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

What is the difference between Hypertensive Emergency vs Urgency?

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