Hypertension Management for Specific Emergencies

Aka: Hypertension Management for Specific Emergencies, Hypertensive Crisis, Malignant Hypertension, Severe Hypertension

1. See Also
   1. Hypertension
   2. Hypertension Criteria
   3. Hypertension Evaluation
   4. Hypertension Management
   5. Antihypertensive Selection
   6. Resistant Hypertension
   7. IV Antihypertensives
2. Definitiion
   1. Severe Hypertension: Blood Pressure >180/110 mmHg
3. Evaluation
   1. Hypertension Evaluation History
   2. Hypertension Evaluation Exam
   3. Hypertension Evaluation Labs
4. Precautions
   1. Avoid rapidly lowering Blood Pressure in asymptomatic patients with Severe Hypertension
   2. Severe Hypertension typically increases over weeks to months (as opposed to abruptly)
   3. Hypoperfusion may occur with acute Blood Pressure lowering >20-25%
      1. In asymptomatic patients, avoid intravenous or excessive antihypertensive dosing
      2. Gradual Blood Pressure lowering of severe asymptomatic Hypertension over days to weeks is preferred
5. Management: Severe Hypertension Presentations (all have Blood Pressure >180/110)
   1. Hypertensive Emergency (Hypertensive Crisis)
      1. Acute life-threatening complications due to Severe Hypertension (acute Myocardial Infarction, hemorrhagic CVA)
      2. Requires emergent and careful lowering of Blood Pressure (condition specific protocols exist)
      3. Typically requires admission to the ICU
   2. Hypertensive Urgency
      1. Progressive end-organ damage risk factors (pre-existing CHF, Unstable Angina, Chronic Kidney Disease)
      2. Start oral antihypertensive
      3. Consider admission in high risk cases
      4. Follow-up within 2 days with primary care
   3. Severe uncontrolled Hypertension
      1. No criteria met for hypertensive emergency or urgency as described above
      2. Start oral antihypertensive
      3. Follow-up within 7 days with primary care
6. Management: Specific conditions
   1. Hemorrhagic Stroke
      1. Nitroprusside
      2. Trimethaphan
      3. Labetalol
      4. Nicardipine
   2. Left Ventricular Heart Failure
      1. Nitroprusside
      2. Trimethaphan
      3. Avoid labetalol
   3. Myocardial Infarction or Myocardial Ischemia
      1. Nitroglycerin Drip
      2. Labetalol
   4. Aortic Dissection
      1. Trimethaphan
      2. Nitroprusside
      3. Propranolol
   5. Pheochromocytoma
      1. Phentolamine
      2. Avoid Beta Blockers
   6. Preeclampsia or Eclampsia
      1. Magnesium Sulfate
      2. Hydralazine
7. References
   1. Flanigan (2006) Med Clin North Am 90(3): 439-51
   2. Kessler (2010) Am Fam Physician 81(4): 470-6
   3. Handler (2006) J Clin Hypertens 8(1): 61-4
   4. Shayne (2003) Ann Emerg Med 41(4): 513-29