Hypertensive Emergencies

Overview

There are two types of hypertensive crisis:

• Malignant (accelerated) hypertension:
  • Severe hypertension (usually ≥180mmHg systolic or ≥120mmHg diastolic) and end-organ damage
• Hypertensive urgency:
  • Severe hypertension without end-organ damage

Any patient with malignant hypertension needs same-day admission for assessment and treatment to reduce the risk of end-organ damage and life-threatening complications.

Epidemiology

• More common in older patients
• More common in Afro-Caribbean patients
• More common in men

Risk Factors

• Inadequately treated hypertension
• Renal artery stenosis
• Chronic kidney disease
• Renal transplant
• Endocrine disorders:
  • Hyperaldosteronism
  • Cushing’s syndrome
  • Acromegaly
  • Hyperparathyroidism
  • Hyper-/hypothyroidism
  • Phaeochromocytoma
• Pregnancy
• Older age
• Afro-Caribbean ethnicity
• Male sex

Presentation

• Blood pressure >180/120mmHg
• Patients may be asymptomatic
• Neurological symptoms:
  • Vision changes
  • Headaches
  • Dizziness
  • Seizures
  • Weakness
  • Gait problems
• Cardiorespiratory symptoms:
  • Chest pain
  • Shortness of breath
  • Palpitations
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea
  • Oedema
  • New murmurs
  • S3
  • Jugular venous distention
• Oliguria
• Fundoscopy signs:
  • Retinal haemorrhages
  • Retinal exudates
  • Papilloedema
  • Enlarged retinal veins

Differential Diagnoses

Malignant (accelerated) hypertension

• Blood pressure >180/120mmHg and evidence of end-organ damage

Hypertensive urgency

• Blood pressure >180/120mmHg and no evidence of end-organ damage

Poorly-controlled essential hypertension

• Blood pressure <180/120mmHg

Investigations

Examination in all patients

• Blood pressure measurement from both arms and repeated after 5 minutes
  • If there’s a >20mmHg difference between the arms, aortic dissection may need to be considered
• Fundoscopy which may show:
  • Papilloedema
  • Retinal haemorrhages
  • Retinal exudates
• Cardiorespiratory examination
• Neurological examination

Investigations in patients

• Urea and electrolytes (U&Es)
  • May show acute kidney injury
• Urinalysis and microscopy:
  • May show red cells and protein
• ECG:
  • May show myocardial infarction
• Chest x-ray:
  • May show pulmonary oedema, or a widened mediastinum that may suggest aortic dissection

Other investigations may need to be considered to identify underlying causes such as thyroid function tests, troponins etc.

Management

Same-day referral

NICE recommends same-day referral if patients have malignant hypertension and:

• Papilloedema/retinal haemorrhages
• New-onset confusion
• Chest pains
• Signs of heart failure
• Signs of AKI
• Suspected phaeochromocytoma

General management

Management varies in different circumstances e.g. pregnancy or if there’s a concurrent stroke. General management is:

• 1^st line: IV labetalol
• 2^nd line: IV nicardipine
• 3^rd line: IV fenoldopam

Monitoring

• Patients should have their blood pressure checked within 1 week of discharge
• Patients should return for follow-up monthly until blood pressure is achieved
• When adjusting medication doses, blood pressure should be monitored every 2-4 weeks
• When stable, the blood pressure should be reviewed every 6-12 months
• Check U&Es annually

Patient Advice

• Patients should be reminded of the importance of taking medications
• Patients should seek emergency help if they have any dizziness, loss of sensation, weakness, blurred vision, chest pain, shortness of breath, or any other signs of end-organ damage

Complications

• Myocardial infarction
• Encephalopathy
• Intracerebral haemorrhage
• Subarachnoid haemorrhage
• Hypertensive retinopathy
• Hypertensive nephropathy

Prognosis

• Without treatment, over 90% of patients die within a year due to end-organ damage
• With treatment, the 5-year survival rate is >90%