Hypertensive%20crisis 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 pre-eclampsia/eclampsia
• Symptomatic microangiopathic hemolytic anemia

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

• 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

• Blood pressure (BP) in both arms and at least 1 leg, in supine and standing positions
  • Use appropriate-sized cuffs

• 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

• Complete blood count (CBC) with platelet count, fibrinogen, haptoglobin, LDH
• Electrolytes, creatinine, estimated GFR, urine albumin to creatinine ratio, urinalysis with microscopic exam of sediment
• Cardiac enzymes (eg troponin, CK-MB, NT-proBNP) if cardiac involvement is suspected
• Blood smear to detect microangiopathic hemolytic anemia
• Pregnancy test, urine drug screen 
• Chest X-ray in patients suspicious for heart failure or pulmonary disease
• 12-lead electrocardiogram
• Head computed tomography (CT) and/or magnetic resonance imaging (MRI) scan in patients presenting with neurological changes
• Chest CT, transesophageal echocardiogram, or CT angiography of thorax and/or abdomen in patients suspicious for aortic dissection
• Echocardiography to assess LV function and evidence of ventricular hypertrophy
• Renal ultrasound for suspected renal artery stenosis or renal impairment