Hypertensive Emergencies: Guidelines and Best-Practice Recommendations (Pharmacology CME)

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Delivery Method:	Online
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Publication Date: June 2023 (Volume 25, Number 6)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 06/01/2026.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Due to a variety of demographic and public health factors, the number of emergency department visits related to hypertensive emergencies has increased dramatically in recent decades, making it imperative that clinicians clearly understand the current treatment guidelines and definitions for the spectrum of hypertensive disease. This issue reviews current evidence on identifying and managing hypertensive emergencies and the differences between expert opinions on diagnosing and managing these emergencies. Clear protocols differentiating patients with hypertension from patients with hypertensive emergencies are needed to appropriately manage this patient population.

Case Presentations

A 62-year-old man presents via EMS with swelling of his legs that makes it hard for him to walk...

• EMS states he wasn’t able to walk because of his lower extremity swelling. Vital signs en route are: temperature, 37°C; heart rate, 90 beats/min; blood pressure, 193/118 mm Hg; respiratory rate, 20 breaths/min; and oxygen saturation, 94% on room air.
• The patient reports his medication was across the room, and he wasn’t able to reach it due to his inability to walk from his leg swelling. He states he has a history of congestive heart failure with a left ventricular ejection fraction of 25%. He pulls out from his jacket a copy of his latest echocardiogram report.
• On physical examination, you notice he has bilateral lower extremity pitting edema and that he is becoming increasingly more tachypneic. On pulmonary examination, you hear fine crackles bilaterally and diffusely. You notice his oxygen saturation is dropping on the monitor, despite just having put him on 2 L of oxygen via nasal cannula. As you continue to talk to him, his oxygen requirements increase to non-rebreather mask.
• You wonder what type of hypertensive emergency this is, and what treatment must be implemented immediately?

A 76-year-old man presents to the ED with his family, who are concerned he might have dementia…

• The family informs you that he is normally a sweet old man, but recently he has been having episodes of confusion and agitation. Yesterday, the police found him walking along the highway in his bathrobe.
• His family tells you he has a history of diabetes and hypertension. They don’t know if he has been taking his medications regularly or what his medications are.
• His temperature is 37°C; blood pressure, 236/113 mm Hg; heart rate, 62 beats/min; respiratory rate, 14 breaths/min; and oxygen saturation, 96% on room air. His blood glucose level is 185 mg/dL.
• On examination, he is alert and oriented to name only. He complains of a “headache all over,” seeing strange flashing lights, and is annoyed by your continued questioning. As you continue, he no longer participates in the physical examination and begins to have jerking movements.
• Which medication(s) should you use to treat him?

A 59-year-old woman presents to the ED after being seen at her primary care physician’s office…

• Her doctor was concerned because her blood pressure was 206/120 mm Hg. Her blood pressure normally runs high, but they had never seen it this high.
• The patient states that she feels fine. She denies any vision changes, headache, chest pain, or shortness of breath. Her past medical history is relevant for hypertension and pre-diabetes. She states that she did not take her blood pressure medications this morning, since her primary care doctor‘s office told her to not eat or drink anything prior to getting her laboratory work today.
• You wonder whether anything needs to be done in the ED about her blood pressure…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.