Updated: 10/5/2022

Hypertensive Emergency

Review Topic
  • Snapshot
    • 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.
  • Introduction
    • 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 Examshows
      • 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
  • Treatment
    • 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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