Updated: 10/5/2022

Hypertensive Emergency

Review Topic
  • A 58-year-old African American male presents with chest pain and dyspnea. His blood pressure is found to be 210/125 mmHg. Urinalysis indicates proteinuria. Fundoscopy is notable for retinal arteriolar narrowing, flame hemorrhages, and cotton-wool spots.
  • Hypertensive emergency 
    • > 180/120 mmHg in addition to end-organ damage
      • can occur in the presence or absence of preexisting chronic hypertension
    • this is in contrast to hypertensive urgency, which is when there is severe blood pressure elevation (≥180/110 mmHg) in the absence of end-organ damage
  • Malignant HTN 
    • severely elevated blood pressure resulting in end-organ damage that typically involves the retina (i.e., papilledema).
      • other organs may be included (i.e., brain, heart, kidneys)
Presentation and Evaluation
  • Symptoms
    • a common presentation of patients with hypertensive emergency includes
      • cerebral infarction
      • hypertensive encephalopathy
      • pulmonary edema
      • heart failure
  • Physical Exam shows
    • BP > 180/120 mmHg with associated signs and symptoms of end-organ damage
      • signs of heart failure
      • wheezes or rales, suggestive of pulmonary edema
      • abdominal bruits, suggestive or renal artery stenosis
      • seizures, delirium, stupor, suggestive of CNS involvement
    • fundoscopy might demonstrate 
      • retinal arteriolar changes
        • e.g., "copper-wiring" and/or "silver-wiring"
        • arteriolar narrowing
          • "onion-skinning" hyperplasia on biopsy 
      • retinal hemorrhages
      • papilledema
      • cotton-wool spots
  • Gradually reduce mean arterial pressure to about ~ 10-20% in the first hour
    • there are exceptions (e.g., aortic dissection)
  • Intravenous anti-hypertensive agents
    • sodium nitroprusside, nitroglycerin, labetalol, nicardipine, hydralazine (vasodilation), and esmolol

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