Management of Hypertensive Urgency - in an Urgent Care Setting - Journal of Urgent ...
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Clinical
Management of
Hypertensive Urgency
in an Urgent Care Setting
Urgent message: Effective management of patients presenting to
urgent care with acute high blood pressure starts with differentiat-
ing between hypertensive emergency and hypertensive urgency and
ends with appropriate treatment and counseling.
Sanjeev Sharma, MD, Christy Anderson, PharmD, Poonam Sharma, MD, and Donald Frey, MD
Introduction Pressure (JNC 7) classifies hy-
rgent care physicians rou- pertension as shown in Table
U tinely encounter patients
with high blood pres-
sure, but management—
particularly for those pa-
tients with precarious eleva-
tions—remains controversial.
Alternative options involve
1. Four categories of blood
pressures are described, the
most significant being Stage
2, defined as pressures
>160/100 mmHg. While the
JNC 7 does not define a blood
pressure limit for hyperten-
the use of various drug-ther- sive urgency or emergency,
apy modalities in the urgent the report classifies “severe el-
care setting with close obser- evation” in blood pressure as
vation, or initiation of oral >180/120 mm HG.
© Brian Evans / Photo Researchers, Inc
medication and releasing the The World Health Organ-
patient to home with specif- ization (WHO), Interna-
ic instructions. tional Society of Hyperten-
The consequences of inap- sion (IHS), and European
propriate treatment can be Society of Hypertension
disastrous, and include my- (ESH) all classify hyperten-
ocardial infarction, stroke, sion as shown in Table 2. In
and death. this system, there are six blood pressure categories, with
the highest being Stage 3 at >180/110 mmHg.
Classification of Hypertension Historically, systolic blood pressure (SBP) >179 and di-
Hypertension can be classified in various ways. The Sev- astolic blood pressure (DBP) >109 has broadly been
enth Report of the Joint National Committee on Preven- considered to be a “hypertensive crisis.”1 These pressures
tion, Detection, Evaluation, and Treatment of High Blood are further sub-classified as either hypertensive emer-
w w w. j u c m . c o m JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | A p r i l 2 0 0 9 11
MANAGEMENT OF HYPERTENSIVE URGENCY IN AN URGENT CARE SETTING
gency or hypertensive urgency.
Table 1: JNC-7 Classification of Hypertension
Hypertensive emergency exists if there
are signs of acute end-organ damage
Category SBP/DBP (mm Hg)
such as encephalopathy, myocardial
Optimal 160/>100
solute pressure measurement to define
hypertensive emergency, it is identi-
fied by the physical signs of acute end-
Table 2: WHO, ISH, & ESH Classification of Hypertension
organ damage. Consequently, patients
with a low baseline pressure can pres-
Category SBP/DBP (mm Hg)
ent with “normal” or mildly elevated
Optimal 180/110
tensive urgency as “elevated blood
pressure (diastolic pressure usually
>120 mm Hg) that is not associated with new or progres- nosed hypertensive individuals. They actually ex-
sive end-organ damage”.2 hibit normal pressures in their regular environment.
In hypertensive urgency, there is a risk of imminent The goal in hypertensive emergency is to rapidly and
end-organ damage, but such damage has not yet oc- carefully control the blood pressure to prevent fatal
curred. Particularly susceptible patients often have pre- and irreversible end-organ damage. Action is usually
existing conditions, e.g., renal insufficiency, congestive taken in minutes up to a few hours as per the clinical sit-
heart failure, coronary artery disease, CNS disorders, or uation, and intravenous medicines are usually em-
retinal changes. ployed. The aim may not be to reduce the blood pres-
One to two percent of all hypertensive patients may sure into the normal range in certain clinical scenarios
present with hypertensive emergency or crisis at some such as stroke.
point of their lives.1 In hypertensive urgency, blood pressure can be con-
Other terminologies used in these instances include: trolled safely over period of hours or days in the outpa-
! Acute hypertensive episode, which is defined as: tient setting.
– Stage 3 hypertension
– systolic pressure 180 mmHg Etiology
– and diastolic pressure 110 mmHg The etiology of hypertensive urgency is not well under-
with no signs or symptoms of evolving or impending stood. Most such patients have pre-existent hyperten-
target-organ damage. sion,3 and non-adherence with antihypertensive med-
! Transient hypertension, which is the presence of ications near the time of the episode is seen in about
high blood pressure in association with other con- 50% of them.4 Illicit drug usage is also reported to be a
ditions such as anxiety, alcohol-withdrawal, sudden risk factor for the development of hypertensive emer-
medication cessation, and toxic levels of some sub- gency.5 Other causes of both urgency and emergency are
stances. In this case, treatment is aimed at the un- shown in Table 3.
derlying cause.
! White-coat hypertension, or anxiety-related high blood Pathophysiology
pressure readings seen only in a physician’s office, During the hypertensive episode, there is an abrupt in-
with otherwise normal blood pressure. This is a sur- crease in the systemic vascular resistance due to humoral
prisingly common finding, especially in newly diag- vasoconstriction. This may be the triggering event.6
w w w. j u c m . c o m JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | A p r i l 2 0 0 9 15MANAGEMENT OF HYPERTENSIVE URGENCY IN AN URGENT CARE SETTING
Increased blood pressure causes en-
Table 3: Etiologic Causes of Hypertensive Urgency/Emergency
dothelial damage by increasing the en-
dothelial permeability and local activa-
tion of the clotting cascade (platelet Essential Hypertension
and fibrin deposition), resulting in fib- Renal • Renal artery stenosis
rinoid necrosis and intimal prolifera- • Glomerulonephritis
tion. The endothelium is then unable Vascular • Vasculitis
to compensate or auto-regulate for – hemolytic-uremic syndrome
changes in blood pressure. A vicious cy- – thrombotic thrombocytopenia purpura
cle ensues with further increases in re- Pregnancy- • Preeclampsia
sistance and endothelial damage. related • Eclampsia
High blood pressure also increases Pharmacologic • Sympathomimetics
the stretch on the vessel wall which ac- • Clonidine withdrawal
tivates the renin-angiotensin system. • Beta-blocker withdrawal
This plays an important part in severely • Cocaine
elevated blood pressures. • Amphetamines
The combined process of endothelial Endocrine • Cushing’s syndrome
damage, loss of auto-regulation, acti- • Conn’s syndrome
vated renin-angiotensin system, de- • Pheochromocytoma
crease in vasodilators (nitric oxide, • Renin-secreting adenomas
prostacycline), and sustained blood • Thyrotoxicosis
pressure elevation can lead to tissue is-
Neurologic • Central nervous system trauma
chemia and end-organ damage. Major • Intracranial mass
organ systems involved include the
central nervous, cardiovascular, renal, Autoimmune • Scleroderma renal crisis
and gravid uterus.7, 8
Single-organ involvement is found
in approximately 83% of patients presenting with hy- The physical exam should begin with measuring the
pertensive emergencies. Dual-organ involvement is blood pressure in both arms, using an appropriately
found in 14% of cases, and multi-organ involvement (>3 sized cuff. Smaller cuffs can falsely elevate blood pressure
organ systems) is found in approximately 3% of patients readings in obese patients, and vice versa. The physical
presenting with a hypertensive emergency.9 exam should also include a supine and standing blood
pressure, as well as a measurement in the neck to assess
Clinical Presentation for signs of elevated jugular venous pressure.
A proper history and physical examination help a physi- Next, pulses should be assessed in all extremities,
cian to differentiate between hypertensive urgency and and auscultation performed on the lungs (for signs of
emergency. A focused history should be taken to rule out pulmonary edema), the renal arteries (for bruits), and
end-organ damage, the signs and symptoms of which the heart (for murmurs or gallops).
are shown in Table 4. A focused neurologic and fundoscopic assessment
The history should include any previous history of should be done to rule out a cerebrovascular accident.
high blood pressure, antihypertensive medications used Lateralizing signs are uncommon in hypertensive en-
and adherence to medication regimens, over-the- cephalopathy and are more suggestive of a stroke. Other
counter and illicit drug use (cocaine, amphetamines, de- studies which may be employed to help rule out a hy-
congestants, stimulants, oral contraceptives, and pertensive emergency include electrocardiogram, chest
NSAIDs), and the presence of previous end-organ dam- x-ray, urinalysis, complete blood count, evaluation of
age (e.g. renal, cardiac, or cerebrovascular). electrolytes, and serum tests for renal function.
Common symptoms related to hypertensive emer- In a patient with severely elevated blood pressure,
gencies are chest pain (27%), dyspnea (22%), and neu- symptoms suggestive of acute end-organ damage con-
10
rologic deficits (21%). Non-specific symptoms like a firm the diagnosis of hypertensive emergency, and the
headache may be present in hypertensive urgency. treatment plan should include immediate transfer to the
16 JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | A p r i l 2 0 0 9 w w w. j u c m . c o mMANAGEMENT OF HYPERTENSIVE URGENCY IN AN URGENT CARE SETTING
hospital for further management.
Table 4: Signs and Symptoms of End-organ damage
Patients with hypertensive urgency,
on the other hand, can be treated in
End-organ damage Signs and symptoms the urgent care setting.
Hypertensive • Signs of cerebral edema
encephalopathy – insidious onset headaches Treatment
– nausea The goal of treatment in hypertensive
– vomiting urgency is to slowly reduce the blood
– altered mental status
pressure over a period of 24 hours us-
– confusion
– drowsiness ing oral antihypertensive agents. This is
– seizures usually done on an outpatient basis un-
– occasional focal deficits less patient follow-up is unpredictable.
– coma As non-adherence is the major cause
• Retinal hemorrhage or exudates of hypertensive urgencies, restarting
• Signs of acute renal failure the previously established regimen is
– oliguria
usually sufficient. Treatment may be
– hematuria
– proteinuria restarted with a lower dose and gradu-
ally increased as tolerated over a period
Intracranial • May occur with routine physical activity, especially of several days.
hemorrhage/stroke during intense emotional activity or exertion The mean arterial blood pressure
syndrome • Headache and vomiting may lead to decrease level
of consciousness should not be reduced by more than
• Typically, there is gradual progressive worsening of 25% in the first 24 hours.10 Rapid or ex-
symptoms and increasing neurologic deficits, cessive reductions in blood pressure
depending upon site of bleed can have deleterious effects, including
Acute left • Cough, dyspnea and fatigue rapidly becoming hypotension. This is more commonly
ventricular failure severe seen in high-risk patients like the eld-
with pulmonary • Chest discomfort or pain may be apparent erly, or patients with severe peripheral
edema • Tachypnea, tachycardia, S3 and/or S4 sounds, vascular disease, or severe atheroscle-
crackles at the pulmonary bases can be present rotic, cardiac, or intracranial disease.10
• Signs of concomitant right-sided failure, including We should stress the importance of
jugular venous distension and pedal edema, may
lowering blood pressure gradually to
be present
acceptable measurements; there is no
Acute coronary • Typical or atypical chest pain (atypical chest pain evidence suggesting that immediately
syndrome especially in diabetic patients and inpatients with decreasing blood pressure to levels be-
known cardiac or non-cardiac atherosclerotic
low “normal” reduces risk in the hyper-
disease)
tensive patient.
Acute myocardial • Typical or atypical chest pain Close follow-up, usually within 24
infarction (AMI) • Electrocardiogram changes consistent with AMI hours, is recommended. If there are se-
Dissecting aortic • Abrupt onset of thoracic or abdominal pain vere comorbid conditions or safety is-
aneurysm • Mediastinal or aortic widening on chest x-ray sues at home, the patient can be ob-
• Absence of proximal extremity or carotid pulse served in an inpatient setting for a day.
• Blood pressure difference of more than 20 mmHg A reduction in blood pressure to
between the right and left arm 160/110 mmHg is all that is required in
Worsening renal • Azotemia the first 24 hours.
failure • Proteinuria Essential information for oral antihy-
• Oliguria pertensive agents commonly used for
• Hematuria the treatment of hypertensive urgency
Eclampsia • Pregnant patient with nausea, vomiting, or is provided in Table 5.
seizures Nifedipine is a dihydropyridine-de-
rived calcium channel blocker that has
w w w. j u c m . c o m JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | A p r i l 2 0 0 9 19MANAGEMENT OF HYPERTENSIVE URGENCY IN AN URGENT CARE SETTING
Table 5: Oral Antihypertensive Medications used in Hypertensive Urgency
Onset/Duration Special
Medication Classification of action Adverse effects Dosing schedule considerations
Clonidine Centrally acting Onset: 30–60 • Dry mouth 0.1 to 0.2 mg; • Safe for elderly
!-2-adrenergic minutes • Drowsiness additional doses or renal failure
agonist • Constipation of 0.1 mg given patients
Duration: 6–8 • Bradycardia every hour until • Beta-blockers
hours • Orthostatic diastolic isHYPERTENSIVE URGENCY
been used extensively in the past
for the treatment of hypertensive
urgency. However, nifedipine has
never been approved by the FDA
for short-term use in hypertension.
More recently, the risks of serious
adverse reactions like severe hy-
potension, acute coronary events
and ischemic stroke have led the
U.S. National Heart, Lung, and
Blood Institute to issue a warning
that this agent should not be used
in the treatment of hypertension,
angina, and myocardial infarction.
Conclusion
Initial recognition of an absence of
end-organ damage is crucial in dif-
ferentiating hypertensive urgency
from hypertensive emergency, and
establishing a treatment plan. Judi-
cious use of oral antihypertensive
agents in the outpatient clinical
setting can safely lower blood pres-
sure over a period of several days,
leading to improved outcomes. ■
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Available at: http://www.turner-white.com/memberfile.
php?Pub Code=hp_mar07_hypertensive.pdf. Accessed
January 22, 2009.
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