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Hypertensive Urgency – Say no to the ER!


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Hypertensive Urgency Introduction

Let’s get started…

Severe hypertension is usually defined as a systolic blood pressure over 180 and/or a diastolic over 120. It is important to note that in order for this to be considered a hypertensive URGENCY– there CAN NOT be any sign of end organ damage.

Typically, you will see emergencies when the systolic is over 220.

Two risk factors are non compliance with medications and an intake of a high salt diet.

Disclaimer: todays topic addresses the non pregnant adult.

Symptoms in Hypertensive Urgency

Typically the patient will not have symptoms. But, the most common are headache and epistaxis.

First Things First

Repeat the blood pressure to confirm the presence of a severely elevated blood pressure. Ideally, you’ll want to take the blood pressure in both arms and palpate the pulses in both the upper and lower extremities. A blood pressure difference of more than 20 mm Hg between arms suggests aortic dissection.

It’s very important to differentiate between hypertensive urgency from emergency – because this will dramatically affect management.

The good news is most of your patients will fall into the urgency category. Hypertensive emergencies are rare. 1-2 cases per million per year will have the diagnosis of hypertensive emergency.

Typically, you’re going to be focusing on the brain, heart, and kidney.

Physical Exam for Hypertensive Urgency

The history and physical exam findings that may signify end organ damage are:

Agitation, altered mental status, seizure, visual disturbance, stroke like symptoms.

Flame hemorrhages, cotton wool spots (retinal nerve fiber layer microinfarcts), papilledema = hypertensive retinopathy and possibly encephalopathy.

Nausea and vomiting occurs in increased intracranial pressure. 

Chest pain can occur in ischemia or dissection (chest pain radiating to the back pain).

Unequal pulses and a new diastolic murmur (aortic insuffiency) can signify aortic dissection. Neurologic symptoms can also be due to dissection – can disrupt cerebral circulation.

Dyspnea occurs in pulmonary edema.

Elevated jugular venous pressures, S3 heart sounds, and pulmonary rales is seen in heart failure.TestsEKG (ischemia)CXR (pulmonary edema or thoracic aortic dissection).

Labs in Hypertensive Urgency

1. Urinalysis (proteinuria, red blood cells, or red cell casts)

2. Serum Electrolytes/Creatinine (acute rise in AKD)

3. Cardiac enzymes (rule out MI)

4. Head CT if neurologic symptoms, hypertensive retinopathy, or vomiting are present

5. Chest CT with contrast or echocardiogram if dissection is suspected.

Treatment of hypertensive urgency

First off, your going to want to slowly lower the blood pressure over a period of days. There isn’t any data or evidence that says lowering the blood pressure rapidly decreases morbidity or mortality.  Lowering the blood pressure too quickly can result in ischemia (stroke or MI).

This is especially true with sublingual nifedipine – which should no longer be given. It causes unpredictable lowering of blood pressure and a reflex tachycardia.

Patients who have a high pulse pressure should have their levels lowered much more slowly. This is when the systolic is over 180 and the diastolic is under 90.If the cause of the elevated blood pressure was simply because the patient did not take their medication – simply have them restart it.

As a rule of thumb, you don’t want to lower the pressure more than 30% in the first few hours. The easiest thing to do is to place the patient in a quiet room. One study showed a reduction of 20/10 mmHg in 30% of adults after 30 minutes.

Who should have their pressures lowered more quickly?

Those who are at high risk for cardiovascular complications, with aortic aneurysms, and/or intracranial aneurysms should have their levels lowered in a few hours. Typically, you’re going to use furosemide 20mg if the patient is fluid overloaded, captopril 12.5mg, or clonidine .2mg. Captopril typically takes the longest to achieve a reduction in blood pressure.

After a few hours, the blood pressure should be reassessed.  Once it has been lowered about 30% – the patient is started on long term therapy and should be reassessed in a few days.

Long Term Therapy

There is no preference given to any one class of medications for those coming in with hypertensive urgency. You will choose an agent just as you would if the patient came in with hypertension.

Typically, you’re going to want to start the patient on two different medications.Common options are amlodipine, hydrochlorothiazide, and an ACE (ie lisinopril). The problem with starting a patient on two medications is discerning adverse reactions if they were to occur.

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