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 |
|
Large vessels |
|
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