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Hypertensive Crisis

Hypertensive crisis is a severe increase in blood pressure and can present as hypertensive urgency or as a hypertensive emergency.


Presentation

The clinical presentation of hypertensive crisis varies from individual to individual. The manifestations of this crisis are mainly associated with end organ dysfunction, which does not happen with diastolic readings lower than 130mm Hg. Though the rate at which the pressure is rising is more important than absolute readings.

Patients suffering from hypertensive encephalopathy will present with headache, vomiting, altered levels of consciousness and may show focal neurological signs. During a crisis, cardiac signs are angina or an acute myocardial infarction or left ventricular failure. Other symptoms include dyspnea, orthopnea, cough, chest pain, epistaxis, vertigo, and fatigue.
Damage to the kidneys present as oliguria or hematuria and proteinuria which can ultimately lead to acute renal failure. Eyes may show retinal hemorrhageIschemic stroke and pulmonary edema are common end organ complications which occur. Other end organ dysfunctions include congestive heart failure, cerebral vascular trauma and acute renal injury. Hypertensive emergency usually results in quick deterioration of end organs which is not the case in hypertensive urgency.

Hoarseness
  • He presented with recent onset of hoarseness of voice and was found to have a vocal cord nodule. He developed a hypertensive crisis during surgery. He was subsequently evaluated and found to have bilateral phaeochromocytoma.[ncbi.nlm.nih.gov]
Regurgitation
  • Echocardiography demonstrated mild left ventricular dysfunction [median shortening fraction (SF) 25%, range 10-30] and mild aortic regurgitation in 83% (5/6) of patients.[ncbi.nlm.nih.gov]
  • Beta-blockers should be avoided if there is aortic valvular regurgitation or suspected cardiac tamponade. Keep the SBP 110 mmHg unless signs of end-organ hypoperfusion exists 28 .[bjmp.org]
  • However, avoid beta-blockers if there is aortic valvular regurgitation or suspected cardiac tamponade.[emedicine.medscape.com]
Hypertension
  • These changes include a modification in terminology replacing 'malignant hypertension' with 'hypertensive crisis with retinopathy and reclassification of hypertensive crisis with retinopathy under hypertensive emergencies instead of urgencies.[ncbi.nlm.nih.gov]
  • RESULTS: The mean systolic/diastolic BP in the hypertensive crisis patients was 161/102 mmHg. The major causes of hypertensive crisis were essential hypertension, renal disorders and endocrine/metabolic disorders.[ncbi.nlm.nih.gov]
  • Hypertensive crisis is a severe increase in blood pressure and can present as hypertensive urgency or as a hypertensive emergency. The clinical presentation of hypertensive crisis varies from individual to individual.[symptoma.com]
  • BACKGROUND: Hypertensive crisis is an extreme phenotype of hypertension and hypertension-related thrombotic complications. This is most evident in patients with hypertensive crisis having advanced retinopathy and thrombotic microangiopathy (TMA).[ncbi.nlm.nih.gov]
  • Hypertension affects 10% of pregnancies, many with underlying chronic hypertension, and approximately 1-2% will undergo a hypertensive crisis at some point during their lives.[ncbi.nlm.nih.gov]
Diastolic Murmur
  • A diastolic murmur indicates aortic dissection. Determination of rales on examination heavily suggests vascular congestion and pulmonary edema. Complete neurological examination for presence of focal neurological signs should be done.[symptoma.com]
Flame-shaped Hemorrhage
  • Grade 3 (white cotton wool spots, flame shaped hemorrhage and yellow white exudates) and grade 4 (papilledema along with hemorrhage and exudates) retina changes are cardinal features of hypertensive emergency.[symptoma.com]
Epistaxis
  • Oxymetazoline nasal spray is not FDA approved for use in children less than 6 years; however, its safety and efficacy are widely accepted, and it is in widespread use in children prior to procedures that may lead to epistaxis.[ncbi.nlm.nih.gov]
  • Renal failure may be suspected if oliguria and/or hematuria is present Patients may also present with acute myocardial infarction (AMI) or angina Hypertensive urgency patients may present with: S evere headache, shortness of breath, chest pain, edema, epistaxis[specialty.mims.com]
  • Hypertensive urgencies frequently present with headache (22%), epistaxis (17%), faintness, and psychomotor agitation (10%) and hypertensive emergencies frequently present with chest pain (27%), dyspnea (22%) and neurological deficit (21%).[ncbi.nlm.nih.gov]
  • Other symptoms include dyspnea, orthopnea, cough, chest pain, epistaxis, vertigo, and fatigue.Damage to the kidneys present as oliguria or hematuria and proteinuria which can ultimately lead to acute renal failure. Eyes may show retinal hemorrhage.[symptoma.com]
Facial Edema
  • Between diagnosis and planned tumor removal, the patient developed signs and symptoms of Cushing's syndrome (facial edema and hirsutism, myopathy and fatigue).[ncbi.nlm.nih.gov]
Flaccid Paralysis
  • We describe a case of a 62-year-old woman presented to the emergency department for hypertensive crisis with symmetric flaccid paralysis, hypotonia and hyporeflexia of both upper and lower limbs.[ncbi.nlm.nih.gov]
Mental Deterioration
  • She promptly developed mental deterioration, blurred vision, worsening respiration, tachycardia, and hypertension.[ncbi.nlm.nih.gov]

Workup

The most important aspect in managing such cases is immediate recognition and prompt treatment. Early diagnosis and therapy is the key to successfully keeping blood pressure under control and preventing life threatening complications. Diagnosis protocol should include a complete medical history evaluation, physical examination and laboratory tests for confirmation [7].

A complete evaluation of medical history includes prior blood pressure readings, current medications the patient is on and any complaints the patient is suffering from. Once this has been ascertained, the blood pressure is measured on both the arms to understand whether this condition is a hypertensive emergency or urgency. Measuring BP in supine and standing position is also mandatory. Determining this fact is vital to plan the appropriate mode of treatment. Palpation of all pulses on all extremities is also essential.

A complete fundoscopic examination is performed which includes head and neck examination as well. Grade 3 (white cotton wool spots, flame shaped hemorrhage and yellow white exudates) and grade 4 (papilledema along with hemorrhage and exudates) retina changes are cardinal features of hypertensive emergency. Auscultation for new murmurs should be done. A diastolic murmur indicates aortic dissection. Determination of rales on examination heavily suggests vascular congestion and pulmonary edema. Complete neurological examination for presence of focal neurological signs should be done. Delirium indicates hypertensive encephalopathy which is a diagnosis of exclusion. Other neurological conditions have to be eliminated.

Laboratory investigations include a complete blood count, serum electrolytes, blood urea nitrogen (BUN), creatinine and urine analysis should always be done. Creatinine should always be compared to previous readings to detect renal impairment. Electrocardiogram should be done to detect any myocardial infarction or left ventricular failure. Chest X-ray should also be done to exclude vascular congestion or pulmonary edema. Computed tomography of head is advised for determining any neurological signs. Certain investigations are done parallel to initiation of antihypertensive drugs [8].

White Matter Lesions
  • Once blood pressure was controlled and indinavir replaced by nelfinavir, white matter lesions at magnetic resonance imaging disappeared.[ncbi.nlm.nih.gov]
  • Cognitive decline associated with worsening of white matter lesions: a 6-year follow-up study. J Stroke Cerebrovasc Dis. 1996; 6 : 106–109. F Google Scholar 292 Schmidt R, Fazekas F, Kapeller P, Schmidt H, Hartung HP.[doi.org]
Hepatocellular Carcinoma
  • Radiofrequency ablation (RFA) is a minimally invasive procedure that has been considered as a relatively safe treatment for patients with small hepatocellular carcinoma (HCC).[ncbi.nlm.nih.gov]
  • A 73-year-old man with hepatocellular carcinoma was scheduled to undergo right hemi-hepatectomy.[ncbi.nlm.nih.gov]

Treatment

Management of hypertensive crisis mainly revolves on the type of prevention and extent of involvement of end organs. A number of antihypertensive drugs are now available which can be given orally or intravenously. In a patient presenting with hypertensive crisis, the first goal should be to reduce the systolic and diastolic pressure immediately which should be followed by trying to reduce vascular damage, and reverse the pathological reaction. In any emergency situation, usually intravenous sodium nitroprusside injection is given which has rapid blood pressure lowering effects. Blood pressure reduction should be done gradually and never abruptly. A rather sudden and rapid lowering of blood pressure can lead to cerebral, coronary, or renal infarct.

  • Hypertensive urgency cases can be controlled with oral medications with graded dosages and avoiding too large doses at one time. Blood pressure should be reduced to 160/110mm Hg over a period of few days. Specific oral medications such as captopril, clonidine, labetalol or prazosin are given which have slightly slower onset of action. Follow up is important.
  • Hypertensive emergency is usually managed in an intensive care setup with a continuous monitoring of blood pressure. Immediate admission to I.C.U. is required [9]. Treatment should be individualized according to the level of morbidity and end organ damage. Patients with volume depletion should be administered intravenous saline. Administration of vasodilator drugs to allow a slow drop of blood pressure. In case of neurological emergencies such as encephalopathy and ischemic stroke, gradual drop in blood pressure should be done. Intravenous administration of short acting drugs such as nitrates, fenoldopam, nicardipine or even labetalol. The aim of therapy should be to reduce mean arterial pressure (MAP) by about 20-25% in about one to two hours. The choice of drugs used will be influenced by end organ involvement. A reduction in BP is required not achieving a normal BP. Thus, the thumb rule in managing such emergencies is IV medication, oxygen supply and persistent monitoring. In spite of blood pressure elevated always keep a tab on patient's fluid levels.

Prognosis

Hypertensive crisis is a serious and fatal condition if not treated and managed well. The survival rate is only about three years after a crisis, if no medical treatment is given. The rates of mortality and morbidity depend upon the level of organ dysfunction and how well the blood pressure is controlled [5]. Risks for people with poorly controlled blood pressure are heart and brain disease. Main causes for death in people with uncontrolled blood pressure are ischemic heart attack and stroke. Hypertensive crisis tends to affect African Americans more than other races. Regularly adhering to medication [6] and control over blood pressure reduces the rate of mortality and morbidity drastically.

Etiology

A combination of many factors and conditions contributes to a sharp rise in the blood pressure. The most common reason for sudden elevation in blood pressure is forgetting a dose of antihypertensive medication. Discontinuation of antihypertensive medication without medical guidance is also another factor which leads to such a hypertensive crisis. This condition mostly occurs in patients with previous history of hypertension.

Certain factors which contribute to development of hypertensive crisis:

  1. Withdrawal or discontinuation of antihypertensive drugs mainly clonidine
  2. Renal diseases which include glomerulonephritis, tubulointerstitial nephritis and chronic pyelonephritis
  3. Autonomic hyperactivity
  4. Collagen vascular disorders such as systemic lupus erythematosus, systemic sclerosis and vasculitis
  5. Drugs: Cocaine, cyclosporine, amphetamines
  6. Endocrine causes like Cushing syndrome or pheochromocytoma
  7. Eclampsia or Preeclampsia
  8. Coarctation of the aorta
  9. Neoplasias
  10. Head trauma

Epidemiology

Hypertension is a common clinical condition affecting almost one billion individuals worldwide. In the United States of America, 50 million people are affected. Many cases remain undiagnosed which may result in a crisis at some point of time. Hypertension affects men more than women and the rate of incidence increases with age. Survey suggests that only about 15-30% patients of hypertension in the United States have an adequate control over their blood pressure. About 1% of patients suffering from hypertension will suffer from hypertensive crisis at some point, which was much higher prior to advent of antihypertensive drugs.

The epidemiological rate of hypertensive crisis is almost parallel to the distribution of individuals affected with essential hypertension, though much higher in elderly and affecting men twice more than women. Most of the people who present with an emergency [2] or crisis are patients who have been on antihypertensive medications as they have been diagnosed with clinical hypertension. The reason for a large number of hypertensive crisis nowadays in spite of a large number of new drugs available is chiefly due to failure to adhere to the medication regime. Most of the hospital admissions for a hypertensive crisis are mainly due to a skipped medication. Over the past four decades, the incidence of hypertensive crisis [3] has dramatically risen although antihypertensive drugs widely available. The rates of hospital admissions for hypertensive crisis have almost tripled over the past few years.

Sex distribution
Age distribution

Pathophysiology

The development of hypertensive crisis is indirectly related to the severity of underlying hypertension, as a result of which the stress to the vessel wall appears to be the main pathology [4] responsible for this condition. This vascular endothelium is responsible for maintaining blood pressure levels in the body. The mechanical stress on the wall triggers release of vasoconstrictor substances which perpetuate a crisis. A rising blood pressure leads to damage to the endothelial wall leading to activation of clotting cascade, necrosis of smaller blood vessels, fibrin and platelet deposition and vasoconstrictor substance release from the kidneys. This leads to disruption of the normal autoregulatory function which further prompts release of more vasoconstrictor substances and a vicious cycle results. Body fluid depletion further stimulates the kidneys to continue releasing the vasoconstrictor substances due to the spontaneous natriuresis. Thus, an increased production of renin leads to continuous stimulation of vasoconstrictor substances which elevates blood pressure. A persistent elevation of blood pressure leads to tissue ischemia and further end organ damage. This vicious cycle causes continued damage to the endothelium.
Thus the activation of renin angiotensin system seems to play a major role in the pathogenesis of this condition.

Prevention

Patient education is the key to preventing a hypertensive crisis. Widespread education regarding how to prevent uncontrolled blood pressure is essential. Certain parameters can lead to uncontrolled blood pressure such as increasing age, hyperlipidemia, uncontrolled diabetes and skipping hypertensive medications. Follow up with a medical provider is crucial for prevention of such a crisis. For uncontrolled [10] hypertension, a more aggressive form of therapy should be approached. Widespread patient education on weight, diet and exercise for avoidance of diabetes mellitus, blood pressure, cardiovascular disease and hyperlipidemia should be done. All these medical conditions are closely interlinked and a balance has to be maintained. Importance should be laid on adherence of medication to prevent stroke and cardiovascular conditions.

Summary

Hypertension is a common clinical condition encountered regularly by medical practitioners in increasing numbers. Hypertension is a chronic systemic disorder [1] wherein a high blood pressure leads to damage of the heart, blood vessels and other organs of the body gradually over a period of time if not managed well. It is possible that a critical elevation of blood pressure (BP) (diastolic BP>130 mmHg or systolic BP>220 mmHg) may occur which may warrant rapid lowering of BP in a hospital setting. These conditions are usually characterized by target organ dysfunction, and constitute hypertensive emergencies or urgencies. The definition of these entities does not solely depend on the level of BP, but also on the extent of vascular and target organ damage.

Immediate and prompt treatment is required to reduce the extent of morbidity and mortality. The therapeutic goal should be to arrest or reverse the target organ damage by immediate control of hypertension within minutes to hours. A diuretic therapy is never required as there is volume depletion in this condition. The quicker the blood pressure is controlled, the lesser are the chances of complications for the patient.

Hypertensive crisis is a broad term which basically includes two conditions, one being a hypertensive urgency wherein there is elevation of blood pressure without organ damage and the other a hypertensive emergency where along with a rapid elevation of blood pressure organ damage can occur. These emergencies should be controlled immediately and usually done in a hospital setting, as it can be life threatening. It is of utmost importance to differentiate between both the conditions in order to plan the mode of therapy. Any sudden spike in blood pressure should be treated immediately either with oral or intravenous medications.

Patient Information

Hypertensive crisis is a broad term which encompasses two conditions that is hypertensive urgency and hypertensive emergency. In both conditions, there is an sharp elevation of blood pressure which can lead to organ damage and life threatening conditions, more so in emergency as compared to urgency. Hypertensive urgency results when blood pressure readings cross 180/110mmHg but no damage to any organs of the body occurs. This pressure can be lowered by oral medications over a couple of hours. Urgency is differentiated from emergency cases owing to the lack of organ damage signs such as heart failure, papilledema or aortic dissection. Any of these signs surely indicate hospital admission without further delay to prevent further deterioration of the vital organs. This usually occurs when diastolic readings shoot to more than 120 mm Hg. Along with this, patient may experience altered consciousness, heart attack, chest pain, memory loss and damage to vital organs such as heart, kidneys, lungs and eyes. Medical assistance is required immediately in such cases if you experience any of the above symptoms.

The most common reason for such a crisis is skipping of regular antihypertensive medications or if a patient is unable to control the blood pressure. With increasing prevalence of hypertension, it is vital for early identification of condition, prompt treatment and management. Of both the types emergency is least common, being only about 5% of cases. Thus to prevent such a crisis, managing your blood pressure is the key.

References

Article

  1. Aggarwal M, Khan IA. Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin. 2006 Feb. 24(1):135-46.
  2. Shayne PH, Pitts SR. Severely increased blood pressure in the emergency department. Ann Emerg Med. 2003 Apr. 41(4):513-29.
  3. Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension. 1996 Jan. 27(1):144-7.
  4. Slovis CM, Reddi AS. Increased blood pressure without evidence of acute end organ damage. Ann Emerg Med. 2008 Mar. 51(3 Suppl):S7-9.
  5. Amraoui F, Van Der Hoeven NV, Van Valkengoed IG, et al. Mortality and cardiovascular risk in patients with a history of malignant hypertension: a case-control study. J Clin Hypertens (Greenwich). 2014 Feb. 16(2):122-6.
  6. Vadera R. Does antihypertensive drug therapy decrease morbidity or mortality in patients with a hypertensive emergency? Ann Emerg Med. 2011 Jan. 57(1):64-95.
  7. Varon J, Marik PE. Review: the diagnosis and management of hypertensive crisis. Chest. 2000 Jul; 118(1):214–27.
  8. Marik PE, Varon J. Hypertensive crises: challenges and management. Chest. 2007 Jun;131(6):1949–62.
  9. Vidt DG. Emergency room management of hypertensive urgencies and emergencies. J Clin Hypertens. (Greenwich) 2001 May-Jun;3(3):158–64.
  10. Egan BM, Basile JN. Controlling blood pressure in 50% of all hypertensive patients: an achievable goal in the Healthy People 2010 report?. J Investig Med. 2003 Nov;51(6):373–85.

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Last updated: 2019-07-11 21:15