Hypertensive Emergency
Hypertensive emergencies are a grab bag of diagnoses that all need to be treated differently - Claire Heslop
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Hypertensive Emergency: Pearls and Pitfalls for the ED Physician
Hypertensive emergency is characterized by severe hypertension, defined as systolic blood pressure (SBP) >180mmHg or diastolic blood pressure (DBP) >120mmHg, with evidence of end-organ dysfunction. Hypertensive emergencies require prompt recognition and treatment with IV antihypertensives to prevent from potentially fatal sequalae.
In contrast, hypertensive urgencies present with severe hypertension, SBP >180mmHg or DBP >120mmHg, but lack evidence of end-organ failure and therefore can often be managed with optimization of oral antihypertensives...
With a multitude of intravenous (IV) antihypertensives available, it canbequite painstaking to acutely navigate treatment options.…
Resources
EM in 5: Hypertensive Emergency Treatment
... treatment of hypertensive emergencies, with a detailed look at medications.
EM@3AM: Hypertensive Emergency
Defined by hypertension with end-organ dysfunction. Hypertensive urgency, or severely elevated hypertension without symptoms, does not require treatment in the ED.
Hypertensive crisis management in the emergency room time to change?
A rapid, marked and persistent rise in blood pressure (BP) levels above 180/120 mmHg is a clinical condition currently defined as hypertensive emergency or urgency in the presence or absence of acute signs of hypertension-mediated organ damage, respectively.
Mean Arterial Pressure (MAP)
The formula for calculating mean arterial pressure (MAP) is systolic + diastolic x’s 2 divided by 3 or (SBP+2DBP)/3.
Hypertensive emergency
We tend to focus on the systolic blood pressure (“she had a systolic of 250!!”). However, the risk of hypertensive emergency seems overall be more closely related to the diastolic pressure than the systolic pressure. MAP is probably the single parameter most closely related to the risk of hypertensive emergency.
Hypertension Management in Emergency Departments
For the vast majority of patients with elevated BP in the ED who do not have new or worsening end-organ injury from elevated BP, immediate BP reduction within the ED is not recommended or safe.
Hypertensive Emergency and Urgency
Goal BP reduction of MAP 20% in the first hour. Gradual normalization over the next 24-48h. Unless unclipped aneurysmal bleed or aortic dissection.
Intravenous IV Vasodilators Remain the First-Line Therapy of Choice for Severe H-AHF
The recommended first-line therapy for patients with severe hypertensive acute heart failure (H-AHF) remains intravenous (IV) vasodilators (via bolus) proven safe and effective (e.g., nitroglycerin), with a treatment target of ≤25% reduction in systolic blood pressure (SBP)...
Management of Hypertensive Urgency and Emergency
In hypertensive emergencies, BP should almost never be rapidly lowered. • Goal of 10-20% reduction of MAP in first hour, and then 5-15% further in next 23 hours. – Usually results in acute target of <180/<120 in first hour, then <160/<110 in next 23 hours. • Exceptions: – Acute aortic dissection (SBP < 120 in 20 minutes) – Acute ischemic stroke (tPA candidate < 185/110)
Hypertensive Emergency: Pearls and Pitfalls for the ED Physician
Calcium channel blockers (CCBs) remain the workhorses for management of hypertensive emergency due to their ideal pharmacokinetics, minimal adverse effects, and (relatively) predictable hemodynamic response.
ACEPNow
Per the JNC 7, a hypertensive emergency is a hypertensive crisis in which there is evidence of acute target-organ damage (e.g., encephalopathy, myocardial infarction, unstable angina, pulmonary edema, stroke, life-threatening arterial bleeding, or aortic dissection). Such cases warrant parenteral drug therapy and hospitalization, often to an intensive care setting.
International Emergency Medicine Education Project
Having end-organ damage is the hypertensive emergency. Having high blood pressure without any signs of end-organ damage is the hypertensive urgency.
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