A 70-year-old female was evaluated in the emergency department for acute onset of dyspnea with severe frontal headaches and diaphoresis. She was diagnosed with a left adrenal pheochromocytoma a week ago, and surgery is scheduled next week. Her PMH is otherwise not significant. Current medications include phenoxybenzamine and propranolol. On physical examination, the patient appears anxious, dyspneic, and diaphoretic. Blood pressure (BP) is 220/120 mm Hg; heart rate is 130/min; respiratory rate is 30/min; oxygen saturation is 92% on room air. On auscultation, lungs reveal bibasilar crackles and heart examination reveals tachycardia. She has 2+ pedal edema. CBC and BMP are normal. Chest x-ray (CXR) shows cardiomegaly and pulmonary congestion. EKG shows no evidence of ischemia.
1. What is the most likely diagnosis?
2. What is the next appropriate initial treatment for this patient's hypertension?
This is a hypertensive crisis, specifically a hypertensive emergency.
When BP exceeds 180/110 mm Hg, think about 3 categories of patients:
Severe hypertension—BP >180/110 in the absence of symptoms beyond mild or moderate headache without evidence of acute target organ damage.
Hypertensive urgency—BP exceeds 180/110 mm Hg with significant symptoms, such as severe headache or dyspnea, but absent or only minimal acute target organ damage.
Hypertensive emergency—BP >220/140 mm Hg accompanied by evidence of life-threatening end-organ dysfunction.
Hypertensive crises include hypertensive emergencies and urgencies. Among the 65 million Americans with hypertension, hypertensive crises occur in less than 1% of individuals. Even though crises are infrequent, significantly elevated BP is a common clinical scenario.
Hypertensive emergencies include accelerated hypertension, defined as progressive hypertension with the funduscopic vascular changes of malignant hypertension but without papilledema, and malignant hypertension, defined as a severe hypertensive state with papilledema of the ocular fundi and vascular hemorrhagic lesions, thickening of the small arteries and arterioles, left ventricular hypertrophy, and a poor prognosis (Table 30-1).
Table 30-1. Target Organ Manifestations |Favorite Table|Download (.pdf)
Table 30-1. Target Organ Manifestations
|Acute||Pulmonary edema, myocardial infarction|
|Chronic||Clinical or EKG evidence of coronary artery disease (CAD); left|
|Ventricular hypertrophy (LVH) by EKG or echocardiogram|
|Acute||Intracerebral bleeding, coma, seizures, mental status changes, transient ischemic attack (TIA), stroke|
|Chronic||Serum creatinine >1.5 mg/dL, proteinuria >1+ on dipstick|
|Chronic||Hemorrhages, exudates, arterial nicking|
As is the case with most patients, a targeted history, targeted physical examination, and selected testing are the important elements of the initial assessment in patients with extremely elevated BPs. When taking the history, the physician should assess the duration and the severity of the HTN as well as symptoms suggesting end-organ damage including headache, chest pain, dyspnea, ...