Definition
The terms HU and HE were proposed as an operational classification of HC in 1993 by the V Joint National Committee on Detection Evaluation and Treatment of High Blood Pressure.1 The HUs are symptomatic clinical situations in which there is significant BP elevation (arbitrarily defined as DBP ≥ 120 mm Hg) without acute and progressive TOD.2,3 The HEs are symptomatic clinical situations in which there is significant BP elevation (arbitrarily defined as DBP ≥ 120 mm Hg) with acute and progressive TOD.2,3
Patients complaining from headache, atypical chest pain, dyspnea, acute psychological stress, and panic syndrome associated with high BP levels characterize neither HU nor HE, but rather a pseudo hypertensive crisis. Treatment comprises the optimization of antihypertensive drugs and raising awareness about treatment adherence.
Classification
Chart 1 shows the classification of HE, and Chart 2 differentiates HU from HE regarding diagnosis, prognosis and management.
Differences in the diagnosis, prognosis and management of hypertensive urgency and emergency
Major epidemiological, pathophysiological and prognostic aspects
Epidemiology
Hypertensive crisis accounts for 0.45-0.59% of all hospital emergency treatments, while HE accounts for 25% of all cases of HC, ischemic stroke and APE, which are the most frequent HEs.4-6
Pathophysiology
Increased intravascular volume and PVR, or reduced production of endogenous vasodilators seem to precipitate greater vascular reactivity, resulting in HC.7 Self-regulation is compromised, particularly in the cerebral and renal vascular beds, resulting in local ischemia, which triggers a vicious circle of vasoconstriction, myointimal proliferation and target-organ ischemia.8
Prognosis
Survival up to 5 years is significantly higher in individuals with HU than with HE.4,9 Absence of nocturnal dipping associates with higher risk for TOD and consequent endothelial dysfunction, a situation involved in acute BP elevation.10
Complementary clinical and laboratory investigation
Clinical and laboratory investigation should properly assess BP and TOD. Initially, BP should be measured in both arms, preferably in a calm environment, and repeatedly until stabilization (minimum of 3 measurements). Data on the patient's usual BP should be rapidly collected, as well as information on situations that can raise it (anxiety, pain, salt), comorbidities, use of antihypertensive drugs (dosage and adherence) or drugs that can increase BP (anti-inflammatory drugs, corticoids, sympathomimetic drugs, alcohol). A systematic approach helps to check for the presence of acute and progressive TOD:
Cardiovascular system: chest, abdominal or back pain or discomfort; dyspnea, fatigue and cough. Assessment of HR, heart rhythm, pulse changes, gallop rhythm, cardiac and vascular murmurs, jugular venous distension, and pulmonary, abdominal and peripheral congestion. Exams requested based on clinical findings and availability: ECG, electrocardiographic monitoring, O2 saturation, chest X ray, echocardiogram, myocardial necrosis markers, blood cell count with platelets, LDH-C, CT angiography and MRI.
Nervous system: dizziness, headache, impaired vision, hearing or speech, consciousness or coma level, agitation, delirium or confusion, focal deficits, neck stiffness, convulsion. Exams: tomography, MRI and lumbar puncture.
Renal and genitourinary system: changes in urine volume, micturition frequency or urine aspect, hematuria, edema, dehydration, abdominal masses and murmurs. Exams: urinalysis, serum creatinine, serum urea, Na+, K+, Cl-, blood gas analysis.
Retinal exam: papilledema, hemorrhages, exudates, vascular changes, such as spasms, pathological arteriovenous crossings, arterial wall thickening and silver- or copper-wire aspect.
General treatment of hypertensive crisis
The treatment of HU should begin after a period of clinical observation in a calm environment, which helps to rule out the cases of pseudocrisis (treated with only rest or use of painkillers or tranquilizers). Captopril, clonidine and BBs are oral antihypertensives used to gradually reduce BP in 24-48 hours. The use of drops of rapid-release nifedipine capsules to treat HU should be banned, because it is neither safe nor effective, and causes rapid and marked BP reductions, which can result in tissue ischemia. The use of nifedipine for preeclampsia is currently debatable.
The treatment of patients with HE is aimed at rapid BP reduction to prevent the progression of TODs. Patients should be admitted to the ICU, on IV antihypertensives and be carefully monitored to prevent hypotension. The general recommendations for BP reduction for HE are:2
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- ? BP ≤ 25% in the 1st hour;
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- ? BP 160/100-110 mm Hg in 2-6 hours;
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- BP 135/85 mm Hg in 24-48 hours.
However, HEs should be approached considering the impaired system or target organ. Thus, each type of HE (CV, cerebral, renal or other) should be previously characterized before beginning specific antihypertensive therapy.
Hypertensive emergency in special situations
Chart 3 shows the medications used for HE.
Stroke
Arterial hypertension is the major risk factor for stroke, especially hemorrhagic stroke. The diagnosis is based on complete neurological exam. To assess the severity of the condition, the National Institute of Health Stroke Scale (NIHSS) should be used. Brain CT and MRI allow defining the type of stroke and territory involved, and, usually, 85% of the strokes are ischemic, and 15%, hemorrhagic.11 For incipient infarctions, MRI is more sensitive than CT.
Hemorrhagic stroke12
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For patients with SBP between 150 and 220 mm Hg and with no treatment contraindication, acute SBP reduction to 140 mm Hg is safe and can be effective to improve the functional outcome. (GR: IIa; LE: B) (in 1 hour with IV infusion of antihypertensives and BP monitoring 5/5 min) (GR: I; LE: A).
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For patients with SBP > 220 mm Hg, consider aggressive BP reduction with continuous IV infusion and frequent BP monitoring. (GR: IIb; LE: C).
Ischemic stroke13
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For patients with no indication for thrombolytic therapy and initial BP > 220/120 mm Hg, BP should not be reduced more than 15-20%, maintaining DBP as 100-110 mm Hg in the first 24 hours.
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The ideal BP level to be attained is not known, but there is consensus that no antihypertensive treatment should be instituted during the initial care, except if SBP is > 220 mm Hg or DBP is > 120 mm Hg. (GR: I; LE: C).
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Consider the possibility of using thrombolytics after BP control. For patients with indication for thrombolytic therapy and initial BP > 185/110 mm Hg, BP should be reduced to < 185/105 mm Hg for, at least, the first 24 hours after the thrombolytic agent. (GR: I; LE: B).
Acute coronary syndromes
Coronary syndromes can be accompanied by BP elevation, because of a reflex of the ischemic myocardium. The increased PVR increases myocardial oxygen demand because of the increased left ventricular wall tension.
The IV nitrates reduce PVR, improve coronary perfusion and have an important systemic vasodilator effect, reducing preload and myocardial oxygen consumption. SNP is not indicated because of the coronary flow steal mechanism caused by generalized coronary vasodilation.2,3
Unstable angina / non-ST elevation MI / ST elevation MI14,15
To treat AH, persistent ischemia and HF, IV nitroglycerin is indicated in the first 48 hours. Its use should not exclude other interventions that have proven to reduce mortality, such as BBs or ACEIs. Nitroglycerin is, however, contraindicated in the presence of recent use of phosphodiesterase inhibitors (previous 24 to 48 hours). (GR: I; LE: B).
The IV use of BBs is indicated for individuals with AH who have no signs of HF, clinical evidence of low cardiac output, increased risk for cardiogenic shock or other contraindications relating to beta blockade. (GR: IIa; LE: B).
Acute pulmonary edema
Approximately one third of the patients admitted with APE and HE have preserved left ventricular function. Myocardial ischemia can also be involved in the pathophysiology of the APE associated with HE.16,17 The HE with APE findings should be controlled in an ICU setting, with parenteral medication, monitoring and gradual BP decrease.18
Acute aortic dissection
Acute aortic dissection should always be considered in patients with precordial pain and BP elevation. Progression of the dissection is related to the BP level and ventricular ejection velocity.19 Target SBP (120 mm Hg) should be achieved in 20 minutes. The isolated use of SNP is not ideal, because it increases HR and the aortic ejection velocity, and can worsen the dissection. Thus, SNP should be associated with a BB. In case of intolerance to SNP or contraindication to BBs, trimethaphan should be used.
Use of illicit substances
Illicit substances that raise BP, such as cocaine, crack, amphetamines and ecstasy, have sympathomimetic action.20 Crack and cocaine increase the risk for stroke and acute coronary insufficiency.21 In addition to increasing HR and BP, ecstasy have other effects, mainly serotoninergic syndrome, and can cause rhabdomyolysis and AKI.22 A complicator of those intoxications is the concomitant ingestion of high doses of caffeine, present in energetic beverages, nicotine and alcohol. Those intoxications have in common the high level of plasma noradrenaline.23 The treatment includes the use of BBs, alpha-blockers and CCBs.24
Rapidly progressive acute kidney injury
Acute and progressive renal function impairment is observed in patients admitted to hospital emergency units.25 Individuals with greater renal function impairment have important cardiac dysfunction and greater loss of renal function during episodes of marked BP elevation, which is accompanied by high in-hospital mortality rates.26 Rapidly progressive AKI is defined as a sudden renal function worsening in 48 hours, with specific classification criteria: RIFLE (Risk, Injury, Failure, Loss, End-Stage Kidney Disease) and AKIN (The Acute Kidney Injury Network).27 Treatment includes hydralazine, loop DIUs and BBs. In case of no result, SNP can be considered until dialysis is performed.
The management for preeclampsia and eclampsia is reported in Chapter 9.
References
- 1 The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med. 1993;153(2):154-83.
- 2 Praxedes JN, Santello JL, Amodeo C, Giorgi DM, Machado CA, Jabur P. Encontro multicêntrico sobre crises hipertensivas: relatório e recomendações. Hipertensão. 2001;4(1):23-41.
- 3 Sociedade Brasileira de Cardiologia; Sociedade Brasileira de Hipertensão; Sociedade Brasileira de Nefrologia. [VI Brazilian Guidelines on Hypertension]. Arq Bras Cardiol. 2010;95(1 Suppl):1-51. Erratum in: Arq Bras Cardiol. 2010;95(4):553.
- 4 Martin JF, Higashiama E, Garcia E, Luizon MR, Cipullo JP. Hypertensive crisis profile: prevalence and clinical presentation. Arq Bras Cardiol. 2004;83(2):131-6; 125-30.
- 5 Pinna G, Pascale C, Fornengo P, Arras S, Piras C, Panzarasa P, et al. Hospital admissions for hypertensive crisis in the emergency departments: a large multicenter Italian study. PLoS One. 2014;9(4):e93542.
- 6 Vilela-Martin JF, Vaz-de-Melo RO, Kuniyoshi CH, Abdo AN, Yugar-Toledo JC. Hypertensive crisis: clinical-epidemiological profile. Hypertens Res. 2011;34(3):367-71.
- 7 Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000;356(9227):411-7.
- 8 Blumenfeld JD, Laragh JH. Management of hypertensive crises: the scientific basis for treatment decisions. Am J Hypertens. 2001;14(11 Pt 1):1154-67.
- 9 Martin JF, Kuniyoshi CH, Andrade LG, Yugar-Toledo JC, Loureiro AC, Cipullo JP. Fatores preditores de mortalidade em pacientes com crise hipertensiva. Arq Bras Cardiol. 2007;89(supl 1):201.
- 10 Saguner AM, Dür S, Perrig M, Schiemann U, Stuck AE, Bürgi U, et al. Risk factors promoting hypertensive crises: evidence from a longitudinal study. Am J Hypertens. 2010;23(7):775-80.
- 11 Truelsen T, Heuschmann PU, Bonita R, Arjundas G, Dalal P, Damasceno A, et al. Standard method for developing stroke registers in low-income and middle-income countries: experiences from a feasibility study of a stepwise approach to stroke surveillance (STEPS Stroke). Lancet Neurol. 2007;6(2):134-9.
- 12 Hemphill JC 3rd, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: a Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015;46(7):2032-60.
- 13 Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947.
- 14 O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127(4):e362-425. Erratum in: Circulation. 2013;128(25):e481.
- 15 Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association for Clinical Chemistry. 2014 AHA/ACC Guideline for the management of patients with non-ST-elevation acute coronary syndromes. a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):e139-228. Erratum in: J Am Coll Cardiol. 2014;64(24):2713-4
- 16 Gandhi SK, Powers JC, Nomeir AM, Fowle K, Kitzman DW, Rankin KM, et al. The pathogenesis of acute pulmonary edema associated with hypertension. N Engl J Med. 2001;344(1):17-22.
- 17 Kumar R, Gandhi SK, Little WC. Acute heart failure with preserved systolic function. Crit Care Med. 2008;36(1 Suppl):pS52-6.
- 18 Peacock WF, Braunwald E, Abraham W, Albert N, Burnett J, Christenson R, et al. National Heart, Lung, and Blood Institute working group on emergency department management of acute heart failure: research challenges and opportunities. J Am Coll Cardiol. 2010;56(5):343-51.
- 19 Khan IA, Nair CK. Clinical, diagnostic, and management perspectives of aortic dissection. Chest. 2002;122(1):311-28.
- 20 Naidoo S, Smit D. Methamphetamine abuse: a review of the literature and case report in a young male. SADJ. 2011;66(3):124-7.
- 21 Sordo L, Indave BI, Barrio G, Degenhardt L, de la Fuente L, Bravo MJ. Cocaine use and risk of stroke: a systematic review. Drug Alcohol Depend. 2014;142:1-13.
- 22 Gahlinger PM. Club drugs: MDMA, gamma-hydroxybutyrate (GHB), Rohypnol, and ketamine. Am Fam Physician. 2004;69(11):2619-26.
- 23 Fitzgerald PJ. Elevated norepinephrine may be a unifying etiological factor in the abuse of a broad range of substances: alcohol, nicotine, marijuana, heroin, cocaine, and caffeine. Subst Abuse. 2013;7:171-83.
- 24 Connors NJ, Hoffman RS. Experimental treatments for cocaine toxicity: a difficult transition to the bedside. J Pharmacol Exp Ther. 2013;347(2):251-7.
- 25 Challiner R, Ritchie JP, Fullwood C, Loughnan P, Hutchison AJ. Incidence and consequence of acute kidney injury in unselected emergency admissions to a large acute UK hospital trust. BMC Nephrol. 2014;15:84.
- 26 James MT, Grams ME, Woodward M, Elley CR, Green JA, Wheeler DC, et al; CKD Prognosis Consortium A meta-analysis of the association of estimated GFR, albuminuria, Diabetes mellitus, and hypertension with acute kidney injury. Am J Kidney Dis. 2015;66(4):602-12.
- 27 Hawkins R. New biomarkers of acute kidney injury and the cardio-renal syndrome. Korean J Lab Med. 2011;31(2):72-80.
Publication Dates
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Publication in this collection
Sept 2016