High Blood Pressure and Hypertensive Crisis

Hypertensive crisis comprises a spectrum of conditions, including hypertensive urgency

and hypertensive emergency. When blood pressure gets critically high, organ damage
may occur.

Hypertensive Urgency

Hypertensive urgency occurs when blood pressure spikes, but there is no damage to the
body's organs as a result and blood pressure can be brought down safely within a few
hours with blood pressure medication.

Hypertensive Emergency

When organ damage occurs as a result of severely elevated high blood pressure, this is
considered a hypertensive emergency. When this occurs, blood pressure must be reduced
immediately to prevent organ damage. This is done in an intensive care unit of a hospital.

Organ damage associated with hypertensive emergency may include:

• Changes in mental status such as confusion or coma (encephalopathy).

• Bleeding into the brain (stroke).
• Heart failure.
• Chest pain (angina).
• Fluid in the lungs (pulmonary edema).
• Heart attack.
• Aneurysm (Bulging blood vessel).
• Eclampsia (occurs during pregnancy).

Fortunately, hypertensive emergency is rare. When it does occur, it is often when

hypertension goes untreated or if the patient does not take his or her medication.

Symptoms of Hypertensive Emergency

Symptoms of a hypertensive emergency include:

• Headache
• Seizure
• Chest pain
• Shortness of breath
• Swelling or edema (fluid buildup in the tissues)

Diagnosing Hypertensive Emergency

To diagnose a hypertensive emergency, the health care provider will ask you several
questions to get a better understanding of your medical history. He or she will also need
to know all medications you are taking including nonprescription and recreational drugs.
Also, be sure to tell them if you are taking any herbal or dietary supplements.

Certain tests will be given to monitor blood pressure and assess organ damage, including:

• Regular monitoring of blood pressure.

• Eye exam to look for swelling and bleeding.
• Blood and urine testing.

What's the Treatment for Hypertensive Emergency and Associated Organ

Damage?

In a hypertensive emergency, the first goal is to bring down the blood pressure as quickly
as possible with intravenous (IV) blood pressure medications to prevent further organ
damage. Whatever organ damage that has occurred is treated with therapies specific to
the organ that is damaged.

Background

Approximately 50 million people in the United States are affected by hypertension

(HTN).1,2 Substantial improvements have been made with regards to improving awareness
and treatment of hypertension. However, approximately 30% of adults are still unaware
of their hypertension; up to 40% of people with hypertension are not receiving treatment;
and, of those treated, up to 67% do not have their blood pressure (BP) controlled to less
than 140/90 mm Hg.3

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New data have shown an increased lifetime risk of hypertension and have also
highlighted the increased risk of cardiovascular complications with BP levels previously
considered to be normal. Given this information, the Joint National Committee (JNC-7)
has introduced a new classification system for hypertension.3

• Prehypertension - Systolic blood pressure (SBP) 120-139 mm Hg or diastolic

blood pressure (DBP) 80-89 mm Hg
• Stage I hypertension - SBP 140-159 mm Hg or DBP 90-99 mm Hg
• Stage II hypertension - SBP >160 mm Hg or DBP >100 mm Hg
Hypertensive emergency

Hypertensive emergencies encompass a spectrum of clinical presentations where

uncontrolled BPs lead to progressive or impending end-organ dysfunction (EOD). In
these conditions, the BP should be lowered aggressively over minutes to hours.

Acute end-organ damage4

• Neurological
o Hypertensive encephalopathy
o Cerebral vascular accident/cerebral infarction
o Subarachnoid hemorrhage
o Intracranial hemorrhage
• Cardiovascular
o Myocardial ischemia/infarction
o Acute left ventricular dysfunction
o Acute pulmonary edema
o Aortic dissection
• Other
o Acute renal failure/insufficiency
o Retinopathy
o Eclampsia
o Microangiopathic hemolytic anemia

With the advent of antihypertensives, the incidence of hypertensive emergencies has

declined from 7% to approximately 1% of patients with hypertension.5 In addition, the 1-
year survival rate associated with this condition has increased from only 20% (prior to
1950) to a survival rate of more than 90% with appropriate medical treatment.6

Emergency department considerations

Many patients present to the emergency department (ED) with elevated blood pressures;
however, only a small proportion of patients will require emergent treatment.

The primary goal of the emergency physician (EP) is to determine which patients with
acute hypertension are exhibiting symptoms of end-organ damage and require immediate
intravenous parenteral therapy. In contrast, patients presenting with acutely elevated
blood pressures (SBP >200 mm Hg or DBP >120 mm Hg) without symptoms require
initiation of medical therapy and close follow-up in the outpatient setting.7

Optimal control of hypertensive situations balances the benefits of immediate decreases

in BP against the risk of a significant decrease in target organ perfusion. The EP must be
capable of the following:

• Appropriately evaluating patients with an elevated BP

• Correctly classifying the hypertension
 • Determining the aggressiveness and timing of therapeutic interventions
• Making disposition decisions

An important point to remember in the management of the patient with any degree of BP
elevation is to "treat the patient and not the number."

Pathophysiology

The pathophysiology of hypertensive emergencies is not well understood. Failure of

normal autoregulation and an abrupt rise in systemic vascular resistance (SVR) are
typically initial steps in the disease process. Increases in SVR are thought to occur from
the release of humoral vasoconstrictors from the wall of a stressed vessel. The increased
pressure within the vessel then starts a cycle of endothelial damage, local intravascular
activation of the clotting cascade, fibrinoid necrosis of small blood vessels, and the
release of more vasoconstrictors. If the process is not stopped, a cycle of further vascular
injury, tissue ischemia, and autoregulatory dysfunction ensues.8,9

Single-organ involvement is found in approximately 83% of patients presenting with

hypertensive emergencies. Two-organ involvement is found in 14% of patients, and
multiorgan involvement (>3 organ systems) is found in approximately 3% of patients
presenting with a hypertensive emergency.10

The most common clinical presentations of hypertensive emergencies are cerebral

infarction (24.5%), pulmonary edema (22.5%), hypertensive encephalopathy (16.3%),
and congestive heart failure (12%). Less common presentations include intracranial
hemorrhage, aortic dissection, and eclampsia.10

Central nervous system

Cerebral autoregulation is the inherent ability of the cerebral vasculature to maintain a

constant cerebral blood flow (CBF) across a wide range of perfusion pressures.

Patients with chronic hypertension can tolerate higher mean arterial pressures (MAP)
before they have disruption of their autoregulation system. However, such patients also
have increased cerebrovascular resistance and are more prone to cerebral ischemia when
flow decreases, especially if blood pressure is decreased into normotensive ranges.

Rapid rises in blood pressure can cause hyperperfusion and increased CBF, which can
lead to increased intracranial pressure and cerebral edema.11

Hypertensive encephalopathy is one of the clinical manifestations of cerebral edema and

microhemorrhages seen with dysfunction of cerebral autoregulation and is characterized
by hypertension, altered mentation, and papilledema.12

Cardiovascular system
Chronic hypertension causes increased arterial stiffness, increased systolic BP, and
widened pulse pressures. These factors act to decrease coronary perfusion pressures,
increase myocardial oxygen consumption, and lead to left ventricular hypertrophy.12
During hypertensive emergencies, the left ventricle is unable to compensate for an acute
rise in systemic vascular resistance. This leads to left ventricular failure and pulmonary
edema or myocardial ischemia.4

Renal system

Chronic hypertension causes pathologic changes to the small arteries of the kidney. The
arteries develop endothelial dysfunction and impaired vasodilation, which alter renal
autoregulation. When the renal autoregulatory system is disrupted, the intraglomerular
pressure starts to vary directly with the systemic arterial pressure, thus offering no
protection to the kidney during BP fluctuations. During a hypertensive crisis, this can
lead to acute renal ischemia.4

Frequency

United States

The prevalence of hypertension in the United States from 2003-2004 was approximately
29.3%.13 Although significant increases have been made in the control of hypertension,
the prevalence of the disease has not decreased.

Factors independently associated with hypertension include age older than 40 years,
obesity (body mass index >30 kg/m3), and race (non-Hispanic black race).13 Prevalence of
the disease increases with advancing age such that approximately half of people aged 60-
69 years and three quarters of people aged 70 years or older are affected by
hypertension.3

Hypertensive crises affect less than 1% of hypertensive adults in the United States.14

International

Worldwide, approximately 1 billion people have hypertension, contributing to more than

7.1 million deaths per year.15

Mortality/Morbidity

Death from both ischemic heart disease and stroke increase progressively as the BP
increases. For every 20 mm Hg systolic or 10 mm Hg diastolic increase in blood
pressures above 115/75 mm Hg, the mortality rate for both ischemic heart disease and
stroke doubles.3

The morbidity and mortality of hypertensive emergencies depend on the extent of EOD
on presentation and the degree to which BP is controlled subsequently. With BP control
and medication compliance, the 10-year survival rate of patients with hypertensive crises
approaches 70%.16

Race

Hypertension develops at an earlier age, leads to more clinical sequelae, and is more
common and severe in African Americans compared with age-matched non-Hispanic
whites.17 Hypertensive crises are also more common in African Americans compared with
other races.

The prevalence and incidence of hypertension in Mexican Americans are similar to or

lower than those in non-Hispanic whites.18 In general, Mexican Americans and Native
Americans have lower BP control rates than non-Hispanic whites and African
Americans.19

Sex

The lifetime risk for hypertension is 86-90% in females and 81-83% in men.3

Age

Hypertensive crises are more common among elderly persons.

Clinical
History

The history should focus on the presence of end-organ dysfunction (EOD), the
circumstances surrounding the hypertension, and any identifiable etiology. The history
and physical examination determine the nature, severity, and management of the
hypertensive event.

• Medications
o Details of antihypertensive drug therapy and compliance
o Intake of over-the-counter preparations such as sympathomimetic agents
o Use of illicit drugs such as cocaine
• Duration and severity of preexisting hypertension
• Degree of BP control
• Presence of previous EOD, particularly renal and cerebrovascular disease
• Date of last menstrual period
• Other medical problems (eg, prior hypertension, thyroid disease, Cushing disease,
systemic lupus, renal disease)
• Assess whether specific symptoms suggesting EOD are present.
o Chest pain - Myocardial ischemia or infarction
o Back pain - Aortic dissection
 o Dyspnea - Pulmonary edema, congestive heart failure
o Neurologic symptoms - Seizures, visual disturbances, altered level of
consciousness (hypertensive encephalopathy)

Physical

The physical examination should assess whether EOD is present.

• Vital signs
o BP should be measured in both the supine position and the standing
position (assess volume depletion).
o BP should also be measured in both arms (a significant difference may
suggest aortic dissection).
• Ear, nose, and throat (ENT): The presence of new retinal hemorrhages, exudates,
or papilledema suggests a hypertensive emergency.
• Cardiovascular - Evaluate for the presence of heart failure.
o Jugular venous distension
o Crackles
o Peripheral edema
• Abdomen - Abdominal masses or bruits
• CNS
o Level of consciousness
o Visual fields
o Focal neurologic signs

Causes

The most common hypertensive emergency is a rapid unexplained rise in BP in a patient

with chronic essential hypertension. Most patients who develop hypertensive
emergencies have a history of inadequate hypertensive treatment or an abrupt
discontinuation of their medications.

• Other causes
o Renal parenchymal disease - Chronic pyelonephritis, primary
glomerulonephritis, tubulointerstitial nephritis (accounts for 80% of all
secondary causes)
o Systemic disorders with renal involvement - Systemic lupus
erythematosus, systemic sclerosis, vasculitides
o Renovascular disease - Atherosclerotic disease, fibromuscular
dysplasia, polyarteritis nodosa
o Endocrine - Pheochromocytoma, Cushing syndrome, primary
hyperaldosteronism
o Drugs - Cocaine, amphetamines, cyclosporin, clonidine
withdrawal, phencyclidine, diet pills, oral contraceptive pills
o Drug interactions - Monoamine oxidase inhibitors with tricyclic
antidepressants, antihistamines, or tyramine-containing food
o CNS - CNS trauma or spinal cord disorders, such as Guillain-Barré
syndrome
o Coarctation of the aorta
o Preeclampsia/eclampsia
o Postoperative hypertension