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 hemorrhage. Ischemic 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.

• Renal Artery Stenosis

  Renovascular disease, e.g. renal artery stenosis Endocrine causes - Pheochromocytoma 3) Management of hypertensive crises HTN urgency - goal to reduce BP to gradually, over days, using PO meds HTN emergency - reduce BP over minutes to hours. [errolozdalga.com]

  Renal artery stenosis, pheochromocytoma (most pheochromocytomas can be localized by using computed tomography [CT] of the adrenals), aortic coarctation, and hyperaldosteronism are also secondary causes of hypertension. [emedicine.medscape.com]

  Aetiology Accelerated or malignant hypertension may be associated with any cause of secondary hypertension.[3] Unilateral renovascular hypertension - eg, renal artery stenosis. Renin-secreting neoplasms. Trauma to the kidneys. [patient.info]

  Renal artery stenosis Glomerulonephritis Chonic pyelonephritis Polycystic kidney disease Endocrine Cushing’s syndrome Conn’s syndrome Acromegaly Hyperthyroidism Phaeochromocytoma Arterial Coarctation of the aorta Drugs Alcohol Cocaine Amphetamines Pregnancy [oxfordmedicaleducation.com]

• Inflammation

  Vasoconstriction, coagulation cascade activation and inflammation of the perivasculature are typical characteristics of endothelial dysfunction. [cancertherapyadvisor.com]

  Meningitis Meningitis is an infection of the spinal fluid causing inflammation of the tissues (the meninges) that line and surround the brain and spinal cord. [levinlaw.com]

  The two categories of hypertensive emergencies Microvascular disorders (e.g. encephalopathy, pre-eclampsia/eclampsia), which are characterized by small vessel dysregulation, with endothelial damage and local inflammation “Macro” vascular disorders (i.e [emergencymedicinecases.com]

• Coarctation of the Aorta

  Some important etiologies to consider: Renal Pathology Glomerulonephritis Hemolytic Uremic Syndrome Wilm’s Tumor Nephrotic syndromes Polycystic kidney disease Renovascular disease Coarctation of the Aorta Neuroendocrine Neuroblastoma Pheochromocytoma [emdocs.net]

  Esmolol as an adjunct in the treatment of systemic hypertension after operative repair of coarctation of the aorta. Am J Cardiol. 1990;65(13):941–943. 49. Wiest DB, Garner SS, Uber WE, Sade RM. [dovepress.com]

  […] of the aorta Drugs Alcohol Cocaine Amphetamines Pregnancy Pre-eclamplsia Pathophysiology of hypertensive emergency Abrupt rise in systemic vascular resistance Failure of normal autoregulatory mechanisms Fibrinoid necrosis of arterioles Damage to red [oxfordmedicaleducation.com]

  Except for rare cases of coarctation of the aorta, the film will not yield a diagnosis in patients with hypertensive crisis. Other radiologic studies. [tele.med.ru]

• Epilepsy

  The following conditions should also be considered when making the diagnosis: stroke, intracranial mass, head injury, epilepsy or postictal state, connective-tissue disease (especially lupus with cerebral vasculitis), drug overdose or withdrawal, cocaine [emedicine.medscape.com]

• Nausea

  Headache was the most common symptom (54.5%), followed by dizziness (45.5%), nausea/vomiting (36.4%) and chest pain (29.1%). A family history of hypertension was a significant predictive factor for the older patients with hypertensive crisis. [ncbi.nlm.nih.gov]

  Nausea or vomiting: Hypertensive crisis can cause people to feel nauseous or throw up by increasing the pressure in the head. [buoyhealth.com]

  Other symptoms of a hypertensive crisis may include blurred vision, nausea or vomiting, dizziness or weakness, and problems thinking, sleeping, and behavior changes. [belmarrahealth.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]

  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]

• Palpitations

  A 51-year-old lady presented with left-sided chest pain, palpitations and headache in the context of significant hypertension after eating soft cheese. [ncbi.nlm.nih.gov]

  – TROUBLES DU RYTHME PALPITATIONS TROUBLES DU RYTHME SUPRA-VENTRICULAIRE TROUBLES DU RYTHME VENTRICULAIRE DÉFIBRILLATEUR AUTOMATIQUE IMPLANTABLE 4– Insuffisance cardiaque ITEM 232 – INSUFFISANCE CARDIAQUE AIGUË ITEM 232 – INSUFFISANCE CARDIAQUE CHRONIQUE [s-editions.com]

  Institute for Health and Care Excellence (NICE) recommends same day referral for accelerated hypertension with papilloedema and/or retinal haemorrhages, or for patients suspected of having a phaeochromocytoma (labile or postural hypotension, headache, palpitations [patient.info]

  Onset: 1 - 2 min Duration: 4 - 12 h Adverse effects: Na retention, hyperglycemia, tachycardia, palpitations, chest pains, sedation & somnolence Oral Medications: Clonidine (Catapres) 0.2 mg PO, followed by 0.1 mg/hr to total of 0.8 mg until the diastolic [enotes.tripod.com]

• Epistaxis

  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]

  Table 4 reports the frequency of signs and symptoms in all hypertensive crises, urgencies, and emergencies; headache, epistaxis, psychomotor agitation, and arrhythmia were more frequent in urgencies than emergencies ( P P P P Discussion The present study [hyper.ahajournals.org]

  […] occurs with retinopathy (flame hemorrhages, papilledema) [2] Clinical features Hypertensive urgency Asymptomatic or nonspecific symptoms Although commonly associated with high blood pressure, isolated findings of nonspecific headache, dizziness, or epistaxis [amboss.com]

• Anuria

  Clinical parameters to identify include systemic hypotension, hypoxia, tachycardia, decreased urine output, and/or frank anuria. Confirmation of pulmonary hypertensive crisis is via invasive hemodynamics, thus the need for perioperative monitoring. [phaonlineuniv.org]

  […] seizures, altered mental status (lethargy, coma, confusion), change in behavior, facial nerve palsy, hemiplegia Kidney Findings include: renal insufficiency/failure Symptoms include: flank pain, dysuria, hematuria, frothy or tea-colored urine, oliguria/anuria [resperate.com]

• Papilledema

  Ischemic or hemorrhagic stroke: focal neurological deficits, altered mental status Renal Acute renal failure: azotemia and/or oliguria, edema Ophthalmic Acute hypertensive retinopathy: blurry vision, decrease in visual acuity, retinal flame hemorrhages, papilledema [amboss.com]

  Hypertensive emergency: same, but symptoms of end organ damage: Neuro: Hypertensive encephalopathy and PRES (posterior reversible encephalopathy syndrome), Stroke: Ischemic, Intraparenchymal bleed, and Subarachnoid bleed, Papilledema and retinal hemorrhages [errolozdalga.com]

  Retinal papilledema and/or fundal bleeds and exudates are another sign of target organ damage. [en.wikipedia.org]

  Urgency is differentiated from emergency cases owing to the lack of organ damage signs such as heart failure, papilledema or aortic dissection. [symptoma.com]

  Fundoscopic exam: evaluate for papilledema, retinal hemorrhage, exudates, cotton wool spots, AV nicking Papilledema, retinal hemorrhage, or exudates may be the only sign of a hypertensive emergency The presence of papilledema should prompt investigation [cancertherapyadvisor.com]

• Vertigo

  […] għandhom jikooperaw mill-qrib fl-ipprogrammar u l-implimentazzjoni tal-programmi transkonfinali relevanti en In the overdose cases below # mg or unknown dose the patients revealed symptoms from central nervous system (confusion, drowsiness, somnolence, vertigo [mt.glosbe.com]

  See also malignant hypertension. observations Characteristic signs include severe headache, vertigo, diplopia, tinnitus, photophobia, nosebleed, twitching of muscles, tachycardia or other cardiac arrhythmia, distended neck veins, narrowed pulse pressure [medical-dictionary.thefreedictionary.com]

  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]

  Dizziness: The dizziness of very high blood pressure is described as vertigo (a sensation that the room is spinning). [highbloodpressure.about.com]

  History Patient may complain of — Chest pain — Dyspnea — Neurologic deficit — Faintness — Paresthesia — Headache — Vertigo — Vomiting — Agitation — Epistaxis Most patients have persistently elevated BP for years before presenting with hypertensive emergency [clinicaladvisor.com]

• Hyperactivity

  Inhibitors Cocaine Amphetamines Anti-hypertensive drug withdrawal or failed compliance Centrally acting anti-hypertensives (eg. clonidine) Peripheral alpha blockers (eg. prazosin) Beta-Blocker acute withdrawal Pre-eclampsia and Eclampsia Autonomic hyperactivity [enotes.tripod.com]

  […] factors which contribute to development of hypertensive crisis: Withdrawal or discontinuation of antihypertensive drugs mainly clonidine Renal diseases which include glomerulonephritis, tubulointerstitial nephritis and chronic pyelonephritis Autonomic hyperactivity [symptoma.com]

  The most common cause is patients with diagnosed, chronic hypertension who have discontinued anti hypertensive medications. [5] Other common causes of hypertensive crises are autonomic hyperactivity such as pheochromocytoma, collagen-vascular diseases [en.wikipedia.org]

  Other common causes are autonomic hyperactivity, collagen-vascular diseases, drug use (stimulants, e.g. amphetamines and cocaine), glomerulonephritis, head trauma, pre-eclampsia and eclampsia, and renovascular hypertension 6. [bjmp.org]

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].

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.

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.

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

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.

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.

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.

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.

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.

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.