Editorial Comment
Hypertensive crisis management in the emergency
room: time to change?
Giuliano Tocci a,b, Vivianne Presta a, and Massimo Volpe a,b
See original paper on page 52
A
rapid, marked and persistent rise in blood pressure
(BP) levels above 180/120 mmHg is a clinical con-
dition currently defined as hypertensive emergency
or urgency in the presence or absence of acute signs of
hypertension-mediated organ damage, respectively [1].
Beyond the magnitude of BP rise and absolute BP levels,
early recognition of these conditions is crucial from both a
prognostic and a therapeutic point of view. Indeed, current
European guidelines recommend clinical observation with
repeated BP measurements and gradual BP reductions
throughout the administration of oral antihypertensive drug
therapies in individuals with hypertensive urgencies [2]. On
the other hand, patients with hypertensive emergencies
should immediately receive pharmacological and nonphar-
macological interventions for lowering BP levels, mostly
through the administration of intravenous drugs, and
undergo specific treatment protocols for the clinical man-
agement of associated clinical conditions, such as acute
coronary syndromes, stroke, pulmonary oedema, eclamp-
sia, and aortic dissection [2]. Similar recommendations
have been issued by the United States guidelines on hyper-
tension [3].
Whatever the cause and in any clinical presentation, two
aspects should be always taken in mind when approaching
hypertensive emergencies or urgencies. The first is that
there is lack of evidence from randomized controlled
trials for the best therapeutic protocol or drug to adopt.
The second is that in both cases, BP reductions should be
obtained gradually, avoiding excessive BP drops and com-
plications because of low blood flow to the brain, the
kidney or the heart.
In view of the widespread prevalence of hypertension in
both low-income and high-income countries, and consider-
ing the progressive increase in the number of hospitalizations
Journal of Hypertension 2020, 38:33–34
a
Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular
Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, San-
t’Andrea Hospital, Rome and bIRCCS Neuromed, Pozzilli, Italy
Correspondence to Giuliano Tocci, MD, PhD, Hypertension Unit, Department of
Clinical and Molecular Medicine, University of Rome Sapienza, Sant’Andrea Hospital,
Via di Grottarossa 1035, 00189 Rome, Italy. E-mail: giuliano.tocci@uniroma1.it
J Hypertens 38:33–34 Copyright ß 2019 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/HJH.0000000000002235
Journal of Hypertension
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
because of hypertension or hypertension-related comorbid-
ities, greater attention has been devoted to hypertension
emergencies or urgencies over the last few years. In particu-
lar, several clinical studies have been carried out to identify
predisposing factors that may promote hypertensive emer-
gencies or urgencies; these studies demonstrated that the
most relevant factors responsible for the rapid rise of BP
levels are represented by low adherence to prescribed anti-
hypertensive medications, discontinuation from assumption
of BP-lowering drugs, overuse (or abuse) of illicit substances
or recreational drugs, and poor control of concomitant risk
factors (e.g. smoke, obesity, hypercholesterolemia, and dia-
betes) [4,5]. In addition, several hypertensive phenotypes,
such as masked hypertension and white-coat hypertension,
have been related to an increased risk of hospitalization
because of uncontrolled hypertension [6], highlighting the
need for proper assessment of control of BP levels during the
entire 24-hour period.
In this issue of the Journal of Hypertension, Muiesan and
co-workers describe the 7-year experience of the Emer-
gency Department and their reference hypertension center
at the Spedali Civili of Brescia, Italy, on hypertensive
emergencies and urgencies [7]. The analysis they provide
(which consists of the large amount of data collected over a
12-month period at two different times, 2008 and 2015)
allows several considerations and favours some specula-
tions. In this study population, patients presenting to the
emergency department with hypertensive emergency or
urgency (about 2% of the total admissions) were predomi-
nantly men and aged more than 60 years. All were affected
by hypertension, and about one-third had also diabetes or
previous cardiovascular events. SBP/DBP levels at entry
were higher in hypertensive emergencies than in urgencies.
Although no data were available on how many patients
with hypertension were treated or not, these features allow
to delineate a ‘phenotype’ of hypertensive patients at high
risk of having hospitalization for an acute BP elevation, and
thus to suggest some preventive therapeutic strategies to
reduce the risk of this outcome.
At entry, dyspnoea, chest pain, and headache were the
most frequent symptoms in both conditions. In patients
with hypertensive emergencies, the most frequent acute
organ damage was stroke (38%), followed by pulmonary
oedema (35%), and coronary syndrome (25%), which is in
www.jhypertension.com 33
Tocci et al.
line with the evidence that uncontrolled hypertension is a
main contributor to the risk of having all major cardiovas-
cular outcomes, not only coronary disease [8], but also
stroke, left ventricular dysfunction, and congestive heart
failure [9]. In this regard, current European guidelines [2]
recommend to achieve lower BP treatment targets than
those recommended by previous guidelines [10], thus
highlighting the need for a more effective BP control by
treatment. It remains to be seen, however, whether these
lower recommended targets will have a favourable reflec-
tion on the risk of developing a hypertension emergency
or urgency
Another aspect of particular relevance in the study of
Muiesan and co-workers [7] was the detailed analysis of the
therapeutic approaches adopted for treating hypertensive
emergencies and urgencies in 2008 compared with those
applied in 2015, that is, over a period during which the
influential medical documents on this issue were a position
paper from ESC published in 2006 [11] and the ESH/ESC
guidelines released in 2013 [10]). In the second observation
period, that is, 2015, larger proportions of patients with
hypertensive urgencies received oral drugs, mostly dihy-
dropyridinic calcium-channel blockers, and drugs blocking
the renin–angiotensin system, than those in the first obser-
vation period, in which intravenous (furosemide, nitrates)
or intramuscular (clonidine) drugs were more frequently
adopted. As properly observed by the authors, this suggests
a clear therapeutic shift of the way physicians address
hypertension emergency and urgency. Interestingly, anti-
hypertensive treatment for patients with hypertensive
emergencies was driven by the specificity of concomitant
diseases in both observation periods. That is, patients with
pulmonary oedema or coronary syndrome were more
frequently treated (and received more intravenous drugs,
such as nitrates, beta-blockers, and loop diuretics) than
those with stroke from any cause. This reflects the indica-
tions of guidelines to avoid excessive BP reductions during
the acute phases of stroke [12]. Use of sublingual nifedipine
was progressively abandoned, and in 2015 avoided in all
patients, as repeatedly recommended by guidelines.
A final consideration is that almost all patients with
hypertensive emergencies were admitted to hospital as
inpatients, whereas only 40–45% of patients with hyper-
tensive urgencies required hospitalization. This implies that
more accurate treatment approach with high level of adher-
ence to prescribed medications and sustained BP control
during the 24-hour period would ideally reduce number
of unnecessary hospitalizations because of uncontrolled
34 www.jhypertension.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
hypertension, thus reducing costs related to hypertensive
urgencies and ameliorating clinical outcomes of hyperten-
sive emergencies.
ACKNOWLEDGEMENTS
Conflicts of interest
There are no conflicts of interest.
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Volume 38  Number 1  January 2020