HYPERTENSIVE

CRISES
Mini-Lecture
Objectives:
 Define the various types of hypertensive
crises
 Recognize signs and symptoms
associated with hypertensive crises
 Treatment options
Clinical Vignette
 65 y/o M with past medical history of Type II DM (on oral
hypoglycemics), presenting with headache, chest pain
and shortness of breath that developed after lunch the
day of admission; non-exertional; no alleviating factors.
 Physical Exam:
 Vitals: 37.3, 195/125, 92, 24, 93% on RA
 HEENT: Decreased A:V on retinal exam (<25%)
 Heart: S4 heard on exam, no m/r/g
 Lungs: mild resp distress, otherwise clear to auscultation

What’s the diagnosis and next best step in management?

Definitions:
 Hypertension:
 Stage I: 140-159/90-99
 Stage II: >160/100

 Hypertensive Urgency:
 Systolic
BP >180 or Diastolic BP >120 in the
absence of end-organ damage
Definitions Continued:
 Hypertensive Emergencies:
 SBP >180 OR DBP>120 in the presence of
end-organ damage
 Malignant Hypertension: End-organ damage--
eyes, kidneys, brain (hemorrhage/infarct) affected
 Hypertensive encephalopathy: Cerebral edema

leading to neurological symptoms

Signs and Symptoms:
 Hypertensive Urgency:
 Canbe completely asymptomatic
 Some symptoms include:
 Severe headache
 Shortness of breath
 Nosebleeds
 Severe anxiety
 Signs:
 Elevated BP on consecutive readings
S&S Continued
 Hypertensive Emergencies
 Symptoms:
 nausea, vomiting (cerebral edema)
 Chest Pain

 SOB

 Blurry vision

 Confusion

 Loss of consciousness
 Signs:
 Retinal hemorrhages, exudates, or papilledema
 Renal involvement (malignant nephrosclerosis) with
AKI, proteinuria, hematuria
 Cerebral edema  seizures and coma
 Pulmonary Edema
 Myocardial Infarction
 Hemorrhagic Stroke, lacunar infarcts
Treatment Options
 Hypertensive Urgency:
 Goal: Reduce BP to <160/100 over several
hours to day
 Elderly at high risk of ischemia from rapid
reduction of BP, therefore slower reduction in BP in
this patient population
 Previously treated hypertension:
 Increase dose of existing med or add another med
 Reinstitution of med in non-compliant patients
Treatment continued
 Hypertensive Urgency continued:
 Previously untreated hypertension:
 Slow reduction of BP (one to two days):
Amlodipine, Metoprolol XL, lisinopril (po anti-
hypertensives usually enough)
 Experts recommend: Initiate two agents or a

combination agent (one being a thiazide diuretic)

 Rationale: Most patients with BP >20/10 above goal will
require two agents to control their BP
Treatment Continued
 Hypertensive Emergency:
 Goal: Lower Diastolic BP to approximately 100-105
over 2-6 hours; max initial fall not to exceed 25%
 More aggressive decrease can lead to ischemic stroke and
myocardial ischemia
 Iffocal neurological sx presentobtain MRI to r/o
acute stroke (rapid BP correction contraindicated)
 Parenteral antihypertensives (IV Drip) recommended
over oral agents in hypertensive emergency
Treatment
 Recommended parenteral
antihypertensive agents (IV drip) for
Hypertensive Emergencies and admission
to ICU
 Nitroprusside (cautious about cyanide
toxicity), Nicardipine, and Labetalol.
 Once BP controlled, switch to oral anti-
hypertensives and follow-up closely
Clinical Vignette Revisited
 65 y/o M with past medical history of Type II DM (on oral
hypoglycemics), presenting with headache, chest pain
and shortness of breath that developed after lunch the
day of admission; non-exertional; no alleviating factors.
 Physical Exam:
 Vitals: 37.3, 195/125, 92, 24, 93% on RA
 HEENT: Decreased A:V on retinal exam (<25%)
 Heart: S4 heard on exam, no m/r/g
 Lungs: mild resp distress, otherwise clear to auscultation

What’s the diagnosis and next best step in management?

Summary
 Hypertensive Crises are common
 Differentiate Hypertensive Urgency from
Emergency on the basis of end-organ damage
 Can treat hypertensive urgency with oral
antihypertensives, but parenteral medications
required for hypertensive emergencies
 25% reduction in diastolic BP over 2-6 hours for
hypertensive emergencies
 Don’t forget to start Oral antihypertensives and
follow-up closely!