Evaluation and treatment of hypertensive emergencies in adults
- William J Elliott, MD, PhD
William J Elliott, MD, PhD
- Professor of Preventive Medicine, Internal Medicine and Pharmacology
- Head, Division of Pharmacology
- Chair, Department of Biomedical Sciences
- Pacific Northwest University of Health Sciences, Yakima, WA
- Joseph Varon, MD, FACP, FCCP, FCCM, FRSM
Joseph Varon, MD, FACP, FCCP, FCCM, FRSM
- Professor of Acute and Continuing Care, The University of Texas Health Science Center at Houston
- Clinical Professor of Medicine, The University of Texas Medical Branch
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
INTRODUCTION AND TERMINOLOGY
Most patients with significantly elevated blood pressure (systolic pressure ≥180 and/or diastolic pressure ≥120 mmHg) have no acute, end-organ injury (so called severe asymptomatic hypertension). Although some propose relatively rapid initiation of antihypertensive therapy in this setting, there may be more risk than benefit from such an aggressive regimen. (See "Management of severe asymptomatic hypertension (hypertensive urgencies) in adults".)
By contrast, some patients with significantly elevated blood pressure have signs or symptoms of acute, ongoing target-organ damage. Such patients have a hypertensive emergency. Hypertensive emergencies can develop in patients with or without preexisting chronic hypertension [1,2]. Often, the diastolic pressure is ≥120 mmHg, but there is no specific threshold since individuals who develop an acute rise in blood pressure can develop symptoms if the previous pressure was normal (such as in a pregnant woman who develops eclampsia or a young adult who develops acute glomerulonephritis).
The term "malignant hypertension" entered the medical lexicon in 1928 because, at that time, patients with this condition had a prognosis that was similar to patients with many cancers. However, antihypertensive therapies that can quickly and safely lower blood pressure have improved outcomes  and, therefore, the term is now used only by billing and coding personnel.
EVALUATION AND DIAGNOSIS
The history and physical examination in patients presenting with a severely elevated blood pressure (or an acute rise in blood pressure over a previously normal baseline, even if the presenting pressure is <180/120 mmHg) should determine whether or not any of the following are present :
●Acute head injury or trauma
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- Kaplan NM, Victor RG. Chapter 8: Hypertensive Crises. In: Kaplan's Clinical Hypertension, 10th Ed, Lippincott, Williams & Wilkins, Philadelphia 2010. p.274.
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- González R, Morales E, Segura J, et al. Long-term renal survival in malignant hypertension. Nephrol Dial Transplant 2010; 25:3266.
- Brown H, Goldberg PA, Selter JG, et al. Hemorrhagic pheochromocytoma associated with systemic corticosteroid therapy and presenting as myocardial infarction with severe hypertension. J Clin Endocrinol Metab 2005; 90:563.
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- INTRODUCTION AND TERMINOLOGY
- EVALUATION AND DIAGNOSIS
- Overall approach to therapy
- Neurologic emergencies
- Cardiac emergencies
- Vascular emergencies
- Renal emergencies
- Sympathetic overactivity resulting in hypertensive emergencies
- Hypertensive emergencies during pregnancy
- ANTIHYPERTENSIVE DRUGS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS