hypertensive%20crisis
HYPERTENSIVE CRISIS
Hypertensive emergency is having severely elevated blood pressure (>180-220 mmHg/120-130 mmHg) that is complicated by progressive target end-organ damage of the central nervous system, heart, kidneys, or the gravid uterus.
There is no definite blood pressure threshold for the diagnosis of hypertensive emergency.
Most target end-organ damage happen with diastolic blood pressure of ≥130 mmHg.
Hypertensive urgency refers to patients with severely elevated blood pressure (>180/110-120 mmHg) but with little or no evidence of acute end-organ damage.
The clinical differentiation between hypertensive emergencies and urgencies is dependent on the presence of target end-organ damage rather than the level of blood pressure.

Diagnosis

Clinical conditions or associated target organ damage that meet the diagnostic criteria for hypertensive emergency

  • Acute left ventricular (LV) failure with pulmonary edema
  • Acute coronary syndrome
  • Acute renal failure
  • Crisis associated with pheochromocytoma
  • Dissecting aortic aneurysm
  • Hypertensive encephalopathy
  • Intracranial hemorrhage or cerebrovascular accident (CVA)
  • Illicit drug use (amphetamines, cocaine)
  • Perioperative hypertension
  • Severe preeclampsia/eclampsia
  • Symptomatic microangiopathic hemolytic anemia

History

  • Assessment of the patient is quickly performed simultaneously with the initiation of antihypertensive therapy

History 

  • Duration and severity of hypertension
  • Current prescribed medications and recreational drugs
    • Eg monoamine oxidase inhibitors (MAOI), phenylpropanolamine, cocaine, amphetamines
  • Usual BP control
  • Comorbid conditions or end-organ damage (eg potential damage in cardiovascular, cerebrovascular or renal system)
  • Prior hypertensive crises
  • Noncompliance to antihypertensive medications
    • Many of the patients with hypertensive urgency are noncompliant with antihypertensives or not adequately treated

Physical Examination

  • Blood pressure (BP) in both arms and at least 1 leg, in supine and standing positions
    • Use appropriate-sized cuffs
RECOMMENDED CUFF SIZES
Arm Circumference Description Cuff Size
22-26 cm Small Adult 12x22 cm
27-34 cm Adult 16x30 cm
35-44 cm Large Adult 16x36 cm
45-52 cm Adult Thigh 16x42 cm
  • Palpate for pulses
    • Compare in the upper, femoral and lower extremities
  • Careful cardiovascular exam
    • Assessment of jugular venous pressure
    • Check for murmurs, gallop or left ventricular heave
    • Evaluate for lower extremity edema
  • Auscultate carotid and abdominal arteries for bruits
  • Auscultate lungs for signs of pulmonary edema, eg rales
  • Focused neurologic exam
  • Funduscopic exam to detect papilledema, hemorrhages or exudates

Laboratory Tests

  • Complete blood count, electrolytes, creatinine, urinalysis with microscopic exam of sediment
  • Cardiac enzymes if acute coronary syndrome is suspected
  • Blood smear to detect microangiopathic hemolytic anemia
  • Chest x-ray in patients suspicious for heart failure or pulmonary disease
  • Electrocardiogram
  • Head computed tomography (CT) and/or magnetic resonance imaging (MRI) scan in patients presenting with neurological changes
  • Chest CT or transesophageal echocardiogram in patients suspicious of aortic dissection
  • Echocardiography to assess left ventricular (LV) function and evidence of ventricular hypertrophy
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Cardiology - Malaysia digital copy today!
Sign In To Download
Editor's Recommendations
Most Read Articles
02 Jul 2018
The use of beta-blockers in patients with heart failure with preserved ejection fraction (HFpEF), especially in those without histories of myocardial infarction, appears to increase the risk of adverse cardiovascular events, according to a recent study.
Stephen Padilla, 09 Jul 2018
Compared with warfarin, apixaban appears to be the safest drug among direct oral anticoagulants (DOACs), with decreased risks of major, intracranial and gastrointestinal bleeding, suggests a study. However, low-dose apixaban and rivaroxaban are associated with increased risks of all-cause mortality compared with warfarin.
24 Jun 2018
Sleep problems and depressive symptoms, and a combination of both, are differentially associated with the future incidence of physical illness, according to a study.
05 Jul 2018
Different measures of fitness and physical activity appear to be inversely associated with the risk of developing cardiovascular disease in the general population, as well as in individuals with elevated genetic risk for these diseases, according to a study.