Inpatient / cardiology
Hypertensive Urgency and Emergency
# Hypertensive Urgency/Emergency
Checklist
-- Gut Check: manual BP with correct sized cuff, check on both arms
-- ABCs: is there end-organ dysfunction suggesting emergency and need for ICU for a-line and close monitoring and titration of antihypertensives?
-- Chart Check: usual BP range, home BP meds, co-morbidities (CAD, CHF, CKD/ESRD)
-- Admission Criteria: evidence of end-organ dysfunction
-- HPI Intake: missed HTN meds, missed dialysis, drug use, pain, anxiety, headaches, visual changes, dyspnea, chest pain, oliguria
-- Can't Miss: red flags - dyspnea, chest pain, AMS, focal neuro symptoms
-- Admission Orders: CBC, CMP, UA, trop, BNP, EKG, CXR; consider tele, UDS, CTA Chest, CT head; restart home HTN regimen if applicable
-- Initial Treatment to Consider: IV vs. PO medications - usually labetalol unless ACS, CHF
Intake
-- HTN Meds and Adherence: ***
-- Other Med or Drug Use: ***
-- Symptoms: ***
-- Co-Morbidities: ***
Assessment:
-- History: *** h/o HTN, aortic disease, medications
-- Clinical: *** headaches, seizure, visual changes, dyspnea (edema), angina, tearing chest pain c/f dissection
-- Exam: *** BP on both arms, AMS, focal neuro deficit, papilledema, distress, diaphoresis, crackles
-- Data: *** CBC (Hgb), creatinine, UA (hematuria), troponin, CXR (flash edema), CT Head (stroke, PRES)
-- Etiology/DDx: *** nonadherence to home HTN meds, pain, anxiety, urinary retention, medications (NSAIDs, steroids), drugs (cocaine, amphetamines), pheo
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
Plan:
Workup
-- f/u CBC (MAHA), BMP (renal fx), BNP (CHF), trop (ACS), UA (glomerular injury)
-- f/u EKG, CXR (edema)
-- Consider UDS (drug-mediated), CT chest (dissection), CT head (focal deficits)
-- Consider secondary workup of hypertensive etiology - sleep study, renal artery doppler US, aldo:renin ratio >30, metanephrines, TSH
Treatment
Urgency
-- goal to reduce BP to <160/100 over hours, then <130/90 over days; give short acting PO meds and discharge on long-acting PO meds
-- captopril, labetalol > hydralazine, isosorbide dinitrate
-- Dosages: Captopril 12.5-25mg q8h; Labetalol - PO 100mg q8-q12 (max 2400mg/d) or IV 10-80mg q10minutes → PO; Hydralazine - PO 10mg q6 or IV 5-20mg q15-30 minutes → PO; Isosorbide dinitrate - PO 5-20mg BID; Amlodipine - PO 2.5-5mg qday - increase 2.5mg q7d - takes few days for effect)
Emergency
-- goal to reduce no more than 25% in first hour (no lower than 160/100 within 2-5 hours, then to normotensive over 3-4 days
-- labetalol (10-80mg q10 min) > hydralazine (5-20mg q6); drips if transferred to the ICU
-- Dosages: Labetalol - dissection, CAD - 0.5-2mg/min to goal BP (max 10mg/min); Nitroprusside - CHF but not CAD - 0.25-2ug/kg/min to goal BP (max 10ug/kg/min); Nicardipine - SAH, dissection, renal failure - 5mg/hr up to 15mg/hr; Nitroglycerin - ACS, flash pulm edema - 10-30ug/min (max 400 ug/min)
Counseling: smoking cessation, weight loss, exercise, DASH diet, reduced salt intake, caffeine <2 cups daily, EtOH <2-3 drinks daily
If You Remember Nothing Else
The difference between HTN urgency and HTN emergency is the presence of end-organ damage above and beyond mild-moderate symptoms like headache. If you are genuinely concerned about HTN emergency, the best place for the patient is the ICU for tight titration of BP with IV drips. There are real and serious risks of lowering BP too quickly including ischemia with watershed infarcts. The ideal rate of BP change and drug choice depends on the etiology and the patient’s co-morbidities. In general, labetalol is likely agood option, but you should avoid BB'sin ACS/cardiogenic shock and CHF (prefer nitro drugs in those cases) and acute pulmonary edema.
Clinical Pearls
- Crisis is the umbrella term that includes any BP >180/120; Urgency is without severe sxs (beyond mild-mederate headache, dizziness, etc) or end-organ damage; Emergency is with severe sxs or end-organ damage; mild-moderate headache is the most common symptom in crises and does not necessarily represent an emergency
- 30% of adults in U.S have HTN - 1-2% of which will have a hypertensive crisis
- The rate of BP rise is likely more important to damage than the severity of rise
- IV hydralazine has variable response and duration - should be used with caution
- Avoid beta-blockers in ACS or pulmonary edema and prioritize sublingual nitroglycerine - goal SBP <140 within 1 hour
- Beta-blockers (lavetalol, esmolol) first line in aortic dissection - goal SBP <120 within 1 hour
- If concerned about catecholamine excess (meth, cocaine, pheo) give benzos and avoid beta blockers
- PRES (posterior reversible encephalopathy syndrome) - headache, seizure, AMS, visual loss - edema of white matter of occipital and parietal lobes on MRI - often from high BP
- Secondary HTN Etiologies - Medications (NSAIDs, steroids, OCPs, stimulants, d/c HTN meds); OSA (sleep study); Renal Artery Stenosis (rise in creatinine after starting ACE, duplex doppler US); Primary Aldosteronism (hypokalemia, aldo:renin ratio >30); Pheochromocytoma (24-hour urine metanephrines, plasma metanephrines); Rare (Cushing Disease, Hyperthyroidism, coarctation of the aorta)
- Lifestyle Counseling (and BP reduction) - Weight Loss (1 mmHg per kg); Exercise - 40 mins 3-4x per week at mod-vig intensity (5-8 mmHg); DASH Diet (8-14 mmHg); Salt Intake <2g/day (2-8 mmHg); Caffeine <2 cup/day (2-5 mmHg); Alcohol <2-3 drinks/day (2-4 mmHg); Smoking Cessation (3-5 1 year, 6-7 3 years)
Trials and Literature
- Review - Acute Severe Hypertension (NEJM, 2019)
Other Resources
- Clinical Problem Solvers - HTN Diagnostic Schema
Video
