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.[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]

Causes

Life Threatening Causes

Hypertensive crisis is a life-threatening condition and must be treated as such irrespective of the cause.

Common Causes

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

The management of hypertensive crisis differs based on the presence of end-organ damage and on the level of blood pressure. In case of absence of end-organ damage and SBP above 160 and DBP above 110, then the patient is suffering from hypertensive urgency. In such cases the goal is to decrease the blood pressure gradually over 24-48 hours using oral antihypertensive drugs. Rapid decrease in the BP is very dangerous as this may precipitate organ hypo perfusion as (Brain, heart or Kidneys) causing ischemia and infarction. For those 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.

Several classes of antihypertensive agents are recommended and the choice for the antihypertensive agent depends on the cause for the hypertensive crisis, the severity of elevated blood pressure and the patients usual blood pressure before the hypertensive crisis. In most cases, the administration of an intravenous sodium nitroprusside injection which has an almost immediate antihypertensive effect is suitable but in many cases not readily available. In less urgent cases, oral agents like captopril, clonidine, labetalol, prazosin, which have all a delayed onset of action by several minutes compared to sodium nitroprusside, can also be used.

It is also important that the blood pressure is lowered not too abruptly, but smoothly. The diagnosis of a hypertensive emergency is not only based on the absolute level of blood pressure, but also on the individual regular level of blood pressure before the hypertensive crisis. Individuals with a history of chronic hypertension may not tolerate a "normal" blood pressure.

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).

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:
  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.[4]
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

References

  1. 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. 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. 3.0 3.1 3.2 3.3 3.4 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. Chobanian, AV.; Bakris, GL.; Black, HR.; Cushman, WC.; Green, LA.; Izzo, JL.; Jones, DW.; Materson, BJ.; Oparil, S. (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. Unknown parameter |month= ignored (help)

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