Hypertensive crisis: Difference between revisions
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===Increase chronic therapy for hypertensive ''urgency''=== | ===Increase chronic therapy for hypertensive ''urgency''=== | ||
Per the 2018 multi-society practice guideline: | |||
* "hypertensive urgencies ... are treated by reinstitution or intensification of antihypertensive drug therapy"<ref name="pmid29133356">{{cite journal| author=Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C | display-authors=etal| title=2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. | journal=Hypertension | year= 2018 | volume= 71 | issue= 6 | pages= e13-e115 | pmid=29133356 | doi=10.1161/HYP.0000000000000065 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29133356 }} </ref> | |||
Evidence for this approach exists<ref name="pmid2679473">{{cite journal| author=Zeller KR, Von Kuhnert L, Matthews C| title=Rapid reduction of severe asymptomatic hypertension. A prospective, controlled trial. | journal=Arch Intern Med | year= 1989 | volume= 149 | issue= 10 | pages= 2186-9 | pmid=2679473 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=2679473 }}</ref><ref name="pmid4862069">{{cite journal| author=| title=Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg. | journal=JAMA | year= 1967 | volume= 202 | issue= 11 | pages= 1028-34 | pmid=4862069 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4862069 }} </ref> | |||
Intensifying treatment of hospitalized patients in the absence of emergency may worse outcomes, at least for noncardiac patients<ref name="pmid33369614">{{cite journal| author=Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB| title=Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions. | journal=JAMA Intern Med | year= 2021 | volume= 181 | issue= 3 | pages= 345-352 | pmid=33369614 | doi=10.1001/jamainternmed.2020.7501 | pmc=7770615 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33369614 }} </ref><ref name="pmid31424475">{{cite journal| author=Anderson TS, Jing B, Auerbach A, Wray CM, Lee S, Boscardin WJ | display-authors=etal| title=Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. | journal=JAMA Intern Med | year= 2019 | volume= 179 | issue= 11 | pages= 1528-1536 | pmid=31424475 | doi=10.1001/jamainternmed.2019.3007 | pmc=6705136 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31424475 }} </ref>. However, one study found better outcomes when treated<ref name="pmid33369614">{{cite journal| author=Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB| title=Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions. | journal=JAMA Intern Med | year= 2021 | volume= 181 | issue= 3 | pages= 345-352 | pmid=33369614 | doi=10.1001/jamainternmed.2020.7501 | pmc=7770615 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33369614 }} </ref>. The prevalence of end-organ damage was not clear in this study. | Intensifying treatment of hospitalized patients in the absence of emergency may worse outcomes, at least for noncardiac patients<ref name="pmid33369614">{{cite journal| author=Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB| title=Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions. | journal=JAMA Intern Med | year= 2021 | volume= 181 | issue= 3 | pages= 345-352 | pmid=33369614 | doi=10.1001/jamainternmed.2020.7501 | pmc=7770615 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33369614 }} </ref><ref name="pmid31424475">{{cite journal| author=Anderson TS, Jing B, Auerbach A, Wray CM, Lee S, Boscardin WJ | display-authors=etal| title=Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. | journal=JAMA Intern Med | year= 2019 | volume= 179 | issue= 11 | pages= 1528-1536 | pmid=31424475 | doi=10.1001/jamainternmed.2019.3007 | pmc=6705136 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31424475 }} </ref>. However, one study found better outcomes when treated<ref name="pmid33369614">{{cite journal| author=Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB| title=Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions. | journal=JAMA Intern Med | year= 2021 | volume= 181 | issue= 3 | pages= 345-352 | pmid=33369614 | doi=10.1001/jamainternmed.2020.7501 | pmc=7770615 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33369614 }} </ref>. The prevalence of end-organ damage was not clear in this study. | ||
Latest revision as of 19:44, 28 February 2024
 |
Resident Survival Guide |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]
Synonyms and keywords: Hypertensive emergency; hypertensive urgency; severe hypertension
Overview
Hypertensive crisis is a term used to describe a severe elevation in the blood pressure which may or may not be associated with end-organ damage.[1] Noncompliance with antihypertensive medications is the most common cause of hypertensive crisis.[2] Hypertensive crisis includes both hypertensive emergency and hypertensive urgency. Hypertensive urgency is the severe elevation in the blood pressure without any evidence of acute end-organ damage. Hypertensive emergency mostly falls into stage 2 of hypertension. It is usually the severe elevation in the blood pressure (systolic blood pressure >180 mm Hg, or diastolic blood pressure >120 mm Hg) complicated by acute end-organ dysfunction, such as hypertensive encephalopathy, eclampsia, dissecting aortic aneurysm, acute left ventricular failure with pulmonary edema, acute myocardial infarction, acute renal failure, or symptomatic microangiopathic hemolytic anemia.[3] The treatment of hypertensive urgency requires a gradual reduction in blood pressure over 24 to 48 hours. In hypertensive emergency, the treatment should be targeted to reduce the blood pressure by not more than 25% within the first hour; when blood pressure is stable, it should be reduced to 160/100-110 mmHg within the next 2 to 6 hours.[3]
Classification
Hypertensive crisis can be further classified as hypertensive urgency and hypertensive emergency based on either the absence or presence of acute end-organ damage.[1]
| Hypertensive crisis Acute elevation of blood pressure - Systolic blood pressure >180 mm Hg, or - Diastolic blood pressure >120 mm Hg | |||||||||||||||
| Hypertensive emergency Evidence of end organ damage | Hypertensive urgency No evidence of end organ damage | ||||||||||||||
Hypertensive Urgency
Hypertensive urgency is an acute severe elevation in the blood pressure without any evidence of acute end-organ damage.
Hypertensive Emergency
Hypertensive emergency mostly falls into stage 2 of hypertension (systolic blood pressure greater >160 mm Hg or diastolic blood pressure >100 mm Hg). It is usually an acute severe elevation in the blood pressure (systolic blood pressure >180 mm Hg, or diastolic blood pressure >120 mm Hg) complicated by acute end-organ dysfunction, such as hypertensive encephalopathy, eclampsia, dissecting aortic aneurysm, acute left ventricular failure with pulmonary edema, acute myocardial infarction, acute renal failure, or symptomatic microangiopathic hemolytic anemia.[3]
Hypertensive Emergency as a Specific Term
The term hypertensive emergency is primarily used as a specific term for a hypertensive crisis with a diastolic blood pressure of 120 mm Hg and above plus end organ damage (brain, cardiovascular, renal) (as described above) in contrast to hypertensive urgency where as yet no end organ damage has developed. The former requires immediate lowering of blood pressure such as with sodium nitroprusside infusions (NOT injections) while urgencies (about 3/4 of cases with diastolic blood pressure of 120 mm Hg and above) can be treated with parenteral administration (NOT oral) of labetalol or some calcium channel blockers. The former use of oral nifedipine, a calcium channel antagonist, has been strongly discouraged or banned because it is not absorbed in a controlled and reproducible fashion and has led to serious and fatal hypotensive problems.
Hypertensive Emergency as a Generic Term
Sometimes, although not very often, the term hypertensive emergency is also used as a generic term, comprising both hypertensive emergency as a specific term for a serious and urgent condition of elevated blood pressure and hypertensive urgency as a specific term of a less serious and less urgent condition (the terminology hypertensive crisis is usually used in this sense).
Causes
Life Threatening Causes
Hypertensive crisis is a life-threatening condition and must be treated as such irrespective of the cause.
Common Causes
- Antihypertensive medications withdrawal ( beta blockers, clonidine)
- Noncompliance with antihypertensive medications[2]
- Pheochromocytoma
- Side effects of monoamine oxidase inhibitors
- Stimulants (cocaine, methamphetamine, phencyclidine)
- Phenylephrine
Causes by Organ System
| Cardiovascular | No underlying causes |
| Chemical/Poisoning | No underlying causes |
| Dental | No underlying causes |
| Dermatologic | No underlying causes |
| Drug Side Effect | Axitinib, Naphazoline, Naratriptan, Phendimetrazine, Sorafenib , Ziv-aflibercept |
| Ear Nose Throat | No underlying causes |
| Endocrine | No underlying causes |
| Environmental | No underlying causes |
| Gastroenterologic | No underlying causes |
| Genetic | No underlying causes |
| Hematologic | No underlying causes |
| Iatrogenic | No underlying causes |
| Infectious Disease | No underlying causes |
| Musculoskeletal/Orthopedic | No underlying causes |
| Neurologic | No underlying causes |
| Nutritional/Metabolic | No underlying causes |
| Obstetric/Gynecologic | No underlying causes |
| Oncologic | No underlying causes |
| Ophthalmologic | No underlying causes |
| Overdose/Toxicity | No underlying causes |
| Psychiatric | No underlying causes |
| Pulmonary | No underlying causes |
| Renal/Electrolyte | No underlying causes |
| Rheumatology/Immunology/Allergy | No underlying causes |
| Sexual | No underlying causes |
| Trauma | No underlying causes |
| Urologic | No underlying causes |
| Miscellaneous | No underlying causes |
Causes in Alphabetical Order
- List the causes of the disease in alphabetical order. You may need to list across the page, as seen here
Treatment
Management is directed by clinical practice guidelines[4]:
- "Hypertensive emergencies are defined as severe elevations in BP (>180/120 mm Hg) associated with evidence of new or worsening target organ damage."
- "hypertensive urgencies are situations associated with severe BP elevation in otherwise stable patients without acute or impending change in target organ damage or dysfunction....Reinstitution or intensification of antihypertensive drug therapy and treatment of anxiety as applicable. There is no indication for referral to the emergency department, immediate reduction in BP in the emergency department, or hospitalization for such patients"
Provide acute therapy for hypertensive emergency
For patients with end-organ damage and SBP >179 and DBP >119, the patient is suffering from hypertensive emergency. These patients should be admitted to the ICU and receive parenteral antihypertensive medications to avoid fluctuating drug levels from the oral or intramuscular routes. The immediate goal is to decrease the DBP by 10-15 % or to approximately 110 mm Hg in the first 30-60 minutes, then when blood pressure is stable, reduce to 160/100-110 mmHg within the next 2-6 hours. Start the treatment with short-acting IV antihypertensive drugs depending on the type of the end-organ damage. Keep close monitoring to the blood pressure and in severely ill patients intra-arterial blood pressure monitoring is used. Once the blood pressure is stable we shift to oral antihypertensive drugs. When the patient is stable and the blood pressure is well tolerated, reduce the blood pressure to normal within 24-48 hours.
Increase chronic therapy for hypertensive urgency
Per the 2018 multi-society practice guideline:
- "hypertensive urgencies ... are treated by reinstitution or intensification of antihypertensive drug therapy"[4]
Evidence for this approach exists[5][6]
Intensifying treatment of hospitalized patients in the absence of emergency may worse outcomes, at least for noncardiac patients[7][8]. However, one study found better outcomes when treated[7]. The prevalence of end-organ damage was not clear in this study.
Intravenous Antihypertensive Drugs
Shown below is a table of the IV antihypertensive drugs and their appropriate doses.[3]
| Drug | Dose |
|---|---|
| Clevidipine | 1 to 2 mg/h as IV infusion, max 16 mg/h |
| Enalaprilat | 1.25–5 mg every 6 hrs IV |
| Fenoldopam | 0.1–0.3 µg/kg per min IV infusion |
| Hydralazine | 10–20 mg IV |
| Nicardipine | 5–15 mg/h IV |
| Nitroglycerin | 5–100 µg/min as IV infusion |
| Nitroprusside | 0.25–10 µg/kg/min as IV infusion |
| Esmolol | 250–500 µg/kg/min IV bolus, then 50–100 µg/kg/min by infusion May repeat bolus after 5 min or increase infusion to 300 µg/min |
| Labetalol | 20–80 mg IV bolus every 10 min 0.5–2.0 mg/min IV infusion |
| Phentolamine | 5–15 mg IV bolus |
Oral Antihypertensive Drugs
Shown below is a table of the oral antihypertensive drugs and their appropriate doses.[3]
| Drug | Dose |
|---|---|
| Captopril | 12.5 to 25 mg PO or SL, repeat as needed. max dose - 50 mg PO |
| Clonidine | 0.1-0.2 mg PO x 1, then 0.05 to 0.1 mg/1-2 hrs. Max dose - 0.6 to 0.7 mg |
| Labetalol | 200 mg PO, then 200 mg/hr until desired effect. Max dose - 1200 mg |
- Other agents to consider include:
- PO frusemide 20mg (repeat as necessary)
- PO nifedipine SR 30mg, single dose
- PO felodipine 5 mg, single dose
Management of Specific Hypertensive Emergencies
| Hypertensive emergencies | Preferred agents |
|---|---|
| Aortic dissection | Labetalol, or nicardipine + esmolol, or nitroprusside + esmolol or nitroprusside + IV metoprolol Note: Administer beta blocker to control the heart rate before initiating a vasodilator e.g. nitroprusside
|
| Acute pulmonary edema / systolic dysfunction | Nitroglycerin + (Nicardipine or, fenoldopam, or nitroprusside) + loop diuretic |
| Acute pulmonary edema / diastolic dysfunction | Low-dose Nitroglycerin + (esmolol, metoprolol, labetalol, or verapamil) + loop diuretic |
| Acute coronary syndrome | Nitroglycerin + (labetalol or esmolol) |
| Hypertensive emergency with acute or chronic renal failure | Nicardipine or fenoldopam |
| Hypertensive encephalopathy | Nicardipine, labetalol, fenoldopam Note: the blood pressure should not be lowered by more than 25% |
| Pre-eclampsia / eclampsia | Labetalol or nicardipine |
| Sympathetic crisis / cocaine overdose | Benzodiazepine + (verapamil, diltiazem, or nicardipine) Note: Beta blockers should NOT be administered alone to prevent un-opposed alpha-adrenergic stimulation |
| Cerebrovascular accident | Nicardipine, labetalol, fenoldopam, or clevidipine Note: An expert's judgement is required to determine if the blood pressure should be lowered. |
| Withdrawal of antihypertensive therapy e.g. clonidine or propanolol | Re-administer the discontinued drug; phentolamine, nitroprusside, or labetalol, if necessary |
Prognosis
Patient may be at risk of readmission[9][10].
References
- ↑ 1.0 1.1 "The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V)". Arch Intern Med. 153 (2): 154–83. 1993. PMID 8422206. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Stewart, DL.; Feinstein, SE.; Colgan, R. (2006). "Hypertensive urgencies and emergencies". Prim Care. 33 (3): 613–23, v. doi:10.1016/j.pop.2006.06.001. PMID 17088151. Unknown parameter
|month=ignored (help) - ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA. 289 (19): 2560–72. doi:10.1001/jama.289.19.2560. PMID 12748199.
- ↑ 4.0 4.1 Whelton PK, Carey RM, Aronow WS, Casey DE, Collins KJ, Dennison Himmelfarb C; et al. (2018). "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines". Hypertension. 71 (6): e13–e115. doi:10.1161/HYP.0000000000000065. PMID 29133356.
- ↑ Zeller KR, Von Kuhnert L, Matthews C (1989). "Rapid reduction of severe asymptomatic hypertension. A prospective, controlled trial". Arch Intern Med. 149 (10): 2186–9. PMID 2679473.
- ↑ "Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm Hg". JAMA. 202 (11): 1028–34. 1967. PMID 4862069.
- ↑ 7.0 7.1 Rastogi R, Sheehan MM, Hu B, Shaker V, Kojima L, Rothberg MB (2021). "Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions". JAMA Intern Med. 181 (3): 345–352. doi:10.1001/jamainternmed.2020.7501. PMC 7770615 Check
|pmc=value (help). PMID 33369614 Check|pmid=value (help). - ↑ Anderson TS, Jing B, Auerbach A, Wray CM, Lee S, Boscardin WJ; et al. (2019). "Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge". JAMA Intern Med. 179 (11): 1528–1536. doi:10.1001/jamainternmed.2019.3007. PMC 6705136 Check
|pmc=value (help). PMID 31424475. - ↑ Kumar N, Simek S, Garg N, Vaduganathan M, Kaiksow F, Stein JH; et al. (2019). "Thirty-Day Readmissions After Hospitalization for Hypertensive Emergency". Hypertension. 73 (1): 60–67. doi:10.1161/HYPERTENSIONAHA.118.11691. PMC 6310036. PMID 30571563/ Check
|pmid=value (help). - ↑ Agarwal R (2019). "Rehospitalization Rates in Hypertensive Emergency". Hypertension. 73 (1): 49–51. doi:10.1161/HYPERTENSIONAHA.118.11789. PMC 6883922 Check
|pmc=value (help). PMID 30571571.