Hypertensive Emergencies

Dr Swapnil Pawar February 7, 2021 72

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
Management	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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