Differences between Hypertensive urgency and Emergency

1. HYPERTENSIVE URGENCY
and
HYPERTENSIVE EMERGENCY
Prepared by ; Dr Sajaad Othman

2. Objectives
• Define hypertensive emergency and hypertensive urgency
• Accurate measurement of blood pressure
• Identify signs/symptoms of acute end organ damage
associated with severe high blood pressure.
• Investigations required for acute end organ damage.
• Approach to management of Hypertensive urgency and
emergency.

3. Definitions
Severe hypertension in adults (often defined as SBP ≥180 mmHg and/or
DBP ≥120 mmHg)
Acute End Organ damage
Yes No
HYPERTENSIVE
EMERGENCY
HYPERTENSIVE
URGENCY

4. Accurate measurement of blood pressure
Confirm by repeating BP
measurement utilizing proper
technique

5. How many errors in BP measurement do you see?

7. Key steps for proper BP measurements
Step 1: Properly prepare the patient
1. Have the patient relax, sitting in a chair (feet on floor, back
supported) for >5 minutes.
2. The patient should avoid caffeine, exercise, and smoking for at
least 30 minutes before measurement.
3. Ensure patient has emptied their bladder.
4. Neither the patient nor the observer should talk during the
rest period or during the measurement.
5. Remove all clothing covering the location of cuff placement.
6. Measurements made while the patient is sitting or lying on an
examining table do not fulfill these criteria.

8. Step 2: Use proper technique for BP measurements
1. Use a BP measurement device that has been validated, and ensure that
the device is calibrated periodically.
2. Support the patient's arm (eg, resting on a desk).
3. Position the middle of the cuff on the patient's upper arm at the level
of the right atrium (the midpoint of the sternum).
4. Use the correct cuff size, such that the bladder encircles 80% of the
arm, and note if a larger- or smaller-than-normal cuff size is used.
5. Either the stethoscope diaphragm or bell may be used for auscultatory
readings.

9. Step 3: Take the proper measurements needed for
diagnosis and treatment of elevated BP/hypertension
1. At the first visit, record BP in both arms. Use the arm that gives the
higher reading for subsequent readings.
2. Separate repeated measurements by 1 to 2 minutes.
3. For auscultatory readings, deflate the cuff pressure 2 mmHg per
second, and listen for Korotkoff sounds.

10. Step 4: Properly document accurate BP readings
1. Record SBP and DBP. If using the auscultatory technique, record SBP and
DBP as onset of the first Korotkoff sound and disappearance of all
Korotkoff sounds, respectively, using the nearest even number.
2. Note the time of most recent BP medication taken before
measurements.
Step 5: Average the readings
Use an average of ≥2 readings obtained on ≥2 occasions to estimate the
individual's level of BP.
Step 6: Provide BP readings to patient
Provide patients the SBP/DBP readings both verbally and in writing

11. Correct position for blood pressure measurement

12. Acute end organ damage due to elevated high BP
• Presence of acute EOD distinguish hypertensive emergency
from hypertensive urgency
• Identification of acute EOD is accomplished by detailed
history, focused physical examination and appropriate
ancillary investigations(guided clinically )
• End organ damage can broadly be classified as
 neurologic,
 cardiovascular,
 renal .

13. Neurologic emergencies
consist of three primary manifestations:
1) hypertensive encephalopathy,
2) intraparenchymal or subarachnoid hemorrhage,
3) acute ischemic stroke.

14. Cardiovascular emergencies
include:
1) acute left ventricular failure and pulmonary edema,
2) acute coronary syndrome, and
3) aortic dissection.

15. Renal emergencies
• Include rapidly progressive renal failure (Acute kidney injury,
AKI),
• Evidenced by
 rapidly rising serum creatinine,
 decreased urine output, and
 microscopic hematuria

16. • Other comorbidities associated with hypertensive
emergencies include
1) Eclampsia,
2) Pheochromocytoma crisis, classically presents with
paroxysmal headache, sweating, tachycardia, and
hypertension
3) Ingestion of sympathomimetic agents (cocaine,
amphetamines).

17. General approach to severe high blood pressure
• A detailed medical history must be obtained to determine
 Underlying renal, cardiac, or endocrine manifestations.
 Current medications and ingestion of illicit drugs (cocaine or other
sympathomimetic substances (phenylephrine, monoamine oxidase
inhibitors)
 Elucidate any symptoms related to end-organ damage such as
 Visual changes (papilledema, retinal hemorrhages), altered mental
status, and seizures.(Hypertensive encephalopathy
 Chest pain (myocardial infarction, aortic dissection),
 Dyspnoea (congestive heart failure, pulmonary edema),
 Anuria (renal failure),
 For patients more than 20 weeks pregnant or who recently gave birth,
investigate symptoms of preeclampsia.

18. • The physical examination should assess for signs of end-organ
damage.
 Fundoscopy can reveal papilledema, retinal hemorrhages, and
exudates.
 Cardiovascular examination can identify signs of heart failure
such as jugular venous distension, an S 3 gallop, pulmonary
rales, and extremity edema.
 Neurologic examination should evaluate the mental status
and signs of focal deficit

19. • Ancillary testing varies in the patient with hypertensive emergency
depending on the patient’s symptoms and which end-organ is
affected.
 ECG and cardiac enzymes for suspected myocardial infarction.
 Electrolytes including creatinine (Cr) and blood urea nitrogen (BUN),
hemoglobin, and proteinuria and red blood cell casts on urinalysis may
point toward renal failure or glomerulonephritis.
 A chest radiograph in the diagnosis of congestive heart failure,
pulmonary edema, and aortic dissection.
 A head CT scan should be obtained in all patients with altered mental
status or a focal neurologic deficit in order to rule out a mass lesion,
ischemic and hemorrhagic stroke.
 UPT (Suspected severe pre eclampsia)

20. Management of Hypertensive urgency
• There is no proven benefit from rapid reduction of blood
pressure in patients with severe asymptomatic hypertension
and most such patients who present in the ambulatory setting
can be managed as outpatients.
• Rapid and aggressive antihypertensive therapy can induce
cerebral or myocardial ischemia or infarction, or acute kidney
injury, if the blood pressure falls below the range at which
tissue perfusion can be maintained by autoregulation.

21. How quickly should BP reduced?
• The blood pressure should be reduced over a period
of hours to days.
• Although slower reductions may be needed in older
adult patients at high risk for cerebral or myocardial
ischemia resulting from excessively rapid reduction
of blood pressure

22. What is the BP target(short term)?
• The short-term blood pressure target, during the first several
hours, may need to be above 160/100 mmHg in patients who
present with very high pressures.
• mean arterial pressure should not be lowered by more than
25 to 30 percent over the first several hours
• In the long-term, the blood pressure should usually be
reduced further (eg, <140/<90 mmHg or <130/<80 mmHg)

23. How should this goal be achieved?
• depends upon whether the blood pressure should be
1. lowered more quickly (period of hours) (patients who at high
risk of imminent cardiovascular events due to severe HTN,
known aortic or intracranial aneurysms).
2. or less quickly (period of days)
 Untreated hypertension
 Previous Hypertension
Treated by resuming of anti hypertensives

24. Therapeutic strategies
• All patients should be provided a quiet room in which to rest. In one study,
30 minutes of rest in a quiet room produced a fall in blood pressure
≥20/10 mmHg.
• Two most common agents are:
 Oral clonidine (but not intended as long-term therapy)
 Oral captopril (if the patient is not volume overloaded)
 sublingual nifedipine is contraindicated in this setting and should not be
used
• Following administration of an antihypertensive agent, the patient is
observed for a few hours to ascertain a reduction in blood pressure of 20
to 30 mmHg. Thereafter, a longer-acting agent(eg Amlodipine) is
prescribed, and the patient is sent home to follow-up within a few days.

25. Management of Hypertensive Emergencies
Hypertensive emergency is a true medical emergency.
• The patient should be placed in ICU for immediate evaluation
and management.
• Patients require immediate administration of parenteral
antihypertensive medications to prevent irreversible end
organ damage (except in the case of acute ischemic stroke).
• Choice of agent and BP target depends on the specific
Hypertensive emergency

26. Case scenario 1
• A 55-year-old man is brought in to the emergency department (ED) by his
wife for altered mental status (AMS). She states that for the past day, he
has been confused and unsteady when he walks. The patient has a history
of hypertension (HTN) and hyperlipidemia.
• He complains of headache and blurry vision. On examination, he is alert
and oriented to person only.
• On fundoscopy, the optic discs appear hyperemic and swollen, with a loss
of sharp margins.
• His neurologic examination is non focal and otherwise has a normal
physical examination. The patient’s vital signs are a blood pressure of
245/140 mm Hg, heart rate of 95 beats per minute, respiratory rate of 18
breaths per minute, oxygen saturation of 98% on room air and he is
afebrile.
• What is the most likely diagnosis?
• How will you manage this patient?

27. Case scenario 2
A 55 year old male came to our centre for routine check up
otherwise he feels fine, he has no significant past medical
history. On examination BP 190/115mmhg PR 80b/min
afebrile, saturation 98% on room air, not in distress.
Systemic examination; unremarkable
• What is the most likely diagnosis?
• How will you manage this patient?

28. References
1.UptoDate
2.Case file Emergency medicine book

29. THANK YOU