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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.

Introduction

Important note: The clinical differentiation between hypertensive emergencies and urgencies is dependent on the presence of target organ damage (TOD) rather than the level of blood pressure (BP)

  • For successful management of patients, it is necessary to differentiate hypertensive emergencies from hypertensive urgencies

Definition

Hypertensive Emergency

  • Severely elevated blood pressure (BP) (>180-220 mmHg/120-130 mmHg) that is complicated by progressive target organ damage (TOD) of the central nervous system (CNS), heart, kidneys, lungs or the gravid uterus
  • There is no definite BP threshold for the diagnosis of hypertensive emergency
  • Most TOD happen with diastolic BP ≥130 mmHg

Hypertensive Urgency

  • Refers to patients with severely elevated BP (>180 mmHg/110-120 mmHg) but with little or no evidence of acute end-organ damage
  • Frequently associated with noncompliance to or discontinuing or decreasing treatment as well as anxiety, acute pain, or emotional stress

Signs and Symptoms

  • Hypertensive encephalopathy may present with:
    • Neurologic symptoms like headache, dizziness, altered level of consciousness, seizures, agitation, and visual disturbances
      • Focal neurologic findings can occur, although rare, and should raise suspicion of ischemic stroke or cerebral hemorrhage
    • These patients usually have advanced retinopathy with arteriolar changes, hemorrhages and exudates, along with papilledema
  • Patients suspected of aortic dissection may present with severe chest pain, unequal pulses and widened mediastinum
  • Patients suffering from cardiac decompensation may have chest pain or pressure, dyspnea, cough, orthopnea or pulmonary edema
  • Renal failure may be suspected if oliguria and/or hematuria is present
  • Patients may also present with acute myocardial infarction (AMI) or angina
  • Hypertensive urgency patients may present with:
    • Severe headache, shortness of breath, chest pain, edema, epistaxis, severe anxiety or faintness
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