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Hospital Management Of Hypertension: Urgencies And Emergencies
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Publication Date

November 2014 (Volume 2, Number 11)

CME

This issue includes 4 AMA PRA Category 1 CreditsTM; and 4 AOA Cetegory 2A or 2B CME credits

Author

Elizabeth Cerceo, MD
Assistant Professor of Medicine, Cooper Medical School of Rowan University, Camden, NJ

Jean-Sebastien Rachoin, MD
Assistant Professor of Medicine, Cooper Medical School of Rowan University, Camden, NJ

Peer Reviewers

Roselyn Cristelle I Mateo, MD
Assistant Professor and Attending Physician, Department of Internal Medicine, Section of Hospital Medicine, Rush University Medical Center, Chicago, IL

Wei-I Vickie Wu, MD, MHS
Assistant Professor of Clinical Medicine, Department of Medicine, Keck Medical Center of the University of Southern California, Los Angeles, CA

Abstract

Hypertensive crises are commonly encountered in the inpatient setting. Evidence to guide the management of hypertensive urgency and hypertensive emergency is limited, with few randomized clinical trials comparing medications and regimens. This issue reviews the difference between urgency and emergency, which is defined by the end-organ damage manifest and determines blood pressure reduction goals and optimal reduction speed. Hypertensive urgency is treated gradually over days, while hypertensive emergency requires a blood pressure reduction of approximately 15% (but no more than 25%) in the first hour, with a more gradual reduction thereafter. Physical examination findings associated with end-organ damage are summarized, and the safe and effective use of oral and intravenous medications are discussed. The selection of specific medications is based on patient clinical presentation, and evaluation for secondary causes of hypertension can be considered. Clear discharge instructions and outpatient follow-up are needed to increase the likelihood of patient compliance and to reduce the risk of readmission.

Excerpt From This Issue

A 60-year-old man is admitted through the emergency department with acute onset of severe left lower quadrant pain associated with a fever to 38.7°C (101.7°F), nausea, and vomiting. A CT scan is consistent with diverticulitis, though there is no abscess, perforation, or obstruction. His initial blood pressure on presentation was 185/98 mm Hg. He was started on intravenous hydration and antibiotics and was made NPO. He was also given intravenous morphine to control his pain. He has a history of hypertension and hyperlipidemia and reports compliance with his home regimen of ramipril 10 mg daily and atorvastatin 40 mg daily. As you evaluate the patient, you note that he is still nauseated and cannot tolerate oral intake. His blood pressure remains elevated at 174/97 mm Hg. How should you manage his blood pressure now?

A 77-year-old woman is brought in by her family for progressively worsening shortness of breath, confusion, and headache over the past 3 days. She has a history of systolic heart failure, ischemic stroke, hypertension, diabetes, hyperlipidemia, and hypothyroidism. Assessment of her vital signs reveals the following: blood pressure, 210/106 mm Hg; heart rate, 78 beats/min; respiratory rate, 22 breaths/min; oxygen saturation, 91% on 4L. When you examine her, she has bibasilar crackles, elevated jugular venous pressure to 9 cm, and 2+ bilateral leg edema. She is slow to respond to questions but answers appropriately, has no focal neurologic deficits, and has no papilledema or retinal hemorrhages. ECG reveals signs of hypertrophy but no acute ischemia. What is your next step?

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