Hypertensive crisis

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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. Noncompliance with antihypertensive medications is the most common cause of hypertensive crisis. 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. 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.

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.

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.

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
• 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

• Naratriptan
• Sorafenib

Treatment

Management is directed by clinical practice guidelines:

• "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"

Evidence for this approach exists

Intensifying treatment of hospitalized patients in the absence of emergency may worse outcomes, at least for noncardiac patients. However, one study found better outcomes when treated. 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.

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.

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:

1. PO frusemide 20mg (repeat as necessary)
2. PO nifedipine SR 30mg, single dose
3. 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 Reduce blood pressure to 120 mmHg within 20 minutes with protection against reflex tachycardia.
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.

Related Chapters

• Malignant Hypertension
• Hypertension
• Hypertensive Retinopathy

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