Acute Severe Hypertension in Out Patient Clinic

What is Hypertensive emergency?

  • BP – 180/110 to 120 mm Hg
  • Associated with acute Target Organ Damage (TOD)

What is Hypertensive Urgency?

  • BP – 180/110 to 120 mm Hg
  • Absence of acute TOD

How to identify Target Organ damage (TOD)?

  • TOD associated with signs and symptoms and listed below
Brain
  • Stroke
  • Intra cranial hemorrhage
  • Encephalopathy
Heart
  • Acute Coronary Syndrome
  • Acute Heart Failure
Eye
  • Hemorrhages
  • Exudates
  • Papilledema
Kidney
  • Acute Kidney Injury
Large vessels
  • Aortic Dissection
Small vessels
  • Micro Angiopathic Hemolytic Anemia

What is the difference between Hypertensive Emergency vs Urgency?

  Emergency Urgency
Level of BP (mm Hg) 180/110 to 120 180/110 to 120
Target organ damage Present Absent
Setting Acute rise of BP Chronic BP elevation
Hospitalization Needed – ICU Not needed – OPD
Morbidity & Mortality Increased Not increased
Medicines Intra venous Oral

Causes of Acute Severe Hypertension in out patient setting

  • Drug non-compliance
  • Dietary sodium indiscretion
  • Over-the-counter drugs, NSAIDs, Steroids
  • Anxiety or panic
  • Acute stroke/Heart failure
  • Renal disease

Causes of Acute Severe Hypertension in-patient setting

  • Withholding of antihypertensive medications
  • Urinary retention
  • Pain
  • Intravenous fluids

When to suspect secondary hypertension?

Despite treatment of hypertension if BP remains high during follow up

What is the importance of cerebral blood flow auto regulation?

  • Chronic uncontrolled hypertension patients have normal cerebral flow despite high BP levels. This prevents development of cerebral edema.
  • If BP is controlled rapidly this leads to cerebral hypoperfusion and should not be done.

How to manage Hypertensive Urgency?

  • Most managed as out patient
  • Guideline directed management of hypertension
  • Out patient visit within next 5 days
  • Intra venous medicines for BP control are discouraged
  • Symptoms related to hypertension like headache, atypical chest pain or epistaxis is present
  • Choose rapid acting drugs such as clonidine, labetalol, captopril, prazosin etc.
  • Avoid Nifedipine sub lingual because of unpredictable BP reductions causing cardio vascular event
  • BP medicines to be administered every 30 minutes till BP controlled
  • Patient to be sent home after BP stabilizes below 160-180/100-110

How to manage Hypertensive Emergency?

  • To be admitted into intensive care unit.
  • Intra venous medicines needed
  • Choice of the agent depends on TOD


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Copyright © 2019, Dr. Raghu. All rights reserved.
Designed & Developed by Deepak Kambhampati.