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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- Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266.
- Elliott WJ, Weber RR, Nelson KS, et al. Renal and hemodynamic effects of intravenous fenoldopam versus nitroprusside in severe hypertension. Circulation 1990; 81:970.
- 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.
- Börgel J, Springer S, Ghafoor J, et al. Unrecognized secondary causes of hypertension in patients with hypertensive urgency/emergency: prevalence and co-prevalence. Clin Res Cardiol 2010; 99:499.
- 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
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS