Hypertensive Crisis

Management of Patients with Hypertensive

Urgencies and Emergencies
A Systematic Review of the Literature
David Cherney, MD. Sharon Straus, MD FRCPC
 Introduction

 One of the most common chronic medical

conditions in the United States, affecting close
to 30% of the population1.

 Hypertensive urgencies and emergencies may

account for as many as 27.5% of all medical
emergencies presenting to the emergency
department2.
 Definition of Hypertensive Crisis

 Hypertensive emergency – increased BP

leading to evidence of target end-organ
damage, such as encephalopathy, unstable
angina, stroke, or dissecting aortic aneurysm.

 Hypertensive urgencies – increased BP but no

evidence of end-organ damage. Usually
cosidered to be SPB > 179 or DPB > 109
Precipitants of Hypertensive Crisis


Progression of essential HTN +/- medical
noncompliance

Progression of renovascular dz; acute
glomerulonephritis; scleroderma; preeclampsia

Endocrine: pheochromocytoma, Cushing's

Sympathomimetics: cocaine, amphetamines,
MAO inhibitors + foods rich in tyramine

Cerebral injury
 What is the best treatment?

 Clinical treatment practices for the

management of hypertensive urgencies and
emergencies vary considerably

 Lack of evidence supporting the use of one

therapeutic agent over another.
 Methods


MEDLINE search from 1966 to 2001

Included:
 systematic reviews of RCTs
 individual RCTS
 all-or-none studies
 systematic reviews of cohort studies
 individual cohort studies
 outcomes research.
 Study Participants

Exclusion criteria varied and included:
 >80 yo
 Pregnancy
 organ transplantation
 Immunosupression
 acute or ckd
 Dialysis
 valvular heart disease
 recent stoke
 acute MI
 CABG
 CHF
 known secondary cause of HTN ie pheochromocytoma.
 Results

19 studies – 4 hypertensive emergency and 15 hypertensive
urgency studies represent 236 and 1074 patients respectively.

8 trials were open-label

Outcome measurement were not uniform. Included DBP as
endpoint to indicate success and either used a specific blood
pressure, a percentage reduction in BP, or a numeric fall in
DBP

Few studies used SBP as a goal.

Used adverse effects as outcome measurement

None of the studies used immediate or long-term mortality
endpoints.

Resolution of end-organ dysfunction not included
 Treatment of Hypertensive
Emergencies
 No prospective studies that addressed:
 How quickly BP should be controlled?
 When maintenance therapy with
antihypertensive medications would begin?
 Treatment for Hypertensive
Urgencies
 No High-quality studies that addressed:
 What blood pressure defines a hypertensive
urgency?
 how quickly blood pressure should be decreased
in a hypertensive urgency?
 When maintenance therapy should be started?
 Whether patients with hypertensive urgencies
should be treated in observed settings?
 Discussion

 Best hypertensive agent in urgencies and

emergencies remains unclear.

 Future studies need consistent definitions and

cutoffs for BP, longer follow up times and how
quickly to correct BP.
Rate of Correction

 chronically hypertensive patients

will have a rightward shift of the
pressure–flow (cerebral, renal,
and coronary) autoregulation
curve
 Rapid reduction in blood
pressure below the cerebral,
renal, and/or coronary
autoregulatory range will result
in a marked reduction in organ
blood flow, leading to ischemia
and infarction
 JNC 7 Guidelines (2003)
Hypertensive Emergencies
 Patients with a hypertensive emergency should be admitted to an Intensive Care Unit for
continuous monitoring of BP and parenteral administration of an appropriate agent.
 The initial goal of therapy in hypertensive emergencies is to reduce mean arterial BP by no
more than 25% (within minutes to 1 hour), then, if stable, to 160/100 to 110 mm Hg within the
next 2 to 6 hours.
 short-acting nifedipine is no longer considered acceptable in the initial treatment of
hypertensive emergencies or urgencies
 Due to increased morbidity and mortality secondary to uncontrolled
hypotension.
 If this level of BP is well tolerated and the patient is clinically stable, further gradual reductions
toward a normal BP can be implemented in the next 24 to 48 hours.
 Exceptions
 Ischemic stock – no evidence to support immediate antihypertensive treament
 Aortic dissection – SBP lowered to <100 mmHg if tolerated
 JNC 7 Guidelines (2003)
Hypertensive Urgencies
 Some patients with hypertensive urgencies may benefit from
treatment with an oral, short-acting agent such as captopril,
labetalol, or clonidine followed by several hours of observation.
 no evidence to suggest that failure to aggressively lower
BP in the emergency room is associated with any
increased short-term risk to the patient who presents with
severe hypertension.
 patients should not leave the emergency room without a confirmed
follow-up visit within 1 to a few days.
 Goal is normal BP in ~1-2 days
Ref 3
Ref 4
 References

1. Hajjar I, Kotchen TA. Trends in prevalence, awareness,treatment,

and control of hypertension in the United States,1988–2000. JAMA
2003; 290:199–206
2. Kitiyakara C, Guzman N. Malignant hypertension and hypertensie
emergencies. J Am Soc Nephrol. 1998;9: 133-42
3.Chobanian AV, Bakris GL, et al. Seventh report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. JNC 7-complete version. Hypertension. 2003; 42:
1206–1252
4.Marik PE, Varon J. Hypertenisve Crises: Challenges and
Management Chest 2007;131;1949-1962