Management of

Hypertensive Crisis
Bernard V.S. Manansang
Internal Medicine Departement of Bitung District Hospital

Definition
Hypertensive crisis :
Severe elevation of blood pressure, which must be
reduced immediately
Hypertensive emergency :
accompanied by acute target organ damage
BP must be reduced within minutes
Hypertensive urgency :
no acute organ damage
BP must be reduced within hours
Clinical Hypertension, Kaplan 2003

Definition
Not determined by BP level, but rather the
imminent compromise vital organ function
Formerly when :
180 mm Hg
systolic
110 mm Hg
diastolic
(stage III; WHO 2003)

The Kidney and Hypertension, Bakris, 2004

High blood pressure in asymptomatic

chronic hypertension
IS NOT A HYPERTENSIVE CRISES

Precipitating factors in hypertensive crisis

1.
2.
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8.
9.

Accelerated sudden rise in blood pressure in

patient with preexisting essential hypertension
Renovascular hypertension
Glomerulonephritis-acute
Eclampsia
Pheochromocytoma
Antihypertensive withdrawl syndromes
Head injuries
Renin secreting tumors
Ingestion of cathecolamine precursor in patients
taking MAO inhibitors
5

Hypertensive emergency
Accelerated-malignant hypertension with papilledema
Cerebrovascular conditions
Hypertensive brain infarction with severe hypertension
Intracerebral / Subarachnoid
Cardiac conditions
Acute aortic dissection
Acute or impending myocardial infarction
Renal conditions
Renal crises from collagen-vascular diseases
Severe hypertension after kidney transplantation
Eclampsia
Surgical conditions
Severe hypertension in patients requiring immediate surgey
Severe epistaxis
6

Sign and symptom in various types of hypertensive emergency

Type of

Typical symptoms

Typical signs

Comment

Acute stroke in evolution

(thrombotic or embolic)

Weakness, altered
motor skill(s)

Focal neruological
deficit(s)

Hypertension not
usually treated

Suibarachnoid hemorrhage

Headache,
delerium

Altered mental
status, meningeal
signs

Acute head injury/trauma

Headache, altered
sensorium or
motor skills

Lacerations,
ecchymoses,
altered mental
status

Hypertensive
encephalopathy

Headache, altered
mental status

papilledema

Lumbar puncture
typically shows
xanthochromia or red
blood cells
Computed
tomographic (CT)
scan is helpful to
determine extent of
intracranial injury
Usually a diagnosis
of exclusion

Cardiac
ischemia/infraction

Chest discomfort,
nausea, vomiting

Abnormal EKG
(esp. T-wave
elevations)

hypertensive emergency

Sign and symptom in various types of hypertensive emergency

Type of

Typical symptoms

Typical signs

Comment

Acute left ventricular

failure/pulmonary edema

Shortness of
breath

Rales auscultated
in chest

Aortic dissection

Chest discomfort

Widened aortic
knob on chest xray

Recent vascular surgery

Bleeding,
tenderness at
suture lines

Bleeding at suture
lines

Pheochromocytoma

Headache,
sweating,
palpitations
Headache,
palpilations

Pallor, flushing,
rare skin signs
(phakomatoses)
tachycardia

Phentolamine is very
useful

Headache, uterine
irritability

Edema,
hyperreflexia

New treatment
guidelines exist

hypertensive emergency

Drug related
catecholamine excess
state
Preeclampsia / eclampsia

Echocardiogram,
chest CT, or
angiogram usually
needed to confirm
Often require
surgical revision of
vascular anastamosis

History regarding
drug exposure is key

Management of Hypertensive emergency

General principle :
the goal is, inhibit the progression of organ
damage
parenteral drugs must be used
balance the benefit and the organ perfusion,
particularly brain, myocardium and kidney

MIMS Cardiovascular Guide, 2005

9

Therapeutic guidelines
do not lower BP more than 25% over the first 1 hour
unless necessary to protect other organs
reduce the SBP of 160 mmHg, DBP of 100 mmHg, or
MAP of 120 mmHg, in the first 24 hours
begin the concomitant long-term therapy soon after
the initial emergency treatment
attempt the established normotension within a few
days

MIMS Cardiovascular Guide, 2005

10

Parenteral drugs for treatment of hypertensive emergency

Drug

Dose

Onset of
actions

Duration
of action

Special indications

Diuretics
Furosemide

20-40 mg in 1-2 min,

repeated and higher
doses with renal
insufficiency

5-15 min

2-3 h

Ussually needed to
maintain efficacy of
other drugs

Vasodilators
Nitropruside

0.25-10.00
g/min/kg/min as i.v.
infusion

Immediate

1-2 min

Most hypertensive
emergencies; caution
with high intracranial
pressure or azotemia

Nitroglycerin
(Nitro-bid IV)

5-100 g/min as i.v.

infusion

2-5 min

5-10 min

Coronary ischemia

Nicardipine

5-15 mg/h i.v.

5-10 min

1-4 h

Most hypertensive
emergencies; caution
with acute heart failure

11

Parenteral drugs for treatment of hypertensive emergency

Drug

Dose

Onset of
actions

Duration
of action

Special indications

Hydralazine

10-20 mg i.v.

10-20 min

3-8 h

Eclampsia; caution with

high intracranial
pressure

Enalaprilat

1.25-5.00 mg every 6 h

15 min

6h

Acute left ventricular

failure

5-15 mg i.v.
200-500 g/kg/min for 4
min, then 50-300
g/kg/min i.v.
20-80 mg i.v. bolus
every 10 min
2 mg/min i.v. infusion

1-2 min
1-2 min

3-10 min
10-20 min

Catecholamine excess
Aortic dissection, after
operation

5-10 min

3-6 h

Most hypertensive
emergencies except
acute heart failure

75-100 g/unit

5-10 min

3-6 h

Most hypertensive
emergency, high
caution with rebound
effect

Adrenergic
inhibitors
Phentolamine
Esmolol

Labetalol

Clonidin

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Table Recommended antihhypertensive agents for hypertensive

crisis
Condition

Preferred antihypertensive agent

Acute pulmonary edema

Fenoldopam or nitroprusside in combination with

nitroglycerin (up to 60 g/min) and a loop diuretic

Acute myocardial ischemia

Labetalol or esmolol in combination with

nuitroglycerin (up to 60 g/min)

Hypertensive encephalopathy

Labetalol, nicardipine, or fenoldopam

Acute aortic dissection

Labetalol or combination of nicardipine or

fenoldopam and esmolol or combination of
nitroprusside with either esmool or intravenous
metoprolol

Eclampsia

Labetalol or nicardipine. Hydralazine may be used

in a non-ICU setting

Acute renal failure/ microangiopathic

anemia

Fenoldopam or nicardipine

Sympathetic crisis/cocaine overdose

Verapamil, diltiazem, or nicardipinein combination

with a benzodiazepine

13

Hypertensive Urgency
Potentially dangerous BP elevation, without
acute/life-threatening end organ damage
Blood pressure formerly S 180 mmHg, D 110 mmHg
Some of the circumstance :
High BP with retinal changes KW II
Preoperative, perioperative or post operative
condition
Pain-induced or stress induced hypertension
Hypertensive rebound
14

Management of Hypertensive urgency

Goal : prevent to the target organ damage
Therapeutic consideration :
Use oral drugs
Sub lingual drug ?!
Reach the BP 160/100 mmHg in 24 hours, normal
after 24-48 hours

15

Sublingual drug
Still controversial / begin to avoid
Subsequent studies showed that the bioavailability of
sublingual nifedipione was negligible
FDA recommendations 1996 :
Nifedipine sublingual should be used with great
caution, if at al

Bakris, Kidney and Hypertension 2004

16

Table Oral drugs for hypertensive urgencies

Drug

Class

Dose

Onset

Duration (h)

Captopril (Capoten)

Angiotensinconverting
enzyme inhib.

25-50.0 mg

15 min

4-6

Clonidine (Catapres)

Central agonist

0.2 mg initially,
then 0.1 mg/h,
up to 0.8 mg
total

0.2-2.0 h

6-8

Furosemide (Lasix)

Diuretic

20-40 mg

0.5-1.0 h

6-8

Labetalol (Normodyne,
Trandate)

- and Blocker

100-200 mg

0.5-2.0 h

8-12

Nifedipine (procardia,
Adalat)

Calcium
channel
blocker

5-10 mg

5-15 min

3-5

Propanolol (Inderal)

-Blocker

20-40 mg

15-30 min

3-6

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Severe Hypertension
BP > 180 / 110
Encephalopathy
Progressing target organ damage
Yes
(HT Emergency)

No

Admit to ICU
Baseline lab

New onset
(HT Urgency)

Parenteral Rx

Baseline lab
Oral Rx

Workup for
identifiable causes:
Renovascular HT

Prior similar experience;

Negative workup
(Uncontrolled HT)
Reinstitute oral Rx
Follow closely

Pathways for management of patients with severe hypertension, defined as

blood pressure (BP) in excess of 180/110 mmHg.
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The Kidney and Hypertension, Bakris, 2004

THE RIGHT FOUR

1.Right medicine
2.Right indication
3.Right dose
4.Right patient

CARE TO THE ADVERSE EFFECT

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