SIGNS AND SYMPTOMS 
History
- Inquire about:
- Use of any prescribed and OTC medication
- Duration and control of pre-existing HTN
- Details of antihypertensive therapy
- Comorbid conditions (obesity, CAD, DM)
- Recreational drug use
- Assess for end-organ compromise in decreasing order of frequency:
Physical Exam
- BP measured in both arms
- Assess for end-organ compromise:
- Neurologic:
- Level of consciousness
- Visual fields
- Focal motor/sensory deficits
- Ophthalmologic:
- Funduscopic exam (retinal hemorrhages, papilledema)
- Cardiovascular:
- Elevated JVP
- Lung crackles
- Aortic insufficiency murmur
- S3
- Asymmetrical pulses
ESSENTIAL WORKUP
- 12-lead EKG:
- Ischemic changes, LV hypertrophy
- Assess kidney function
- Acute renal failure may be asymptomatic
DIAGNOSIS TESTS & INTERPRETATION
Lab
- CBC
- Anemia and thrombocytopenia are present in thrombotic microangiopathy
- Standard hospital protocols for chest pain
- BUN, creatinine
- Electrolytes
- Hypokalemia present in primary mineralocorticoid excess
- Urinalysis:
- Urine toxicology screen:
- If recreational drugs are suspected
- HCG
Imaging
- Chest x-ray:
- If cardiopulmonary symptoms are present
- Head CT:
- If headache, confusion, neurologic findings
- CTA chest and abdomen:
- If concern for aortic dissection
Diagnostic Procedures/Surgery
- Arterial line
- Lumbar puncture:
DIFFERENTIAL DIAGNOSIS
- Acute coronary syndrome (ACS)
- Acute heart failure (AHF)
- Aortic dissection
- Intracerebral hemorrhage (ICH)
- CVA (ischemic or hemorrhagic)
- Preeclampsia/eclampsia
- Withdrawal syndromes:
- States of catecholamine excess:
- Pheochromocytoma
- Cocaine/sympathomimetic drug intoxication
- Tyramine ingestion when on MAOIs
[Outline]
PRE-HOSPITAL
- ABCs
- Consider gentle BP reduction.
INITIAL STABILIZATION/THERAPY
- ABC, cardiac monitoring, pulse oximetry
- Oxygen administration
- IV access
ED TREATMENT/PROCEDURES
- Hypertensive urgency:
- No need to treat, but close follow-up
- Use oral agents only
- Give any missed home dose
- Goal: Lower the BP gradually over 24–48 hr
- Hypertensive emergency:
- Treat end-organ damage, not absolute BP
- Reduce MAP by ≤20–25% in the 1st hr
- Goal: Systolic ~160 mm Hg, diastolic ~100 mm Hg in 2–6 hr
- Once BP stable with IV therapy, transition to oral therapy within 6–12 hr
- More gradual reduction recommended in:
- Acute ongoing injury to CNS
- More rapid reduction recommended in:
- Hypertensive encephalopathy:
- Goal: MAP lowered by max. 20% or to DBP 100–110 mm Hg within 1st hr then gradual reduction in BP to normal over 48–72 hr
- Drug of choice: Nicardipine, clevidipine, or labetalol
- Ischemic stroke:
- CPP = MAP – ICP
- Decreased CPP from hypotension (low MAP) or cerebral edema (high ICP) may extend infarct
- Treat only SBP > 220 mm Hg or DBP > 120 mm Hg
- Lytic candidates should have BP lowered to < 185/110 mm Hg
- Goal: MAP lowered by no more than 15–20%, DBP not < 100–110 mm Hg in first 24 hr
- Goal post tPA: BP < 180/105 mm Hg
- Drug of choice: Nicardipine, clevidipine, or labetalol
- Hemorrhagic CVA or SAH:
- Treat if SBP > 180 mm Hg/DBP > 100 mm Hg
- Goal: MAP lowered by 20–25% within the 1st hr or SBP 140–160 mm Hg
- Drug of choice: Nicardipine, clevidipine, or labetalol
- Avoid dilating cerebral vessels with nitroglycerin or nitroprusside
- ACS:
- Goal: MAP to 60–100 mm Hg
- Drug of choice: Labetalol or esmolol in combination with nitroglycerin
- Avoid: Hydralazine (reflex tachycardia) and nitroprusside ("coronary steal")
- AHF:
- Goal: MAP to 60–100 mm Hg
- Drug of choice nitroprusside or NTG with ACEI and/or loop diuretic
- Acute renal failure/microangiopathic anemia:
- Goal: MAP lowered by 20–25% within 1st hr
- Drug of choice: Nicardipine, clevidipine, or fenoldopam. For scleroderma renal crises ACEI are drugs of choice.
- Aortic dissection:
- Reduce shear force (dP/dT) by reducing both BP and HR
- β-blockade must precede any drug that may cause reflex tachycardia
- Goal: SBP 100–120 mm Hg and HR < 65 bpm within 1st 20 min
- Drug of choice: Esmolol in combination with dihydropyridine CCB or nitroprusside
- Consult vascular surgery if type A
- Sympathomimetics (pheochromocytoma, cocaine, amphetamines):
- Goal: MAP lowered by 20–25% within 1st hr
- Avoid pure β-blockade (α is left unopposed)
- Drug of choice: Phentolamine or calcium channel blocker with benzodiazepine. Use clonidine in cases of clonidine withdrawal
Pregnancy Considerations
- Preeclampsia:
- Definition: SBP > 140 or DBP > 90 mm Hg with proteinuria (> 300 mg/24 hr or a urine protein/creatinine > 0.3 or dipstick 1+)
- Occurs > 20 wk gestation – 4 wk postpartum
- Headache, vision changes, peripheral edema, RUQ pain
- Complications: Eclampsia, HELLP
- Goal: SBP 130–150 mm Hg and DBP 80–100 mm Hg
- Drug of choice: Labetalol, nicardipine, hydralazine, magnesium
- Consult Obstetrics
- Esmolol:
- β1-blockade
- Onset 60s, duration 10–20 min
- Avoid in AHF, COPD, heart block
- Labetalol:
- Combined α- and β-blocker
- Onset 2–5 min, duration 2–6 hr
- No reflex tachycardia due to β-blockade
- Avoid in: COPD, AHF, bradycardia
- Clevidipine:
- 3rd generation dihydropyridine CCB
- Onset 2–4 min, duration 5–15 min
- Elimination independent of liver/renal function
- Avoid in allergies to soy or egg products, defective lipid metabolism, AFib
- Nicardipine:
- 2nd generation dihydropyridine CCB
- Onset 5–15 min, duration 4–6 hr
- Avoid in: AHF, coronary ischemia
- Nitroglycerin:
- Venous > arteriolar dilation
- Onset 2–5 min, duration 10–20 min
- Perfuses coronaries, decreasing ischemia
- Causes reflex tachycardia, tachyphylaxis, methemoglobinemia
- Nitroprusside:
- Short-acting arterial and venous dilator
- Onset 3 s, duration 1–2 min
- Complications:
- Reflex tachycardia, "coronary steal", increase ICP
- Cyanide toxicity after prolonged use
- Avoid in pregnancy, renal failure (relative)
- Hydralazine:
- Arteriolar dilator
- Onset 5–15 min, duration 3–10 hr
- Hypotensive effect may be less predictable
- Safe in pregnancy
- Enalaprilat:
- ACE inhibitor
- Onset 0.5–4 hr, duration 6 hr
- Avoid in: Pregnancy, AMI
- Fenoldopam:
- Selective postsynaptic dopaminergic receptor agonist (DA1)
- Onset 5–15 min, duration 1–4 hr
- No reflex tachycardia
- Maintains renal perfusion
- Avoid in: Glaucoma
- Phentolamine:
- α1-blocker, peripheral vasodilator
- Onset 1–2 min, duration 10–30 min
MEDICATION
- Clevidipine: 1–16 mg/h IV infusion
- Enalaprilat: 1.25–5 mg q6h IV bolus
- Esmolol: 80 mg IV bolus, then 150 µg/kg/min infusion
- Fenoldopam: 0.1–0.6 µg/kg/min IV infusion
- Hydralazine: 10–20 mg IV bolus
- Labetalol: 20–80 mg IV bolus q10min (total 300 mg); 0.5–2 mg/min IV infusion
- Nicardipine: 2–15 mg/h IV infusion
- Nitroglycerin: 5–100 µg/min IV infusion; USE NON-PVC tubing
- Nitroprusside: 0.25–10 µg/kg/min IV infusion
- Phentolamine: 5–15 mg q5–15min IV bolus
[Outline]
DISPOSITION
Admission Criteria
- All patients with end-organ damage
- ICU for cardiac and BP monitoring
Discharge Criteria
- Absence of end-organ damage
- Likely to be compliant with primary care
- Known history of HTN
- Reversible precipitating cause (e.g., medication noncompliance)
- Able to resume previous medication regimen
- Return with chest pain or headache
FOLLOW-UP RECOMMENDATIONS
Initiation of a suitable medication regimen under care of a primary care provider
[Outline]
- Johnson W, Nguyen ML, Patel R. Hypertension crisis in the emergency department. Cardiol Clin. 2012;30(4):533–543.
- Marik PE, Rivera R. Hypertensive emergencies: An update. Curr Opin Crit Care. 2011;17:569–580.
- Ram CV, Silverstein RL. Treatment of hypertensive urgencies and emergencies. Curr Hypertens Rep. 2009;11(5):307–314.
- Rhoney D, Peacock WF. Intravenous therapy for hypertensive emergencies, part 1. Am J Health Syst Pharm. 2009;66(15):1343–1352.
- Rhoney D, Peacock WF. Intravenous therapy for hypertensive emergencies, part 2. Am J Health Syst Pharm. 2009;66(16):1448–1457.
See Also (Topic, Algorithm, Electronic Media Element)