How Should Hypertensive Emergencies Be Managed?

Case

A 57-year-old male with hypertension and end-stage renal disease is brought into the ED by his family for evaluation of headache, nausea, blurry vision, and confusion. Blood pressure is 235/130 mmHg. He is somnolent but arousable and oriented only to person; the remainder of his neurologic exam is nonfocal. A fundoscopic exam shows retinal hemorrhages, exudates, and papilledema. How should this patient be managed?

KEY Points

  • Hypertensive emergencies are defined as severe elevations in BP (>180/120 mmHg), with evidence of impending or progressive end-organ damage.
  • Patients with hypertensive emergencies should be admitted to an ICU and started on parenteral antihypertensive agents to halt progression of end-organ damage.
  • In general, the initial therapeutic goal is to reduce the MAP by no more than 25% within the first hour and then gradually lower the BP to the patients’ baseline over the ensuing 24 to 48 hours; more precipitous declines in BP can worsen target organ ischemia.
  • Choice of therapeutic agent should be individualized based on pharmacologic properties, patient comobordities, and end-organ(s) involved.

Additional Reading

  • Marik PE, Varon J. Hypertensive crises: challenges and management. Chest. 2007;131(6):1949-1962.
  • Rhoney D, Peacock WF. Intravenous therapy for hypertensive emergencies, part 1. Am J Health Syst Pharm. 2009;66(15):1343-1352.
  • Rhoney D, Peacock WF. Intravenous therapy for hypertensive emergencies, part 2. Am J Health Syst Pharm. 2009;66(16):1448-1457.
  • Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev. 2010;18(2):102-107.
  • Varon J. Treatment of acute severe hypertension: current and newer agents. Drugs. 2008;68(3):283-297.

Overview

Hypertension (HTN) is a medical problem that affects an estimated 1 in 3 adults in the U.S. and more than 1 billion people worldwide. The Joint National Committee (JNC) 7 Report defines hypertensive emergency as severe hypertension with evidence of impending or progressive end-organ dysfunction.1 Systolic blood pressure (SBP) in these settings often is >180 mm Hg with diastolic blood pressure (DBP) >120 mm Hg. The JNC 7 Report defines hypertensive urgency as severe HTN without acute end-organ dysfunction. Whereas hypertensive urgencies can be treated with oral antihypertensive agents with close outpatient follow-up, hypertensive emergencies require immediate BP reduction to halt the progression of end-organ damage.

Severe HTN causes shear stress and endothelial injury, leading to activation of the coagulation cascade, fibrinoid necrosis, and tissue ischemia.2 Due to adaptive vascular changes, pre-existing hypertension lowers the probability of a hypertensive emergency developing at a particular BP. The rate of BP rise, rather than the absolute level, determines most end-organ damage.3 In previously normotensive patients, end-organ damage can occur at BPs >160/100 mm Hg; however, organ dysfunction is uncommon in chronically hypertensive individuals, unless BP >220/120 mm Hg.

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