- Emergency: Very elevated blood pressure with acute, ongoing target-organ damage that should be lowered within minutes.
- Urgency: Very elevated blood pressure without acute, ongoing target-organ damage that should be lowered within hours (controversial).
Many patients present to emergency departments or physician offices with very elevated BPs, but few of these involve either hypertensive emergencies or urgencies. True hypertensive emergencies occur in only one to two people per 100,000 population per year in developed countries, but may be up to four times more common in developing nations, minority populations, economically challenged individuals, and those who are nonadherent to prescribed antihypertensive drugs. To triage such patients appropriately it is important to identify symptoms or signs indicating acute, ongoing target-organ damage. This can take several forms, but usually involves the central nervous system (including the optic fundi), cardiovascular system, kidneys, and/or uterus (see the first three columns of Table 45–1). Patients with acute, ongoing target-organ damage are at very high risk of cardiovascular events and generally should be treated within minutes in a heavily 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 45–1. Common Hypertensive Emergencies with Signs/Symptoms and Other Findings. |Favorite Table|Download (.pdf)
Table 45–1. Common Hypertensive Emergencies with Signs/Symptoms and Other Findings.
Type of emergency
Symptoms and signs
Blood pressure target
Hypertensive encephalopathy (typically a diagnosis of exclusion)
Mental status changes, generally without focal neurologic signs; papilledema is common
No other findings to explain mental status changes
25% reduction over 2–3 hours
Acute ischemic stroke
Focal neurologic signs, headache
CT or MRI may show infarcted or ischemic area
Blood pressure is generally not treated unless it is higher than 180–220/110–120 mm Hg
Headache, focal neurologic signs
CT or MRI typically shows hemorrhagic area
0–25% reduction over 6–12 hours (controversial)
Lumbar puncture shows xanthochromia and/or blood
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
0–25% reduction over 2–3 hours (controversial)
Acute myocardial infarction
Chest discomfort, dyspnea, anxiety
Electrocardiogram may show hyperacute T-wave elevation; troponin is typically elevated
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
Nitroprusside1 or nitroglycerin
Improvement in failure (typically a 10–15% decrease)
Acute aortic dissection
“Tearing” chest pain, pulse deficit in legs
Widened mediastinum on chest x-ray, “intimal flap” on echocardiogram, CT, or MRI
β-Blocker + nitroprusside1...