Description
Hypertensive emergencies in the Emergency Department (ED) are characterized by severely elevated blood pressure (typically >180/120 mmHg) with evidence of acute target organ damage, such as encephalopathy, myocardial infarction, pulmonary edema, or renal failure. Immediate but controlled blood pressure reduction is critical to prevent further organ damage. Intravenous antihypertensives like labetalol, nicardipine, or nitroprusside are commonly used, tailored to the specific clinical scenario. Continuous monitoring and individualized treatment goals are essential, typically aiming to reduce mean arterial pressure by no more than 25% within the first hour. Prompt recognition and appropriate management significantly reduce morbidity and mortality in these patients.
Summary Listen
- World High Potention Day is celebrated annually on May 17th since 2005 by the World High Potention League, aiming to educate and empower people about hypertension. While hypertensive emergencies have declined in the US due to new medications, emergency visits for raised blood pressure have paradoxically increased.
- In India, hypertension is a major public health concern, affecting 24% of males and 21% of females, with an estimated 200-250 million individuals affected. This is likely an underestimation due to undiagnosed cases and a rising trend in rural populations. Older populations and women aged 45-49 are particularly vulnerable.
- Diagnostic terminologies for hypertension, refined by the American College of Cardiology and AHA, encompass asymptomatic elevated blood pressure (BP >130/80 without end-organ damage), hypertensive emergency (BP >180/120 with new or worsening end-organ damage), markedly elevated blood pressure (similar to hypertensive emergency, but can occur with or without end-organ damage), and asymptomatic markedly elevated blood pressure (elevated systolic BP without end-organ damage).
- Hypertensive emergencies necessitate immediate treatment to lower blood pressure, especially when end-organ damage is evident, affecting the brain, heart, kidneys, or eyes. Neurological involvement (stroke, subarachnoid hemorrhage), cardiovascular issues (chest pain, MI, pulmonary edema, aortic dissection), and kidney damage are critical concerns.
- Brain and heart involvement constitute the major complications in hypertensive emergencies. Timely intervention is critical to prevent disability and death. The focus should be on treating the patient's specific condition, not just the blood pressure numbers.
- Not all patients with elevated BP require emergency treatment, only those exhibiting end-organ damage need IV therapy. Isolated elevations without symptoms can be managed medically with close monitoring. Correct classification is essential for appropriate treatment and disposition.
- Hypertension in pregnancy carries significant risks, including maternal stroke, cardiopulmonary decompensation, fetal compromise, and stillbirth. Underlying or new onset hypertension in pregnant patients need careful management.
- Clues for diagnosis includes chest pain for MI, tearing chest pain radiating to the back for aortic dissection, dyspnea and raised jugular venous pressure for pulmonary edema/CHF, altered mental status for hypertensive encephalopathy, and retinal hemorrhages for eye involvement. Initial evaluation includes basic labs and clinical assessment, with imaging as indicated.
- Malignant hypertension is characterized by BP >180/120 with end-organ damage and visual changes like papilledema and flame-shaped hemorrhages.
- Management principles emphasize that not all patients require aggressive treatment. Emergency physicians should identify end-organ damage to determine the need for IV therapy. Asymptomatic elevated BP can be managed medically.
- Pediatric hypertension is classified based on percentile thresholds, varying by age and sex. Stage 1 hypertension requires lifestyle modifications, while Stage 2 and hypertensive emergencies may necessitate medication, guided by a pediatrician. Gradual BP reduction is crucial in pediatric hypertensive emergencies to prevent ischemia.
- Adult hypertension guidelines recommend ICU admission for patients with end-organ damage requiring IV medication, or specific conditions like aortic dissection or preeclampsia. BP reduction targets vary depending on the condition, with more aggressive targets for aortic dissection and severe preeclampsia. A systolic blood pressure of below 140 mmHg during the first hour is considered aggressive management. A systolic blood pressure of below 120 mmHg is considered a more aggressive management during aortic dissection.
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About the Speakers
Dr. Ramit Singh Sambyal
Head of the Department, Metro Hospital, Noida, Uttar Pradesh
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