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 pre-eclampsia/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 (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 left ventricular (LV) function and evidence of ventricular hypertrophy
  • Renal ultrasound for suspected renal artery stenosis or renal impairment
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