FIRSTCONSULT

Hypertensivecrisis
Revised:December12,2013
CopyrightElsevierBV.Allrightsreserved.

Keypoints
Hypertensiveemergencyisatypeofhypertensivecrisiswheremarkedelevationsinbloodpressure
(>180/120mmHg)areaccompaniedbyimminentorprogressiveendorgandysfunction.Organ
dysfunctionoccursinfrequentlywithadiastolicbloodpressurebelow130mmHg,exceptin
childrenandpregnantwomen
Hypertensiveurgencyisahypertensivecrisiswiththesamesevereelevationsinbloodpressure,
butwithoutprogressiveendorgandysfunction.Themajorityofthesepatientspresentas
noncompliantorinadequatelytreatedhypertensiveindividuals
Associatedsymptomsofhypertensivecrisesincludeintenseheadache,dyspnea,epistaxis,or
extremeanxiety
Aclinicalpresentationsuggestiveofendorgandamagewillacceleratetheurgencyand
aggressivenessoftreatment.Hypertensiveemergenciesrequireimmediatebloodpressure
reductionandcontrol(notnecessarilytonormallevels)topreventorlessenadditionalendorgan
damage.Thisiscommonlyachievedbyusingintravenousshortactingblockers,calciumchannel
blockers,orfenoldopamtitratedoverminutestohours.Adecreaseof15%to20%inthesystolic
bloodpressureisconsideredacceptable
Specifictreatmentdependsonthecomorbiditiesassociatedwithhypertensiveemergencies:acute
coronarysyndromeoracutemyocardialinfarctionacuteleftventricularfailureordiastolicfailure
withflashpulmonaryedemadiastolicdysfunction,dissectingaorticaneurysmsevere
preeclampsia,eclampsiaandHELLPsyndromehypertensiveencephalopathyintracerebral
hemorrhageorischemicstrokeacuterenalfailureandmicroangiopathichemolyticanemia
Hypertensiveurgenciesareusuallymanagedwithoralangiotensinconvertingenzyme(ACE)
inhibitormedicationsorclonidinetoachievebloodpressurecontrolwithinthefirst24to48hours
inamannerthatisusuallysufficienttopreventorgandamage

Background
Description
TheJointNationalCommission(JNC)7completereport
(http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf)classifiesbloodpressureinfourstages:
normal,prehypertension,stage1,andstage2,thelatterdefinedasasystolicbloodpressure
higherthan160mmHgoradiastolicbloodpressurehigherthan100mmHg
JNC7identifiespatientswithbloodpressurebeyondstage2,asystolicbloodpressureofhigher

than180mmHgoradiastolicbloodpressureofhigherthan120mmHgashavinga
hypertensivecrisis
Thereportclassifieshypertensivecrisisintooneoftwocategories:
Hypertensiveemergency:severeelevationinbloodpressure(>180/120mmHg)
complicatedbyevidenceofimpendingorprogressiveendorgandysfunctionthatrequires
immediatebloodpressurereduction,althoughnotnecessarilytonormaltopreventor
limitendorgandamage
Hypertensiveurgency:severeelevationsinbloodpressurebutwithoutprogressiveend
organdysfunction
Ahypertensivecrisiscandevelopdenovoorcanoccurinindividualswithknownessentialor
secondaryhypertension.Theabruptnatureofonsetsuggestsaprecipitatingcircumstance
superimposedonpreexistinghypertension
Thereisnoclearexplanationastowhysomepatientswithseverehypertensiondevelopend
organdamageyetotherswiththesameelevationinbloodpressuredonot
Thereisnospecificlevelofbloodpressureatwhichendorgandamageoccurs.Theelevationof
bloodpressureisnottheonlyfactorcontributingtoorgandamage.However,arapidrateof
increaseinbloodpressureismorelikelytobeassociatedwithendorgandamage
Comorbiditiesassociatedwithhypertensiveemergenciesarefrequentandimportant
managementconsiderations.Someconditionsprecipitateahypertensivecrisis,suchassevere
preeclampsiaorpheochromocytoma,whileothersarecomplicationsofhypertensivecrisisand/or
manifestationsofendorgandamage,suchasdissectinganeurysm,stroke,andhypertensive
encephalopathy
Manypatientswhopresentinhypertensivecrisishavesuperimposedpoorlycontrolledchronic
essentialhypertension,whichovertimecausescompensatorydysfunctionsuchasheartfailure,
chronicrenalfailure,andatheroscleroticdiseasedistinctfromtheacuteendorgandamageof
hypertensiveemergencies.Thesedysfunctionsincreasethelikelihoodandseverityof
hypertensivecrises
'Malignanthypertension'isacommonmisnomer.ItwascoinedbytheGermansinthe1920s
whenthemortalityrateforhypertensiveemergencieswasinexcessof70%.In1984,JNCIV
deletedtheterm,asitisinaccurateMedicare,however,stillusesitforpaymenttophysicians

Epidemiology
Incidenceandprevalence:
Approximately72millionpeopleintheU.S.sufferhypertension(definedassystolicpressure
>140mmHgand/ordiastolicpressure>90mmHg),takeanantihypertensivemedication,or
aretoldatleasttwicebyahealthcareproviderthattheyhavehighbloodpressure
Worldwide,hypertensionoccursinapproximately1billionpeopleandmayberesponsiblefor
approximately7.1milliondeathsannually
About5%ofpatientswithahistoryofhypertensionwillhaveatleastonehypertensiveurgency

About1%ofpatientswithahistoryofhypertensionwillhaveatleastonehypertensive
emergency
Demographics(similartoessentialhypertension):
Age:Theincidenceofhypertensionincreaseswithage
Gender:Hypertensionaffectsmenataslightlyhigherratethanwomen
Ethnicity:IntheU.S.,hypertensionandhypertensiveemergenciesarehigheramongAfrican
AmericansascomparedtowhitepeopleorpersonsofAsianethnicity
Geography:Thereisnoevidenceofgeographicinfluences
Socioeconomicstatus:Thereisnoevidencethatsocioeconomicstatusisdirectlylinkedto
hypertensivecriseshowever,lackofaccesstoprimarycareandmedicationnoncompliancedue
tosocioeconomicfactorscanbeprecipitants

Causesandriskfactors
Thepathophysiologyofhypertensivecriseshasnotbeenfullyelucidated,butisspeculatedtoresult
fromsuddenincreasesinsystemicvascularresistancethatarelikelyrelatedtoendogenous
vasoconstrictors.
Causes:
Denovoextremeelevationinbloodpressure
Noncompliancewithantihypertensivemedications
Aprecipitatingeventsuperimposedonpreexistinghypertension,suchasdehydration,angina,
oruseofsympathomimeticmedications
Acutesympatheticcrisissecondarytopheochromocytomaorcocaineintoxication
Renalarterystenosis

Severepreeclampsiaandassociatedconditions
Riskfactors(similartoessentialhypertension):
Oldage
Priorhistoryofhypertension
Priorhistoryofhypertensivecrises
Africanethnicity
Malesex
Tobaccoabuse
Obesity

Diabetesmellitus

Screening
Notapplicable.

Primaryprevention
Summaryapproach
Themajorityofpatientswithhypertensiveurgenciesandemergencieshavepoorlymanaged
chronicessentialhypertension
Primarypreventionwillincludeadequateoutpatientorinhospitaltherapyaswellasclose
outpatientfollowup

Populationatrisk
Patientswithpreviouslydiagnosedorundiagnosedhypertension
Patientswithriskfactorsforhypertensivecrisis(sameasthoseforessentialhypertension)

Preventivemeasures
Patientswithknownhypertensionrequirelifestylemodifications
Whennotsufficient,physiciansneedtoprescribeeffectiveandaffordableantihypertensive
medicationsthatthepatientcantakeindefinitely.Physiciansalsoneedtoscheduleregular
followupvisits

Diagnosis
Summaryapproach
Mostpatientswithseverehypertensionwillpresentwithhypertensiveurgency,withoutany
evidenceofendorgandamage.Thesepatientsmaypresentwithvaguecomplaints,oroftenthey
arebeingseenforanunrelatedmedicalissueforwhichroutinevitalsignsarerecorded.The
elevatedbloodpressurereadingmayhaveasecondarycause,butusuallyitisultimately
diagnosedasessentialhypertension
Incontrast,patientswithahypertensiveemergencypresenttothephysicianoremergency
departmentwithasignificantmedicalcomplaintrelatedtoendorgandamagesuchaschest
pain,dyspnea,changesinmentalstatus,orafocalneurologicdeficit
Allpatientspresentinginhypertensivecrisisshouldundergoacompletecardiopulmonary
examination,auscultationovertherenalarterieslisteningforbruits,andafocusedneurologic
andfundoscopicexamination
Evaluatethepatientforevidenceofpulmonarycongestion,andforthepresenceofnew
cardiacgallopsormurmurs
Headacheandalteredlevelsofconsciousnesswithanonfocalneurologicexaminationmay
beduetohypertensiveencephalopathyinpatientswithfocalneurologicfindings,suspect
acerebrovascularaccident

Fundoscopicexaminationofhypertensiveencephalopathymayrevealretinopathywith
arteriolarchanges,exudates,hemorrhages,orpapilledema

Clinicalpresentation
Symptoms:
Headache
Nausea
Chestpain
Dyspnea
Dizziness
Visualdisturbances
Alteredlevelofconsciousness
Fatigue
Otherhistoricalinformation:
Inpatientswithessentialhypertension,confirmwhetherpatienthasrecentlybeencompliant
withlifestylechangesandantihypertensivemedications
Priorhistoryofhypertensivecrises
Historyofchildhoodhypertension(duetoreninexcessinmanycases)
Familyhistoryofpheochromocytomamayberelevant
Signs:
Bloodpressurehigherthan180/120mmHg
Retinalhemorrhages,exudates,and/orpapilledema
Jugularvenousdistention
Cracklesonlungauscultation
Cardiacmurmursorgallops
Abdominalbruit
Peripheraledema
Seizure
Focalneurologicsigns

Diagnostictesting
Laboratoryevaluationisindicatedinallpatientsinhypertensivecrisis:acompletebloodcount

(1426632)tolookformicroangiopathichemolyticanemia,andbloodureanitrogenandcreatinine
levels(1426633),electrolytelevels(1426634),andurinalysis(1426635)toassessrenalfunction

Additionaltestingdependsonthepatient'spresentation.Chestradiography(1426636),cardiac
markers(1426637),andelectrocardiography(1426638)(ECG)shouldbeperformedinpatientswho
presentwithchestpainorshortnessofbreath.Iftheclinicalpictureisconsistentwithaortic
dissection,emergencychestandabdominal/pelviccomputedtomography(CT)angiography
(1426639)maybethequickestdefinitivestudy.Withnewonsetofseverepulmonaryedema,
echocardiography(1426640)willaidinidentifyingacutemitralregurgitationortransientsystolic

dysfunction,whicharemanageddifferentlythanroutineheartfailure

Completebloodcount

Description
Venousbloodsample
Normalresults
Leukocytecount:4,500to11,000/L
Differentialcount:
Neutrophilssegmented:1,800to7,800/L
Neutrophilsbands:0to700/L
Lymphocytes:1,000to4,800/L
Monocytes:0to800/L
Eosinophils:0to450/L
Basophils:0to200/L
Erythrocytecount:3.9to5.5106/L
Hemoglobin:14.0to17.5g/dL
Hematocrit:41%to50%
Plateletcount:150to350103/L
Peripheralsmear:
Normalmorphology,size,andpigmentationoferythrocytes
Absenceofimmatureerythrocytesorleukocytes
Plateletsnormalinsizeandnumber
Comments
Theperipheralsmearmayshowmicroangiopathicchangesandhemolyticanemiainpatients
inhypertensiveemergency,specificallythosewithacuterenaldysfunctionassociatedwith
microscopicintravascularabnormalities,orwithHELLPsyndrome

Bloodureanitrogenandcreatinine

Description
Venousbloodsample
Normalranges
Bloodureanitrogen:8to23mg/dL
Creatinine:0.6to1.2mg/dL
Comments
Elevatedcreatininemayindicaterenalarterialinvolvementwithdissection

Serumelectrolytes

Description
Venousbloodsample
Normalranges
Sodium:136to142mEq/L
Potassium:3.5to5.0mEq/L
Chloride:96to106mEq/L
Bicarbonate:21to28mEq/L
Comments
Aidsintheevaluationandtreatmentofsodiumorpotassiumabnormalities

Urinalysis

Description
Macroscopic:Urinesampletestedforvariouschemicalparameters,usuallybydipstick
impregnatedwithaseriesofreagents
Microscopic:Urinesamplemaybeexaminedinacountingchambertoquantitatethenumber
ofbloodcellsandbacteriaorcentrifugedformicroscopicexaminationofthesediment
Normalresults
Macroscopic:
Appearance:yellow,clear
Specificgravity:1.010
pH:usually>5,upto6.5
Protein:negative

Glucose:negative
Blood:negative
Microscopic:
Erythrocytes:fewerthan3perhighpowerfieldinuncentrifugedurine
Comments
Protein,microscopichematuria,erythrocytecastsorhyalinecastsmaybefoundinpatients
presentinginhypertensivecrisis

Chestradiography

Description
Radiographicimageoforgansandbonystructureswithinthethorax,includingthelungs,
heart,andmediastinum
Normalresults
Clearlungfields
Normalheartsize
Nomasses,effusion,orwidenedmediastinum
Comments
Diffuseshadowingmayresultfromleftventriculardysfunctionandpulmonaryedemarelated
totheacutehypertensionepisode
Awidenedmediastinumissuggestiveofanaorticdissection

Cardiacmarkers

Description
Venousbloodsample
Normalranges
Cardiacenzymes:
Creatinekinase(CK):40to150U/L
Creatinekinasemethylbromide(CKMB):<5%oftotalCK
Cardiactroponins:
CardiactroponinI(cTnI):0to0.4ng/mL
CardiactroponinT(cTnT):0to0.1ng/mL
Comments

Cardiacenzymes:
CKissensitivebutnotspecific
CKMBismorespecificthanundifferentiatedCKformyocardialinfarctionallowslate
diagnosisorconfirmationofinfarction
Cardiactroponins:
Veryhighspecificityandsensitivityforcardiacmuscle
Becomespositivein3to12hoursprolongedtimecourseofdecay(510daysforcTnIand5
14daysforcTnT)allowslatediagnosisorconfirmationofmyocardialinfarction

Electrocardiography

Description
Recordoftheelectricalactivityoftheheartovertime
Normalresults
Normalsinusrhythm,60to100beatsperminute(bpm)
Noevidencehypertrophyorischemia
Comments
ECGmayshowchangesindicativeofmyocardialischemiaorinfarct,butisoftennotchanged
frombaselineinaorticdissection
Abnormalresultsincludeleftventricularhypertrophy,STsegmentdepressionorTwave
inversion,arrhythmias,andpathologicQwaves

Computedtomographyangiography

Description
Twodimensional,crosssectionalstudycreatedbyuseofionizingradiation,obtainedwith
intravenouscontrastmaterialtoenhancethevasculature
Normalresults
Aortawithsinglelumen
Normalaorticandpulmonaryvasculature
Nomasses,nopleuralorcardiaceffusions
Comments
CTangiographyofthechest,abdomen,andpelvisisthepreferredimagingmodalitytoassess
widenedmediastinumortoruleoutaorticdissection
Maydistinguishbetweenaorticdissectionandothercausesofwideningoftheaorta

Theabdomenandpelvisshouldalwaysbeimagedalongwiththechesttoascertainthefull
extentofdissection

Echocardiography

Description
Sonographicimagingstudyusedtovisualizetheheartandpericardium
Normalresults
Normalcardiacvalvesandchambers
Coordinatedcardiacchambercontractility
Noexcesspericardialfluid
Comments
Abnormalresultsmaybecausedbyabnormalitiesofcardiacanatomy,impairedleft
ventricularsystolicand/ordiastolicfunction,andvalvulardefects
Echocardiographymaybeusefulforevaluationofcardiogenicshock,andforassessmentfor
pericardialeffusionsandcardiactamponade
Providesgoodvisualizationofthethoracicaorta

Consultation
Consultationforpatientswithhypertensivecrisesisdirectedbyendorgandamage
Intensivisttomanagebloodpressurecontrolandtocoordinatecare
Inthosepatientswithsuspectedsecondaryhypertensionsuchasrenalarterystenosis,a
consultationwithinterventionalradiography,interventionalcardiology,ornephrologyis
recommended

Treatment
Summaryapproach
Generalconsiderationsofhypertensiveemergency:
Patientspresentingwithahypertensiveemergencyshouldbeadmittedtoanintensivecareunit
forcontinuouscardiacmonitoring,frequentneurologicexaminations,andprecisemeasurement
ofurineoutput
Asthesepatientsdisplayabnormalautoregulation,rapidandexcessivecorrectionoftheblood
pressurecanfurtherreduceperfusionandpropagatefurtherendorganinjury.Ideal
managementconsistsofacontinuousinfusionofashortacting,titratableantihypertensive
agent.Duetounpredictablepharmacodynamics,thesublingualandintramuscularroutes
shouldbeavoided
Patientswiththemostsevereclinicalmanifestationsorwiththemostlabilebloodpressuremay
benefitfromintraarterialbloodpressuremonitoring

Severalrapidactingintravenousmedicationsareavailableforthetreatmentofahypertensive
crisis,andtheagentofchoicedependsonwhichcomorbidityconditionormanifestationofend
organdamageispresent
Rapidactingintravenousagentsshouldnotbeusedoutsideofamonitoredsettingtoprevent
steepdeclinesofbloodpressurethatmayresultinadverseoutcomes
Inmostpatients,thereshouldbenomorethana15%to20%dropininitialbloodpressureover
thefirsthour.However,inpatientswithaorticdissection,thebloodpressureshouldbereduced
rapidlywithin5to10minutes,targetingasystolicbloodpressurebelow120mmHg,amean
arterialpressurebelow80mmHg,andaheartrateof60bpmorlowertodecreaseshearing
forcesandpreventfurtherdissection.AlsobasedonthenewlypublishedINTERACT2trial,
patientswithacuteintracranialhemorrhagecanhavetheirsystolicbloodpressurelowered
below140mmHginthefirst3hoursoftreatment
Generalconsiderationofhypertensiveurgency:
Hypertensiveurgencypatientspresentwithoutevidenceofendorgandamage
Mostofthesepatientshavehadelevatedbloodpressuresforsometimeanddonotrequire
emergentdecreaseinbloodpressure
Somepatientswillhaveadecreaseoftheirbloodpressureofcloseto20%byjustsittingina
doctor'sofficeexaminationroomoranemergencydepartment
Themostcommoncauseoftheseurgenciesismedicalnoncompliance
Specificmedications:
Ingeneral,thepreferredagentsforhypertensiveemergenciesincludeintravenousblockers(
eg,esmololandlabetalol),dihydropyridinecalciumchannelblockers(eg,nicardipineand
clevidipine),andfenoldopam
Phentolamineislesscommonlyusedtodayhowever,itmaybeusefulinparticularsituations,

suchascatecholamineinducedhypertensivecrisesbypheochromocytomaorcocaine
Sodiumnitroprussidemaybeusedinpatientswithacutepulmonaryedemaand/orsevereleft

ventriculardysfunctionandinpatientswithaorticdissection.Inpatientswithaorticdissection,it
shouldbeusedinconjunctionwithanintravenousblocker.Useofsodiumnitroprussideis
limitedduetothepotentialforcyanidetoxicityafter48hours
Intravenouslabetalolandhydralazinearecommonlyusedfortheacutemanagementofpatients
withpreeclampsia
Oralandsublingualnifedipinearepotentiallydangerousinpatientswithhypertensivecrises
andarenotrecommended.TheCardiorenalAdvisoryCommitteeoftheU.S.FoodandDrug
Administrationconcluded,morethan20yearsago,thatthepracticeofadministering
sublingual/oralnifedipineneededtobeabandonedbecausethisagentwasneithersafenor
efficacious.Nifedipineisnottobeconsideredanacceptabletherapyinthemanagementof
eitherhypertensiveemergenciesorurgencies
Orallabetalolandcalciumchannelblockersarecommonlyusedinpatientswithsevere

preeclampsiawhoarebeingmanagedexpectantlyremotefromterm
ClonidineandACEinhibitors(eg,enalaprilat)arelongactingandpoorlytitratablehowever,

theseagentsmaybeusefulinselectcircumstancesforthemanagementofhypertensive
urgencies.Inpatientswhohavebeennoncompliantwithclonidineandwhoseelevatedblood
pressureisrefractorytootheragents,clonidinemayaidinbloodpressurereduction.Rarely,
diazoxideisusedforhypertensiveurgencies

Nitrates(eg,nitroglycerin)arenotadrugofchoiceforhypertensivecrisis.Theyarenotefficient
atcontrollingbloodpressureandshouldbeavoidedexceptinthecontextofunstableangina,
nonSTsegmentelevationmyocardialinfarction(NSTEMI),orSTEMI
Oncestablebloodpressurecontrolisestablishedwithintravenousagentsandendorgan
damagehasbeencontrolled,parentalmedicationscanbetaperedandoraltherapyinitiated

Medications

Nicardipine

Indications
Nicardipine,asecondgenerationdihydropyridinederivativecalciumchannelblockerwith

highvascularselectivityandstrongcerebralandcoronaryvasodilatoryactivity,isusedin
hypertensivecrises,particularlyinpatientswithcardiacorneurologiccomorbidities
Thisisanofflabelindication
Doseinformation
Initialinfusionrate:5mg/hintravenouslythen,increaseinfusionrateby2.5mg/hevery5
minutestoamaximumof15mg/huntilthedesiredbloodpressurereductionisachieved
Dosageisindependentofthepatient'sweight
Majorcontraindications
Aorticstenosis
Dihydropyridinehypersensitivity
Comments
Theonsetofactionofintravenousnicardipineisfrom5to15minutes,withdurationofaction
of4to6hours
Intravenousnicardipinereducesbothcardiacandcerebralischemia
Anotherusefultherapeuticbenefitofnicardipineisthatitincreasesbothstrokevolumeand
coronarybloodflowwithafavorableeffectonmyocardialoxygenbalance.Thispropertyis
usefulinpatientswithcoronaryarterydiseaseandsystolicheartfailure
NicardipinehasbeenrecommendedintheAmericanHeartAssociation/AmericanStroke
Association'sguidelinesforthetreatmentofischemicstroke
(http://stroke.ahajournals.org/content/44/3/870.full)whendiastolicbloodpressureishigherthan

120mmHgorthesystolicbloodpressureishigherthan220mmHg

Evidence
Asystematicreviewwasperformedtocomparetheefficacyofnicardipineversuslabetalol
inthetreatmentofacutehypertensivecrises.Tenstudies(1,020patients),mostofwhich
wereretrospectiveorprospectiveanduncontrolled,metcriteriaforanalysisinthereview.
Fourstudiesassessedoutcomesofpatientswithcerebrovascularaccidentstheremaining
addressedspecificconditionssuchaspregnancyorpostoperativestate.Thereview
generallyfoundcomparableefficacyandsafetyfornicardipineandlabetalol,but
nicardipinewasfoundtoprovidemorepredictableandconsistentbloodpressurecontrol
thanlabetalol.[1]Levelofevidence:2

References

Clevidipine

Indications
Clevidipine,athirdgenerationdihydropyridinecalciumchannelblockerandultrashort

actingselectivearteriolarvasodilator,isusedinhypertensivecrises,particularlywhen
afterloadreductionisadesiredeffect
Doseinformation
Loadingdose:1to2mgintravenously
Additionaldosing:Repeatedincrementaldoublingofthedoseat90secondintervalsuntil
thedesiredbloodpressureisachieved.Asthebloodpressureapproachesgoal,increasethe
dosebylessthandoublingandlengthenthetimebetweendoseadjustmentstoevery5to10
minutes
Anincreaseofapproximately1to2mg/hwillgenerallyproduceanadditionaldecreasein
systolicpressureof2to4mmHg
Thedesiredtherapeuticresponseformostpatientsoccursatdosesof4to6mg/h.Patients
withseverehypertensionmayrequiredosesupto32mg/h
Majorcontraindications
Aorticstenosis
Egghypersensitivity
Hyperlipidemia
Pancreatitis
Soyalecithinhypersensitivity
Comments
Clevidipinereducesbloodpressurebyadirectandselectiveeffectonarterioles,thereby
reducingafterloadwithoutaffectingcardiacfillingpressuresorcausingreflextachycardia.

Strokevolumeandcardiacoutputusuallyincrease
Aprospectiveopenlabel,uncontrolledstudyfoundthat,after30minutes,88.9%(104/117)
ofpatientswithsystolicbloodpressurehigherthan180mmHgand/ordiastolicblood
pressurehigherthan115mmHgachievedthegoalbloodpressure,andnoadditional
antihypertensivemedicationswererequiredfor92.3%(108/117)ofpatientsreceiving18
hoursormoreofclevidipineinfusion

Esmolol

Indications
Esmolol,anultrashortactingcardioselective,adrenergicblockingagent,isusedtoobtain

rapidcontrolofbloodpressure,particularlywhendecreasedheartrateandcontractilityare
desired
Thisisanofflabelindication
Doseinformation
Loadingdose:500to1,000g/kgintravenouslyover1minute
Infusiondosing:Startat50g/kg/minandincreaseupto300g/kg/minasnecessary
Majorcontraindications
Atrioventricularblock
Bradycardia
Cardiogenicshock
Heartfailure
Pulmonaryedema
Comments
Esmololhasnodirectvasodilatoryactions.Itdecreasesatrialpressurebydecreasingheart
rateandmyocardialcontractilityandthuscardiacoutput
Theonsetofactionofthisagentiswithin60seconds,withadurationofactionof10to20
minuteshowever,becauseitismetabolizedbyerythrocyteesterases,anyconditionthat
precipitatesanemiawillprolongitsshorthalflife

Labetalol

Indications
Labetalol,acombinedselective1adrenergicreceptorblockerandnonselectiveadrenergic

blocker,isusedforthetreatmentofhypertensiveemergencyorurgency,particularlyin
situationswheremaintainingcardiacoutputisdesired
Alsousedinpatientsinwhomblockadeisadvantageousbutblockadeisnecessary,such
asduringacutesympatheticcrisis

Intravenouslabetalolandhydralazinearecommonlyusedfortheacutemanagementof
patientswithpreeclampsia
Orallabetalolandnifedipinecanbeusedinpatientswithseverepreeclampsiawhoarebeing
managedexpectantlyremotefromterm
Doseinformation
Loadingdose:20mgintravenously
Additionaldosing:repeatedincrementaldosesof20to80mgat10minuteintervalsuntilthe
desiredbloodpressureisachievedoraninfusioncommencingat1to2mg/minandtitrated
uptountilthedesiredhypotensiveeffectisachieved
Bolusinjectionsof1to2mg/kghavebeenreportedtoproduceprecipitousfallsinblood
pressureandshould,therefore,beavoided
Majorcontraindications
Asthma
Atrioventricularblock
Bradycardia
Cardiogenicshock
Heartfailure
Hypotension
Comments
Thehypotensiveeffectoflabetalolbeginswithin2to5minutesfollowingintravenous
administration,reachingapeakat5to15minutesfollowingadministration,andlastingfor
about2to4hours
Duetolabetalol'sblockingeffects,theheartrateiseithermaintainedorslightlyreduced.
Unlikepureadrenergicblockingagentsthatdecreasecardiacoutput,labetalolmaintains
cardiacoutput

Evidence
Asystematicreviewwasperformedtocomparetheefficacyofnicardipineversuslabetalol
inthetreatmentofacutehypertensivecrises.Tenstudies(1,020patients),mostofwhich
wereretrospectiveorprospectiveanduncontrolled,metcriteriaforanalysisinthereview.
Fourstudiesassessedoutcomesofpatientswithcerebrovascularaccidentstheremaining
addressedspecificconditionssuchaspregnancyorpostoperativestate.Thereview
generallyfoundcomparableefficacyandsafetyfornicardipineandlabetalol,but
nicardipinewasfoundtoprovidemorepredictableandconsistentbloodpressurecontrol
thanlabetalol.[1]Levelofevidence:2

References

Fenoldopam

Indications
Fenoldopam,anintravenousdopamineagonist,isusedfortheacutetreatmentofsevere

hypertension,particularlyinpatientswithrenalimpairment
Doseinformation
Aninitialstartingdoseof0.1g/kg/minintravenouslyisrecommended,titratedby
incrementsof0.05to0.1g/kg/mintoamaximumof1.6g/kg/min
Comments
Fenoldopamisuniqueamongtheparenteralbloodpressureagentsbecauseitmediates
peripheralvasodilationbyactingonperipheraldopamine1receptors
Theonsetofactioniswithin5minutes,withthemaximalresponseisachievedby15minutes.
Thedurationofactionrangesfrom30to60minutes.Oncetheinfusionisdiscontinued,
bloodpressuregraduallyreturnstopretreatmentvalueswithoutreboundeffect
Fenoldopamimprovescreatinineclearance,urineflowrates,andsodiumexcretionin
severelyhypertensivepatientswithbothnormalandimpairedrenalfunction
Fenoldopamcausesdosedependentincreasesinintraocularpressure,anditsuseshouldbe
avoidedinpatientsatriskforintraocularhypertensionandintracranialhypertension

Hydralazine

Indications
Hydralazine,adirectactingarteriolarvasodilator,isoftenchosenasafirstlineagentfor

criticallyillpatientswithpregnancyinducedhypertensiondespitethefactthatitmaycausea
decreaseintheuteroplacentalbloodflow
Itmaybeusedsecondlineasadjuncttherapytotreathypertensiveemergencyorurgency
Doseinformation
Initialbolus:10to20mgintravenously.Repeatasneeded,usuallyevery4to6hours
Switchtooralantihypertensivetherapyassoonaspossible,usuallywithin24to48hour
Majorcontraindications
Coronaryarterydisease
Rheumaticheartdisease
Comments
Afterintramuscularorintravenousadministration,thereisaninitiallatentperiodof5to15
minutesfollowedbyaprogressiveandoftenprecipitousfallinbloodpressureusuallynoted
between10to80minutesthatcanlastupto12hours

Dosageofhydralazineshouldbemodifiedinpatientswithrenalfailureorsevererenal
impairmentwithacreatinineclearanceoflessthan10mL/min
Becauseoftheprolongedandunpredictableantihypertensiveeffectsofhydralazineandthe
inabilitytoeffectivelytitrateitshypotensiveeffect,itisbestavoidedinmostcasesforthe
managementofhypertensivecrises

Enalaprilat

Indications
Enalaprilat,anACEinhibitor,isusedasasecondorthirdlineagentforthetreatmentof

hypertensiveurgencyoremergency
Thisisanofflabelindication
Doseinformation
1.25to5mgintravenouslyevery6hours
Incongestiveheartfailure:intravenousinjectionof1.25mgover5minutesevery6hours,
titratedbyincrementsof1.25mgat12to24hourintervalstoamaximumof5mgevery6
hours
Majorcontraindications
Angioedema
ACEinhibitorhypersensitivity
Comments
Theonsetofactionforenalaprilatisdelayedfor15minutes,andpeakeffectisnotreachedfor
approximately1hour.Durationofactionisapproximately6hours
Therelativelyslowonsetandlongdurationofactionmakeitapoorchoiceforuseina
hypertensiveemergency
ACEinhibitorshavethepotentialtocauseacuterenalfailure,acuterenaldysfunction,or
hyperkalemiainpatientsincirculatorydecompensatedstates,orwhenmeanarterial
pressureisinsufficienttosupportrenalperfusion
ACEinhibitorsshouldnotbeconsideredfirstlineagentsinthetreatmentofacute
perioperativehypertensionassurgicalpatientsareatanincreasedriskforcirculatory
decompensationinthepostoperativeperiod

Phentolamine

Indications
Phentolamine,anblocker,isusedinthetreatmentofacutehypertensivecrisis

Thisisanofflabelindication
Doseinformation

5to15mgintravenouslyorintramuscularly1to2hoursbeforesurgeryoranytimeto
managehypertensivecrisis
Repeatdoseevery2to4hoursasrequired
Majorcontraindications
Acutemyocardialinfarction
Angina
Coronaryarterydisease
Myocardialinfarction
Comments
Usedforpreventionorcontrolofhypertensiveepisodesinpatientswithpheochromocytoma,
mostcommonlyasaresultofstressormanipulationduringpreoperativepreparationand
surgicalexcision

Clonidine

Indications
Clonidine(oral)hasbeenusedforthetreatmentofhypertensivecrises

Thisisanofflabelindication
Doseinformation
0.1to0.2mgorallyeveryhourasrequiredtoatotalof0.6mg
Comments
Onsetofactionisfrom30minutesto2hours,durationofactionis6to8hours
Suddencessationinapatientwhoischronicallyusingthismedicationcanleadtoarebound
hypertensiveeffect

Diazoxide

Indications
Diazoxide,anarteriolarsmoothmusclerelaxer,isusedtotreathypertensiveemergency

Doseinformation
Initialbolus:1to3mg/kgintravenouslyover10to20minutes
Additionaldoses:Abovedoseisrepeatedat10to15minuteintervals,untilthedesiredeffect
isachievedoruntilamaximumof150mgisgiven
Majorcontraindications
Aorticcoarctation

Arteriovenousshunt
Sulfonamidehypersensitivity
Thiazidehypersensitivity
Comments
Intravenousdiazoxidehasanonsetofactionof1minute,withapeakactionobtainedat10
minutes,anddurationof3to18hours
Thisagentisrarelyusedanymore

Nitroglycerin

Indications
Nitroglycerinisusedasanadjuncttointravenousantihypertensivetherapyinpatientswith

hypertensiveemergenciesassociatedwithacutecoronarysyndromesoracutepulmonary
edema
Nitroglycerinisnottobeconsideredanacceptableprimarytherapyinthemanagementof
eitherhypertensiveemergenciesorurgencies,butmaybeasuitableadjuncttherapy
Doseinformation
Initialdose:5g/minintravenousinfusion.Titrateby5g/minevery3to5minutesuntil
clinicalresponse,ortoadoseof20g/min
Dosagemaythenbefurtherincreasedbyincrementsof10g/min,and,ifthedesiredeffectis
stillnotachieved,dosagemaybeincreasedinincrementsof20g/min
Themaximumrecommendedtitrationis20g/minevery3to5minutes
Theeffectivedosagerangeis5to100g/min
Majorcontraindications
Cardiactamponade
Cardiomyopathy
Constrictivepericarditis
Increasedintracranialpressure
Nitratehypersensitivity
Comments
Nitroglycerinisapotentvenodilatoronlyathighdosesdoesitaffectarterialtone.Ithas
pharmacokineticpropertiessimilartosodiumnitroprussideandcauseshypotensionand
reflextachycardia,whichareexacerbatedbythevolumedepletioncharacteristicof
hypertensiveemergencies

Intravenousnitroglyceringenerallyisnotconsideredasafirstlinetherapyforhypertension,
asitisnotasefficaciousassodiumnitroprusside,mayhavelittleornoefficacywhenused
alone,anditsantihypertensiveactioniscausedbyvenodilation
Intravenousnitroglycerinhasanonsetofactiontimeof2to5minutesanddurationofaction
ofapproximately10to20minutes
Familiaradverseeffectsofintravenousnitroglycerinincludehypotension,hypoxemiafrom
ventilationperfusionmismatching,methemoglobinemia,reflextachycardia,and
tachyphylaxis

Sodiumnitroprusside

Indications
Sodiumnitroprusside,anarterialandvenousvasodilator,isusedforthetreatmentof

hypertensiveemergencyorhypertensiveurgencyonlywhenotherintravenous
antihypertensiveagentsarenotavailableandthen,onlyinspecificclinicalcircumstancesin
patientswithnormalrenalandhepaticfunction
Doseinformation
Initialstartingdose:0.5g/kg/mintitrateastolerated
Thedurationoftreatmentshouldbeasshortaspossible,andtheinfusionrateshouldnot
exceed2g/kg/min
Majorcontraindications
Aorticcoarctation
Arteriovenousshunt
Cyanidetoxicity
Hereditaryopticnerveatrophy
Highoutputacuteheartfailure
Toxicamblyopia
Comments
Nitroprussidedecreasescerebralbloodflowwhileincreasingintracranialpressure,effects
thatareparticularlydetrimentalinpatientswithhypertensiveencephalopathyorfollowinga
cerebrovascularaccident
Inpatientswithcoronaryarterydisease,asignificantreductioninregionalbloodflow
(coronarysteal)canoccur.Inalargerandomized,placebocontrolledtrial,nitroprussidewas
showntoincreasemortalitywheninfusedintheearlyhoursafteracutemyocardialinfarction
(mortalityat13weeks,24.2%vs12.7%)
Intraarterialbloodpressuremonitoringisrecommendedduetonitroprusside'spotency,
rapidityofaction,andthedevelopmentoftachyphylaxis

Themoleculeofsodiumnitroprussidecontains44%cyanidebyweight,theremovalofwhich
requiresadequateliverfunction,renalfunction,andbioavailabilityofthiosulfate.Patients
candevelopcyanidetoxicityasearlyas6to8hoursafterinitiationoftheinfusionofsodium
nitroprusside.Cyanidetoxicityhasbeendocumentedtoresultin'unexplainedcardiacarrest,'
coma,encephalopathy,convulsions,andirreversiblefocalneurologicabnormalities

Specialcircumstances
Comorbidities
Bydefinition,hypertensiveemergencyhasevidenceofendorgandysfunction.Fromaclinical
perspective,comorbidconditionssignificantlyinfluencethetypeandaggressivenessof
emergencyhypertensivemanagement.Someoftheseconditionsarecausedbypoorly
controlledessentialorsecondaryhypertension,thuslongtermmanagementofblood
pressurebecomesthepriorityoncethehypertensiveemergencypasses
Otherconditionsmaycausethehypertensiveemergency,andtheserequireemergency
treatmentoftheprimaryconditioninordertofullycontroltheacutebloodpressure
Allcomorbiditiesunderscoretheneedtoindividualizecareofhypertensiveemergencysothat
managementisbasedonthepatient'soverallconditionandnotsolelytheseverityofthe
hypertension
Acutecoronarysyndrome/acutemyocardialischemia:

Hypertensionisoneriskfactorforcoronaryarterydisease.Initialmanagementofacute
coronarysyndrome,whichincludesunstableanginaandNSTEMI,focusesonpainrelief,
evaluationforsecondarycauses,stabilizationoftheacutecoronarylesion,andearly
considerationforinvasivecoronarytherapy(angiographyandpercutaneouscoronary
intervention)inselected,highriskpatients.Thrombolytictherapyandrevascularizationare
thecornerstonesofthemanagementofSTEMI
Nitratesarehelpfulforpainmanagementinallpatients,particularlythosewithconcurrent
hypertension.Nitroglycerinasanantihypertensiveagentbyitselfisseldomusefultherefore,
patientsmayrequireadditionalmedications
Nicardipine,withorwithoutnitroglycerin,isafirstlineagentforpatientswithacute
coronarysyndromes
Esmololisusedparticularlywhenheartratecontrolisalsodesired
Otherantihypertensiveagentsappropriateinthissettingincludeclevidipine,labetalol,or
fenoldopam
Acutepulmonaryedemaduetodiastolicdysfunctionoracutemitralregurgitation/acuteleft
ventricularfailure:
Inpatientswithdiastolicheartfailure,leftventricularsystolicfunctionispreservedbut
alteredventricularcomplianceresultsinahighfillingpressureanddecreasedcardiacoutput.
Thereisahighprevalenceofdiastolicdysfunctioninpatientswithchronichypertensionin
suchpatients,asuddensevereelevationofbloodpressureasseen,forexample,with
renovascularhypertensionoracutesympatheticcrisis,furtherlimitsmyocardialrelaxation

resultinginacutepulmonaryedema
Damagetothemitralvalve,usuallyrelatedtoacutemyocardialinfarction,resultsinsudden
leftventricularfailureandflashpulmonaryedema
Hypertensioncomplicatedbyacutepulmonaryedemaistreatedwithdiuretics,nitrates,
morphine,and,insomecases,ACEinhibitorsorARBs
Otherantihypertensiveagentsappropriateinthissettingincludenicardipine,clevidipine,or
fenoldopam
Acuteischemicstroke/intracerebralhemorrhage:
Hypertensionisacommoncauseofcerebrovascularaccidents.Firstchoicetherapy,
assumingnocontraindications,isintravenousthrombolytictherapy
Mostexpertsrecommendthatantihypertensiveagentsbewithheldinpatientswithacute
ischemicorhemorrhagicstrokeunlessthediastolicbloodpressureishigherthan120mmHg
orthesystolicbloodpressureishigherthan220mmHg,whichoccursinsomepatients.
Elevatedbloodpressureshouldbetreatedwithlabetalolornicardipine.Ifapatientwill
receiveathrombolyticagent,thensystolicbloodpressuremustbereducedtobelow185mm
Hg
Otherantihypertensiveagentsappropriateinthissettingincludeclevidipine,esmolol,or
fenoldopam
Acuterenalfailure/microangiopathichemolyticanemia:

Hypertensivecrisismaycausemicroscopicintravascularinjuryleadingtomicroangiopathic
hemolyticanemia,renalinsufficiency,andthrombocytopenia.Emergencycontrolofblood
pressurewithfenoldopamsignificantlyimprovesmortalityandmorbidity
Otherantihypertensiveagentsappropriateinthissettingincludenicardipineandclevidipine
Renovasculardisease:
Renalarterystenosiscausesseveresecondaryhypertensionthatmayberefractoryto

antihypertensivemedication.Patientspresentwithextensivevasculardiseaseand/or
worseningrenalfunction.Onphysicalexamination,anabdominalbruitmaybeheardover
renalarteries.Someofthesepatientsmaypresentwithrecurrentflashpulmonaryedema
Treathypertensivecrisiswithcalciumchannelblockersorblockers.Renalfunctionmust
bemonitoredwhenACEinhibitorsorARBsareused
Hypertensiveencephalopathy:
Hypertensiveencephalopathyisthoughttoresultfromthesuddencerebralhyperperfusionof
acutehypertensiveemergency.Presentationisrelatedtoprogressivecerebraledema,from
earlyonsetheadache,nausea,andvomitingtoalteredmentalstatus,andfinallyseizuresand
coma.Fundoscopyexaminationmayrevealhemorrhages,exudates,and/orpapilledema.A
magneticresonanceimagingscanwillhelpruleoutastroke,themostimportantdifferential
diagnosis,andmayalsosuggestwhitematterfeaturesconsistentwithdiagnosis

Intheseinstances,decreasethesystolicbloodpressurebynomorethan15%to20%overthe
firsthoursoftreatmentandnomorethan25%overthefirst4hours.Donotusesodium
nitroprusside,asthisagentdecreasescerebralbloodflowandcanworsentheencephalopathy
Antihypertensiveagentsappropriateinthissettingincludenicardipine,clevidipine,labetalol,
fenoldopam,oresmolol
Acuteaorticdissection:
Mostcasesof(usuallythoracic)aorticdissectionarecausedbyhypertension.Presentsas
suddenseverechestpainandvaryingdegreesofhemodynamicinstability,sometimeswith
asymmetricpulseandbloodpressurereadings
Thefocusofacutemedicaltherapyisoncontrolofhypertensionandreductionoftheshear
force(dP/dt)ofejectedbloodduringsystoliccontractionwithblockersandcalcium
channelblockers.Nitroprussideasarapidbloodpressureloweringagentisnowseldom
used
Incontrasttotreatingothercomorbidities,thebloodpressureinacutedissectionshouldbe
reducedrapidlywithin5to10minutes,targetingasystolicbloodpressureofbelow120mm
Hg,meanarterialpressurebelow80mmHg,andaheartrateof60bpmorlowertodecrease
shearingforcesandpreventfurtherdissection
Eclampsia/severepreeclampsia:
Severepreeclampsiaisdefinedbythepresenceofhypertensivecrisisandproteinuria(orifno
proteinuria,thenotherfeatures)afterthe20thweekofpregnancy.Etiologyisnotwell
understood
Eclampsiausuallypresentsasbrief,selflimited,generalized,tonicclonicseizuresalongwith
eitherconcurrentpreeclampsiaorpreeclampticfeatures,includingseverehypertension,that
developswithin48hoursofseizure
Themainstaysoftreatmentincludebedrest,fluidmanagement,particularlywhenoliguriais
presentserialmonitoringanddeliveryofthefetuswhenappropriate
Magnesiumsulfateisthedrugofchoiceforthepreventionofseizuresandisindicatedduring
laborandfor12to24hourspostpartum
Intravenouslabetalolandhydralazinearecommonlyusedfortheacutemanagementof
patientswithpreeclampsia.Orallabetalolandnifedipinecanbeusedinpatientswithsevere
preeclampsiawhoarebeingmanagedexpectantlyremotefromterm
HELLP,asevereandpotentiallyfatalvariantofpreeclampsiadiagnosedbasedonlaboratory
findingsofmicroangiopathichemolyticanemia,elevatedlivertransaminases,and
thrombocytopenia,isalsoassociatedwithhypertensiveemergencies.Deliveryofthefetusis
thedefinitivetreatment
Otherantihypertensiveagentsappropriateinthissettingincludeesmololorclevidipine
Acutesympatheticcrisis:

Hypertensiveemergencyaspartofanacutesympatheticcrisisisusuallydueto
pheochromocytomaorstimulantdrugs,notablyacutecocaineintoxication

Pheochromocytoma,araretumorofcatecholaminesecretingchromaffincellsusuallyfound
intheadrenalmedulla,classicallypresentswithparoxysmalheadaches,tachycardia,and
sweating.Mostpatientspresentwithparoxysmalhypertension,includingacutehypertensive
crisisthatismanagedwithintravenousphentolamine.Oncethebloodpressureiscontrolled,
patientsaretransitionedtooralphenoxybenzamine.Atimelysurgicalresectionofthetumor
isthetreatmentofchoice
Patientswhousecocaineinparticular,inadditiontoamphetaminesandotherstimulants,
presentwithhypertensiveemergencyandotherfeaturesofadrenergichyperactivity:fever,
tachycardia,diaphoresis,hyperactivity,mydriasis,muscletwitching,andextreme
nervousness,lastingforhoursthroughtheacuteintoxication.Evaluatechestpaincarefully
forevidenceofcoronaryvasospasm.Benzodiazepinessuchaslorazepamanddiazepamare
firstlinetherapyforbothhypertensionandothersignsofcocaineintoxication.Phentolamine
andotherblockersshouldbeconsideredinpatientswhousecocainewhosebloodpressure
isrefractorytobenzodiazepines
Avoidusingblockersotherthanlabetalol,astheunopposedblockingeffectsmaycausea
paradoxicalreboundinhypertension
Acutepostoperativehypertension:
Inthesurgicalsetting,ahypertensivecrisismayoccurduringcardiacsurgery,majorvascular
surgerysuchascarotidendarterectomyoraorticsurgery,neurosurgery,headandneck
surgery,orrenaltransplantation
Postoperativehypertensiondefinedassystolicbloodpressure190mmHgorhigherand/ora
diastolicbloodpressureof100mmHgorhigherontwoconsecutivereadingsfollowing
surgeryisverycommonandfrequent(4%35%)intheearlypostoperativeperiod.Itisrelated
toincreasedsympathetictoneandvascularresistance
Despitethetransientnatureofpostoperativehypertensionandtheuniqueclinicalfactors
presentinthepostoperativeperiod,itmayhavesignificantadversesequelaeinbothcardiac
andnoncardiacpatients
Firstlinetreatmentincludescalciumchannelblockersandshortactingblockers

Consultation
Specialtyconsultationusuallyisappropriatedependingonorgansysteminvolvement.

Followup
Monitoring:
Patientswithhypertensivecrisesrequiremonitoringatleast1weekfollowingdischarge,andthen
ongoingcareforthecauseofthecrisisand/orcomorbidity
Managementofessentialhypertensioniscriticaltomaintaininggoodbloodpressurecontrol

Additionalfollowuptestsshouldbeperformedbasedupontheseverityandchronicityofend
organdamage
Prognosis:
Themorbidityandmortalityofhypertensivecrisesaredependentonpriorendorgandamageand
dysfunction,thedegreeofacuteendorgandamage,rapidinterventionstoachieveadequateblood
pressurecontrol,andadherencetotreatment
Inuntreatedpatients,themortalityrateat1yearcanbeashighas7%.Amongtreatedpatients
presentinginhypertensivecrisis,theoverall5yearmortalityrateisabout25%
Complicationsofhypertensiveemergenciesandurgencies:
Cerebrovasculardisorders
Acuteandchronicmyocardialischemia
Structuralheartdisease
Acuteandchronickidneydisease

Hypertensiveretinopathy
Vasculardisorders(eg,aorticdissection,thoracicorabdominalaorticaneurysms)
Hypertensiveencephalopathy
Obstetricalcomplicationssuchasabruptionincreasedriskofstillbirthandneonataldeathand
maternalrisksofpulmonaryedema,disseminatedintravascularhemorrhage,andpostpartumhemorrhage
Secondaryprevention:
DatafromtheStudyingtheTreatmentofAcutehyperTension(STAT)Registry(http://www.outcomes
umassmed.org/stat/)indicatethatalargenumberofpatientswithhypertensiveemergenciesareat
highriskforrecurrenthypertensivecrisesandassociatedsequelae
Morethan45%ofpatientswillhavenewevidenceofendorgandamage,6.9%willdieinthe
hospital,and37.2%willbereadmittedwithin90days
Therefore,patientsrequireclosepostdischargefollowupforperiodicmeasurementofblood
pressureandformonitoringoflifestyleandmedicationeffectivenessandpatientcompliance

Patienteducation
Patientswithchronichypertensionwhoareselfmonitoringbloodpressureshouldbeadvisedof
thefollowing:
Ifasystolicreadingof180mmHgorhigheroradiastolicreadingof110mmHgorhigheris
made,waitacoupleofminutesandtakeitagain
Ifthereadingremainsatorabovethatlevel,thepatientshouldseekimmediateemergency
medicaltreatmentwithemergencymedicalservices,orbedriventoahospital

Treatmentofhypertensiveurgencyusuallyrequiresreadjustmentand/oradditionaldosingof
oralmedications
Ifthepatienthasasystolicbloodpressurereadingof180mmHgorhigherordiastolicblood
pressureof110mmHgorhigher,andhasanysymptomsofpossibleorgandamage(chest
pain,shortnessofbreath,backpain,numbness/weakness,changeinvision,difficulty
speaking),heorsheshouldseekemergencymedicalassistanceimmediatelyorbedriventoa
hospital
Whenundergoingtreatmentforahypertensivecrisis,patientsshouldunderstandthattheir
physicianscanbringtheirbloodpressuredownnomorethan15%to25%oftheinitialblood
pressureduringthefirsthouroftreatment
Patientsshouldbemadeawareoftheconsequencesofnottreatingacutehypertension.These
includeacutemyocardialinfarction,stroke,andkidneyinjury

Onlineinformationforpatients
AmericanHeartAssociation:Hypertensivecrisis
(http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Hypertensive
Crisis_UCM_301782_Article.jsp#)

MayoFoundationforMedicalEducationandResearch:Hypertensivecrisis:Whatarethe
symptoms?(http://www.mayoclinic.com/print/hypertensivecrisis/AN00626/METHOD=print)

Resources
Summaryofevidence
Evidence
Asystematicreviewwasperformedtocomparetheefficacyofnicardipineversuslabetalolin
thetreatmentofacutehypertensivecrises.Tenstudies(1,020patients),mostofwhichwere
retrospectiveorprospectiveanduncontrolled,metcriteriaforanalysisinthereview.Four
studiesassessedoutcomesofpatientswithcerebrovascularaccidentstheremaining
addressedspecificconditionssuchaspregnancyorpostoperativestate.Thereviewgenerally
foundcomparableefficacyandsafetyfornicardipineandlabetalol,butnicardipinewasfound
toprovidemorepredictableandconsistentbloodpressurecontrolthanlabetalol.[1]Levelof
evidence:2

References
References
Evidencereferences
1.PeacockWF4th,HillemanDE,LevyPD,RhoneyDH,VaronJ.Asystematicreviewof
nicardipinevslabetalolforthemanagementofhypertensivecrises.AmJEmergMed.
201230:98193
ViewInArticle(refInSitu53733)|CrossRef(http://dx.doi.org/10.1016%2Fj.ajem.2011.06.040)

Guidelines

TheNationalHeart,Lung,andBloodInstitute(http://www.nhlbi.nih.gov/)oftheNationalInstitutesof
Healthhasproducedthefollowing:
JointNationalCommitteeonPrevention,Detection,Evaluation,andTreatmentofHigh
BloodPressure.TheSeventhReportoftheJointNationalCommitteeonPrevention,Detection,
Evaluation,andTreatmentofHighBloodPressure,JNC7(CompleteReport)
(http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf).NIHPublicationNo045230.

Bethesda,Md.:NationalHeart,Lung,andBloodInstitute,HealthInformationCenter2004
TheAmericanCollegeofCardiology(http://www.cardiosource.org/acc)andAmericanHeartAssociation
(http://www.heart.org/HEARTORG/)havejointlyproducedthefollowing:

HuntSA,AbrahamWT,ChinMH,etalAmericanCollegeofCardiologyAmericanHeart
AssociationTaskForceonPracticeGuidelinesAmericanCollegeofChestPhysicians
InternationalSocietyforHearthandLungTransplantationHeartRhythmSociety.ACC/AHA
2005guidelineupdateforthediagnosisandmanagementofchronicheartfailureintheadult
(http://circ.ahajournals.org/content/112/12/e154.long):areportoftheAmericanCollegeof

Cardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines(Writing
CommitteetoUpdatethe2001GuidelinesfortheEvaluationandManagementofHeart
Failure):developedincollaborationwiththeAmericanCollegeofChestPhysiciansandthe
InternationalSocietyforHeartandLungTransplantation:endorsedbytheHeartRhythm
Society.Circulation.2005112:e154235
TheWorldHealthOrganization(http://www.who.int/en/)hasproducedthefollowing:
WorldHealthOrganization(WHO).WHOrecommendationsforpreventionandtreatmentofpre
eclampsiaandeclampsia(http://whqlibdoc.who.int/publications/2011/9789241548335_eng.pdf).

Geneva(Switzerland):WorldHealthOrganization(WHO)2011
TheNetherlandsAssociationofInternalMedicineworkinggrouponhypertensivecrisishas
producedthefollowing:
vandenBornBJ,BeutlerJJ,GaillardCA,deGooijerA,vandenMeirackerAH,KroonAA.
Dutchguidelineforthemanagementofhypertensivecrisis2010revision
(http://www.njmonline.nl/getpdf.php?t=a&id=10000726).NethJMed.201169:24855

Furtherreading
AcelajadoMC,CalhounDA.Resistanthypertension,secondaryhypertension,and
hypertensivecrises:diagnosticevaluationandtreatment.CardiolClin.201028:63954
AlexanderJM,WilsonKL.Hypertensiveemergenciesofpregnancy.ObstetGynecolClin
NorthAm.201340:89101
FontesML,VaronJ.Perioperativehypertensivecrisis:newerconcepts.IntAnesthesiolClin.
201250:4058
JohnsonW,NguyenML,PatelR.Hypertensioncrisisintheemergencydepartment.Cardiol
Clin.201230:53343
MayerSA,KurtzP,WymanA,etalSTATInvestigators.Clinicalpractices,complications,
andmortalityinneurologicalpatientswithacuteseverehypertension:theStudyingthe

TreatmentofAcutehyperTensionregistry.CritCareMed.201139:23306
MarikPE,VaronJ.Perioperativehypertension:areviewofcurrentandemergingtherapeutic
agents.JClinAnesth.200921:2209
PerezMI,MusiniVM.Pharmacologicalinterventionsforhypertensiveemergencies.
CochraneDatabaseSystRev.2008:CD003653
RodriguezMA,KumarSK,DeCaroM.Hypertensivecrisis.CardiolRev.201018:1027
VaronJ.Treatmentofacuteseverehypertension:currentandneweragents.Drugs.
200868:28397
VaronJ,StrickmanNE.Diagnosisandtreatmentofhypertensivecrisesintheelderly
patients.JGeriatrCardiol.20074:505
MarikPE,VaronJ.Hypertensivecrises:challengesandmanagement.Chest.2007131:1949
62
PapadopoulosDP,MourouzisI,ThomopoulosC,MakrisT,PapademetriouV.Hypertension
crisis.BloodPress.201019:32836
ThomasCA.Drugtreatmentofhypertensivecrisisinchildren.PaediatrDrugs.201113:281
90
RhoneyD,PeacockWF.Intravenoustherapyforhypertensiveemergencies,part1.AmJ
HealthSystPharm.200966:134352
RhoneyD,PeacockWF.Intravenoustherapyforhypertensiveemergencies,part2.AmJ
HealthSystPharm.200966:144857
HebertCJ,VidtDG.Hypertensivecrises.PrimCare.200835:47587,vi
HaasAR,MarikPE.Currentdiagnosisandmanagementofhypertensiveemergency.Semin
Dial.200619:50212
PrejbiszA,LendersJW,EisenhoferG,JanuszewiczA.Cardiovascularmanifestationsof
phaeochromocytoma.JHypertens.201129:204960
PollackCV,VaronJ,GarrisonNA,EbrahimiR,DunbarL,PeacockWF4th.Clevidipine,an
intravenousdihydropyridinecalciumchannelblocker,issafeandeffectiveforthetreatment
ofpatientswithacuteseverehypertension.AnnEmergMed.200953:32938
AwadAS,GoldbergME.Roleofclevidipinebutyrateinthetreatmentofacutehypertension
inthecriticalcaresetting:areview.VascHealthRiskManag.20106:45764

Codes
ICD9code
401.0Essentialhypertension,malignant(hypertensiveemergencies)
401.9Essentialhypertension,unspecified

405.0Secondaryhypertension,malignant

FAQ
Whatisthedifferencebetweenhypertensiveurgencyandemergency?Thedifference
isthepresenceofendorgandysfunction
Howfastcanwedropthebloodpressureinapatientwithhypertensive
emergency?Nomorethan15%to25%oftheinitialbloodpressurethefirsthour(exceptin
acuteaorticdissection)
Whatarethechoicesintreatment?Esmolol,labetalol,nicardipine,clevidipine,amongst
others
Shouldweutilizesublingualnifedipineinthetreatmentofhypertensive
emergencies?No,theuseofsublingualnifedipineinthetreatmentofhypertensive
emergenciesisdiscouraged
Whatisthepreferredagentforthetreatmentofsympathetichypertensivecrisis?
Thepreferredagentforthetreatmentofsympathetichypertensivecrisisisphentolamine

Currentcontributors
JosephVaron,MD,FACP,FCCP,FCCM,FRSM,ClinicalProfessorofMedicine,TheUniversityofTexas
MedicalBranchandChiefofStaffandChiefofCriticalCareServices,UniversityGeneralHospital,
Houston,Texas

Copyright2016Elsevier,Inc.Allrightsreserved.