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

Table of Contents

 

About This Issue

International guidelines from myriad societies have varying recommendations on how and whether to treat ED patients who present with hypertension. Although hypertensive emergencies are life-threatening, inappropriate treatment of hypertensive urgency can also cause harm. In this issue, you will learn:

How the terms severe hypertension, hypertensive urgency, hypertensive crisis, malignant hypertension, and hypertensive emergency differ, and why it matters in choosing treatments.

The signs of end-organ damage in hypertensive emergencies that will require immediate lowering of blood pressure, and the specific diagnostic studies you’ll need to order for the workup.

The recommendations for blood pressure targets and medications for the most critical hypertension scenarios: heart failure, acute ischemic stroke, acute coronary syndromes, intracerebral hemorrhage, subarachnoid hemorrhage, aortic dissection, hypertensive encephalopathy, pre-eclampsia/eclampsia, and acute renal failure.

The dosages, mechanism, onset, duration of action, and adverse effects of 9 of the most commonly used antihypertensive medications.

The evidence and recommendations on blood pressure targets for patients receiving thrombolytics versus mechanical thrombectomy.

Whether using mean arterial pressure (MAP) instead of diastolic and systolic readings is best.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology And Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Basic Laboratory Analysis
    2. Electrocardiogram
    3. Imaging Studies
11. Treatment
    1. Acute Decompensated Heart Failure
       1. Diuretics
       2. Vasodilators
       3. Other Treatments
       4. Blood Pressure Targets
    2. Acute Ischemic Stroke
    3. Acute Coronary Syndromes
       1. Blood Pressure Targets
       2. Beta Blockers
       3. Nitrates
    4. Intracerebral Hemorrhage
       1. Blood Pressure Targets
       2. Antihypertensive Medications
    5. Subarachnoid Hemorrhage
    6. Aortic Dissection
    7. Hypertensive Encephalopathy
    8. Severe Pre-Eclampsia and Eclampsia
       1. Blood Pressure Targets
       2. Antihypertensive Medications
    9. Acute Renal Failure
    10. Oral Versus Intravenous Antihypertensives
12. Controversies and Cutting Edge
    1. Arterial Monitoring
    2. Beta Blockers in Cocaine-Induced Hypertension
13. Disposition
14. Summary
15. Time- and Cost-Effective Strategies
16. Risk Management Pitfalls for Hypertensive Emergencies in the Emergency Department
17. 5 Things That Will Change Your Practice
18. Case Conclusions
19. Clinical Pathway for Managing Hypertensive Emergencies in the Emergency Department
20. Tables and Figures
21. References

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…

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Managing Hypertensive Emergencies in the Emergency Department

Subscribe to access the complete flowchart to guide your clinical decision making.

Tables and Figures

Subscribe for full access to all Tables and Figures.

Key References

Following are the most informative references cited in this paper, as determined by the authors.

52. * Heidenreich PA, Bozkurt B, Aguilar D, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e1033. (Guideline) DOI: 10.1161/CIR.0000000000001062

65. * Peacock WF, Hollander JE, Diercks DB, et al. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J. 2008;25(4):205-209. (Retrospective study; 147,362 patients) DOI: 10.1136/emj.2007.050419

90. * Perez MI, Musini VM, Wright JM. Effect of early treatment with anti-hypertensive drugs on short and long-term mortality in patients with an acute cardiovascular event. Cochrane Database Syst Rev. 2009(4):CD006743. (Cochrane review; 65 RCTs) DOI: 10.1002/14651858.CD006743.pub2

93. * Qureshi AI, Palesch YY, Barsan WG, et al. Intensive blood-pressure lowering in patients with acute cerebral hemorrhage. N Engl J Med. 2016;375(11):1033-1043. (Prospective study; 1000 patients) DOI: 10.1056/NEJMoa1603460

Subscribe to get the full list of 122 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: hypertension, high blood pressure, severe, hypertensive emergency, MAP, BP, end-organ, asymptomatic, antihypertensive, CT, ultrasound, stroke, ACS, ICH, aortic dissection, eclampsia, renal