm Hg) that causes injury to the heart, retina, brain, kidneys, large arteries, or microcirculation

CLINICAL FINDINGS

Symptoms and Signs

  • Uncontrolled hypertension

    • Usually asymptomatic

    • Presents as an incidental finding

  • Hypertensive emergency

    • Often, the presence of organ injury is apparent from history or physical examination

    • Symptoms depend on the end organ involved

      • Acute hypertensive microangiopathy

        • Malignant hypertension is a complex of elevated blood pressure with retinopathy (retinal hemorrhages, cotton wool spots, or papilledema), acute kidney injury, and thrombotic microangiopathy

        • Hypertensive encephalopathy (headache, vomiting, seizures, lethargy, cortical blindness, or coma) that is not accompanied by classic hypertensive retinopathy occurs in about 10% of patients

      • Posterior reversible encephalopathy syndrome includes headache, seizures, altered consciousness, and disturbance of vision

      • Focal neurologic deficits may indicate cerebral infarction or hemorrhage

      • Abrupt onset of worst headache ever experienced: consider intracranial hemorrhage (intraparenchymal, ventricular, or subarachnoid)

      • Loss of consciousness and neck stiffness may be due to subarachnoid hemorrhage

      • Angina and dyspnea associated with acute elevation of left ventricular afterload

      • Chest or abdominal pain, usually severe, may be caused by aortic dissection or rupture

      • Back pain occurs with aortic dissection

      • Chest pain or dyspnea: cardiopulmonary involvement

      • Cardiac examination may reveal low A2, an S4, or a murmur of aortic regurgitation

      • Crackles on lung examination occur with heart failure

      • Papilledema is indictive of elevated intracranial pressure

      • Blurry or diminished vision occurs with retinal involvement

    • Other signs: absent pulses, asymmetric BP readings

  • In pregnant women or women of child-bearing age, preeclampsia or eclampsia should be excluded

Differential Diagnosis

  • Any of the many causes of hypertension can lead to severe hypertension (see Hypertension, Chronic)

  • The underlying causes most likely to present in this way include

    • Poorly controlled or undiagnosed hypertension

    • Withdrawal from anti-hypertensive medications

    • Chronic kidney disease

    • Renal artery stenosis (atherosclerotic or fibromuscular dysplasia)

      ...

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