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Hypertensive Emergencies

Dr Swapnil Pawar February 7, 2021 72


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    Hypertensive Emergencies
    Dr Swapnil Pawar

Written by – Dr Andrew Lam

Hypertensive Urgency

Severe Asymptomatic Hypertension Hypertensive Urgency Hypertensive Emergency
Blood Pressure > 180/110 mmHg  > 180/110 mmHg  > 220/140 mmHg
Symptoms (i.e. headache, dizziness) Nil Present Present
End Organ Dysfunction Nil Nil ACUTE end organ dysfunction, but moderate non-acute dysfunction may be present Significant acute end organ damage
Management Monitor and reassess or oral medication Oral medication IV medication
Aim for a reduction of systolic BP to below 180mmHg over a period of 1-2 days Aim to reduce symptoms and reduce systolic BP to below 180mmHg over 2-3 hours Aim to reduce BP within minutes to prevent end-organ damage, but no more than 25% in the first 2 hours

 

Acute End Organ Damage: 

Cardiovascular:
– Acute myocardial infarction
– Aortic dissection

Pulmonary:
– Acute pulmonary oedema

Neurological:
– Haemorrhagic stroke (intracerebral haemorrhage, subarachnoid haemorrhage)
– Hypertensive encephalopathy

Renal:
– Acute renal failure

Ophthalmological:
– Retinal haemorrhage
– Papilledema

 

Secondary Causes of Hypertension

Endocrine
Condition Diagnostic Investigations Clinical Signs
Thyrotoxicosis Thyroid Function Tests Heat tolerance, anxiety, weight loss, diarrhea
Phaeochromocytoma 24 hour urine fractionated metanephrines/catecholamines OR plasma fractionated metanephrines Sweating, tachycardia, episodic headache
Conn’s Syndrome (Primary Hyperaldosteronism) Aldosterone to renin ratio (elevated) Hypokalemia (muscle cramps, fatigue, weakness) 
Cushing’s Syndrome Late night salivary cortisol

24 hour urinary cortisol

Dexamethaosone suppression test

Muscle wasting/weakness, adipose tissue redistribution (buffalo hump, central obesity), mood swings, osteoporosis
Other
Condition Diagnostic Investigations Clinical Signs
Renal Parenchymal Disease Urinalysis, EUC’s and further investigation based on clinical presentation to determine underlying cause of renal disease Peripheral oedema, lethargy, anorexia, haematuria 
Obstructive Sleep Apnoea Polysomnography Daytime somnolence, snoring, morning headache
Drug Induced N/A Use of corticosteroids, NSAID’s, anti-depressants or recreational drugs (cocaine, amphetamines, MDMA)
Renal Artery Stenosis Renal duplex US

CT Angiography 

Renal bruit, proteinuria, fluid overload
Aortic Coarctation Echocardiogram

CT Angiography

Exercise intolerance, cold feet, chest pain, dyspnoea, radiofemoral delay, but often asymptomatic

 

References: 

 

Elliott, W.J., Varon, J. Evaluation and treatment of hypertensive emergencies in adults. UpToDate. Retrieved January 30, 2021 from https://www.uptodate.com.acs.hcn.com.au/contents/evaluation-and-treatment-of-hypertensive-emergencies-in-adults

Textor, S. (2020). Evaluation of secondary hypertension. UpToDate. Retrieved January 30, 2021 from https://www.uptodate.com.acs.hcn.com.au/contents/evaluation-of-secondary-hypertension

Electronic Therapeutic Guidelines. (2020) Urgent control of elevated blood pressure. eTG Complete. Retrieved January 30, 2021, from https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?topicfile=urgent-control-severe-bp-elevation&guidelineName=Cardiovascular&topicNavigation=navigateTopic

 

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