• Hypertensive Emergency = a collection of syndromes whereby an acute elevation of BP causes acute target organ damage. Requires immediate treatment.
• Hypertensive Emergencies represent approximately 0.1%-1% of patients. 1-3% with hypertension have a hypertensive emergency in their lifetime.
• In-hospital death is 2.5% (~4.6% when admitted to CCU).
• If untreated, median survival is 10.4 months and 1-year death rate >79%.
• Hypertensive Urgencies or Severe Asymptomatic Hypertension = Systolic BP >180 or Diastolic BP >120 mmHg without target organ damage. Optimal timeframe for initiating treatment is < 1 week to up to 3 months.

* This clinical summary will not address rare conditions such as pheochromocytoma.

What represents acute target organ damage?

• Acute heart failure/pulmonary edema (22-30%).
• Acute coronary syndrome (18-25%).
• Aortic dissection (3.5-8%).
• Hypertensive encephalopathy (2.6-16%).
• Acute ischemic stroke (24%).
• Intracranial hemorrhage (4.5-15%).
• Acute kidney injury (0.5%).
• Hypertensive retinopathy.
• Eclampsia/Pre-eclampsia (up to 6 weeks post-delivery).

Note: Headache (non-pregnant) or epistaxis are not target organ damage

• Hypertensive Emergency patients should be admitted to ICU.
• Immediate BP reduction and hospitalization not indicated for Hypertensive Urgency/Severe Asymptomatic Hypertension.

Historical features

• Missed anti-hypertensives.
• Recently started or discontinued medications (eg. clonidine).
• Recreational drugs (eg. cocaine, amphetamines, phencyclidine).
• Disease processes (eg. hyperaldosteronism, thyroid storm, autonomic dysreflexia).
• Physiological processes (eg. Pain).
• # weeks gestation if pregnant, or delivery date.
• Baseline BP if known and comorbid medical conditions.
• Previous hypertensive emergencies/pre-existing target organ damage.

Most patients: CBC, Electrolytes, BUN, Creatinine, Glucose, B-HCG.

• Acute Coronary Syndrome
  • Chest pain/anginal equivalents, dyspnea, increased fatigue, vomiting.
  • Murmur or S3 – possible papillary dysfunction, diaphoretic.
  • ECG, troponin (+ repeat if indicated by site/guidelines).

• Aortic Dissection
  • Chest pain/anginal equivalents, back/abdo pain, neurological deficits, syncope.
  • Unequal BP (>20 mmHg) in extremities, pulse differential, focal neurological deficits.
  • CXR, POCUS – for dissection flap,
  • CT Chest with contrast,
  • Troponin – coronary dissection.

• Acute heart failure/pulmonary edema
  • Dyspnea, increased fatigue, orthopnea, cough.
  • Murmur or S3, edema, crackles on auscultation, elevated JVP, hypoxia.
  • CXR, ECG, POCUS – myocardial function, TSH, Liver enzymes.

• • Ischemic stroke, intracranial hemorrhage, hypertensive encephalopathy
    • Altered mental status, neurological deficits focal and non-focal, vomiting (raised ICP).
    • CN abnormalities, power/sensation/reflex/cerebellar deficits.
    • INR/PTT, CT Head with + without contrast.

• Pregnancy
  • Pre-eclampsia:
    • Headache, visual disturbance, abdominal pain (RUQ).
    • RUQ pain, edema.
    • B-HCG, CBC, Creatinine, Liver enzymes for HELLP syndrome, urine dip – for protein.
  • Eclampsia:
    • Seizures.

•  Acute kidney injury
  • Decreased urine output.
  • Edema.
  • Creatinine.

•  Sympathomimetics
  • Various presentations, chest pain – cocaine vasospasm, acute heart failure.
  • Hyperthermic.
  • Urine toxicology – cocaine, amphetamines, phencyclidine.

• Hypertensive retinopathy
  • Blurred vision or visual field defects.
  • Fundoscopy flame hemorrhages and exudates.

• Elevated BP without target organ damage (Hypertensive Urgency/Severe Asymptomatic Hypertension) requires no emergent treatment.
• For Hypertensive Emergencies manage target organ damage/reduce complications.
• No RCTs show improved morbidity/mortality benefits from treatment but expert consensus and guidelines suggest high likelihood of benefit.

• Monitored bed, regular BP monitoring.
• 1^st hour: reduce SBP (or MAP) 20-25% (ideally within minutes for eclampsia and aortic dissections).
• 2-6 hrs: subsequent reduction to <160 mmHg Systolic and <100-110 mmHg Diastolic.
• 24-48 hrs: Return to baseline BP if known, <140/90 if unknown (low evidence).

• No single antihypertensive agent is recommended.
• Use intravenous medications.
• Rapid-acting sublingual or oral medications (nitroglycerin spray, captopril) can be useful while setting up infusion/lack of IV access.

Specific Considerations

Acute LV Failure with Pulmonary Edema

• Nitroglycerin OR Sodium Nitroprusside.
• Furosemide.
• Avoid hydralazine (increased cardiac work) and beta-blockers (decreased cardiac contractility).

Acute Coronary Syndromes

• Nitroglycerin OR Labetalol OR Esmolol.
• Avoid hydralazine (increased cardiac work).

Aortic Dissection

• Rapid HR reduction in first 10 minutes to <60.
• BP reduction to <120 mmHg in first 20 min, discussion with ICU on need for arterial line.
• Labetalol OR Esmolol OR Metoprolol OR Nitroglycerin OR Sodium Nitroprusside.

Eclampsia/Pre-eclampsia

• Magnesium sulfate in eclampsia.
• Nifedipine OR Labetalol OR Hydralazine OR Methyldopa in pre-eclampsia.

Hypertensive Encephalopathy

• Diagnosis of exclusion after ruling out intracranial pathology.
• Labetalol OR Hydralazine.
• Avoid sodium nitroprusside if suspected ICP due to intracerebral shunting.

Acute Ischemic Stroke

• Higher MAP essential to perfusion. BP should not be lowered acutely except at extremes (some clinicians use >220/120). Gradual BP reduction should occur.
• Thrombolysis contraindicated with extreme hypertension due to risk of bleeding. Lower BP to <185/110 pre-treatment and maintain <185/105 throughout treatment.
• Labetalol OR Hydralazine OR Enalapril often used.

Acute Intracranial Hemorrhage

• Systolic BP >220 mmHg can be harmful.
• Debate exists over target BP, <140 mmHg or <180 mmHg systolic often used.
• Labetalol OR Esmolol OR Enalapril OR Phentolamine.

Sympathomimetics

• While not target organ damage, it may mimic other presentations (ACS, encephalopathy) and additional medications can be considered.
• IV Lorazepam for stimulants.
• Phentolamine OR Nitroglycerin OR Sodium Nitroprusside.
• Avoid beta-blockers (risk abrupt BP rise/coronary vasoconstriction due to catecholamines on unblocked alpha receptors).

• Hypertensive Emergencies should be admitted to ICU for BP monitoring, intravenous antihypertensives, and target organ damage management.

• A patient with a Hypertensive Emergency should not be discharged home.
• If no target organ damage, the patient does not require immediate treatment and can be discharged home (ie. Hypertensive Urgency/Severe Asymptomatic Hypertension).
  • A patient with SBP >180 or DBP > 110 DBP can be diagnosed with hypertension according to Hypertension Canada guidelines.
  • No immediate lowering of BP is necessary and rapid lowering of BP (IV meds) may cause harm due to the shifted autoregulation of BP; however,
  • Canadian Emergency Medicine Cardiac Research and Education Group advises to consider oral antihypertensive therapy for these individuals >180 SBP or 110 DBP and to initiate treatment for SBP >230 or DBP >130.
  • Follow-up should be arranged within 7 days and electrolytes checked within 1 week for ACE/ARB initiation.

• Figure 11 of AHA Guidelines.
• Table 19 of AHA Guidelines.
• Table 20 of AHA Guidelines.

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2. Papadopoulos D, Sanidas E, Viniou N, et al. Cardiovascular Hypertensive Emergencies. Curr Hypertens Rep.2015, 17:5.

   
   

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4. Baumann B, Cline D, Pimenta E. Treatment of Hypertension in the Emergency Department. Journal of the American Society of Hypertension. 2011, 5(5):366-377

   
   

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