HYPERTENSIVE EMERGENCY

I. DEFINITION
A hypertensive emergency (formerly called "malignant hypertension")
is hypertension (high blood pressure) with acute impairment of one or more
organ systems (especially the central nervous system, cardiovascular system
and/or the renal system) that can result in irreversible organ damage. In a
hypertensive emergency, the blood pressure should be slowly lowered over a
period of minutes to hours with an antihypertensive agent.
The term hypertensive emergency is primarily used as a specific term for a
hypertensive crisis with a diastolic blood pressure greater than or equal to 120
mmHg and/or systolic blood pressure greater than or equal to 180mmHg.
Hypertensive crisis is an umbrella term for hypertensive urgency and
hypertensive emergency. These two conditions occur when blood pressure
becomes very high, possibly causing organ damage. Hypertensive urgency
occurs when blood pressure spikes but there is no damage to the body's
organs. Blood pressure can be brought down safely within a few hours with
blood pressure medication. Hypertensive emergency means blood pressure is
so high that organ damage can occur. Blood pressure must be reduced
immediately to prevent imminent 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
Bleeding into the brain (stroke)
Heart failure
Chest pain (unstable angina)
Fluid in the lungs (pulmonary edema)
Heart attack
Aneurysm (aortic dissection )
Eclampsia (occurs during pregnancy)


Terminology Systolic Pressure (mm Hg) Diastolic Pressure (mm Hg)
Normal < 120 < 80
Pre-hypertension 120-139 80-89
Hypertension stage 1 140-159 90-99
Hypertension stage 2 160 100
Hypertensive crisis 180 120
Hypertensive emergency 180 120





II. ETIOLOGY
Age Up to the age of 45, more men have high blood pressure than women. It
becomes more common for both sexes as they age, and more women have this
by the time they reach the age of 65.
Hereditary A patient with a close family member who has high blood
pressure has a greater risk in acquiring the said condition.
Underlying disease About 60% of people with Diabetes Mellitus has high
blood pressure.
Race African Americans are more likely to develop hypertension, and it
develops at a younger age. Genetic research suggests that they seem to be
more sensitive to salt. In a person who has the gene that makes them salt
sensitive, just a half teaspoon of salt can raise blood pressure by 4 mmHg.
Diet (High salt) Sodium, a major component of salt, can raise BP by causing
the body to retain fluid, which leads to a greater burden on the heart. The
American Heart Association (AHA) recommends eating less than 1,500 mg of
sodium per day.
Weight Being overweight places a strain on your heart and increases your
risk of high blood pressure.
Pregnancy Gestational hypertension is a kind of HBP that occurs in the
second half of pregnancy (2
nd
trimester.) Without treatment, it may lead to a
serious condition called preeclampsia that endangers the mother and baby.
The condition can limit blood and oxygen flow to the baby and can affect the
mothers kidneys and brain. But after the baby is born, BP usually returns to
normal levels.

III. MANIFESTATION

The eyes may show retinal hemorrhage or an exudate. Papilledema
must be present before a diagnosis of malignant hypertension can be made.
The brain shows manifestations of increased intracranial pressure,
such as headache, vomiting, and/or subarachnoid or cerebral hemorrhage.
Patients will usually suffer from left ventricular dysfunction.
The kidneys will be affected, resulting in hematuria, proteinuria, and
acute renal failure.
It differs from other complications of hypertension in that it is
accompanied by papilledema. This can be associated with hypertensive
retinopathy.
Other signs and symptoms can include:
Chest pain
Arrhythmias
Headache
Epistaxis
Dyspnea
Faintness or vertigo
Severe anxiety
Agitation
Altered mental status
Paresthesias
Vomiting


IV. DIAGNOSTIC/LABORATORY PROCEDURES
LABORATORY PROCEDURE
Baseline investigations include a complete blood count with peripheral
smear for the presence of schistocytes, which may suggest microangiopathic
hemolytic anemia. Serum electrolytes, blood urea nitrogen, and serum
creatinine concentrations should be measured to evaluate for renal
impairment. Hypokalemic metabolic alkalosis may be seen as a result of
intravascular volume depletion and secondary hyperaldosteronism.
Comparison of the measured serum creatinine value with baseline values
should be done to evaluate for the presence of acute and/or chronic kidney
disease.

DIAGNOSTIC PROCEDURE
An electrocardiogram should be obtained in all patients with
hypertensive crisis as it may reveal evidence of myocardial ischemia or
infarction in the acute setting as well as evidence of left ventricular
hypertrophy due to chronic hypertension. A chest radiograph should be
obtained to evaluate for pulmonary vascular congestion as well as a widened
mediastinum, which suggests aortic dissection. Urinalysis and urine sediment
examination to evaluate for hematuria and/or cellular casts also should be
done. A computed tomography scan of the head without contrast should be
performed in any patient with neurologic symptoms, which include change in
mental status or focal neurologic signs suggestive of a cerebrovascular
accident or hemorrhage.