hypertensive emergency and urgency

1. Hypertensive emergency

2. DEFINITION HYPERTENSION

3. SEVERE HYPERTENSION
• Severe hypertension is defined as persistent
elevated SBP >180 mmHg and/or DBP >110
mmHg.
Hypertensive urgency Hypertensive emergency
Acute severe hypertension without
any signs of damage to target
organs
Acute severe hypertension with
signs of progressive damage to
target organs

5. EPIDEMIOLOGY
• In a recent large series, only a minority of
patients admitted (5.1%) had hypertensive
crises. Of those more than three quarters
(76.6%) constitute hypertensive emergencies.

6. ETIOLOGY
• Essential hypertension : non-compliance with
antihypertensive medication and inadequate
blood pressure control
• Secondary hypertension

8. Pathophysiology

9. EVALUATION
• A complete history should include:
• • duration and level of elevated BP if known
• • symptoms of secondary causes of hypertension
• • symptoms of target organ complications (i.e. renal failure and heart
failure)
• • symptoms of cardiovascular disease (e.g. CHD and cerebrovascular
disease)
• • symptoms of concomitant disease that will affect prognosis or treatment
e.g.
• diabetes mellitus, heart failure, renal disease and gout
• The evaluation of these patients should include a thorough history and
• physical examination, particularly looking for signs of acute target organ
damage /
• complication and causes of secondary hypertension.

10. • • family history of hypertension, CHD, stroke, diabetes, renal
disease or dyslipidaemia
• • dietary history including salt caffeine, liquorice and alcohol intake
• • drug history of either prescribed or over-the-counter medication
(NSAIDs, nasal
• decongestants) and traditional or complementary medicine
treatment
• • lifestyle and environmental factors that will affect treatment and
outcome (e.g.
• smoking, physical activity, work stress and excessive weight gain
since childhood)
• • presence of snoring and or day time somnolence which may
indicate sleep
• apnoea

12. MANAGEMENT
• Management of these patients depends on
the clinical presentation and laboratory
• investigations.

13. HYPERTENSIVE URGENCY
• Initial treatment should aim for about 25%
reduction in BP over 24
• hours but not lower than 160/90 mmHg

15. HYPERTENSIVE EMERGENCY
• The BP needs to be reduced rapidly. It is
• suggested that the BP be reduced by 25%
depending on clinical scenario over 3 to 12
• hours but not lower than 160/90 mmHg

17. • Rapid reduction of BP (within minutes to hours) in
asymptomatic severe hypertension or
• hypertensive urgencies is best avoided as it may precipitate
ischaemic events.102
• Oral or sublingual drugs with rapid onset of action can
result in an uncontrolled BP
• reduction. Several serious side effects have been reported
with the administration of
• sublingual fast-acting nifedipine and therefore this is no
longer recommended.103 (Level III)
• However oral nifedipine retard can be used and has been
recommended as first line
• therapy for hypertensive urgencies.

18. HYPERTENSIVE CRISIS
• Hypertensive emergency :. These include
patients with complications of severe
hypertension such as acute heart
• failure, dissecting aneurysm, acute coronary
syndromes, hypertensive encephalopathy,
subarachnoid haemorrhage and acute renal
failure.

19. Hypertensive emergency
• Target organ damage:
• Brain:
• Hypertensive encephalopathy is characterized by
lethargy, dullness, headache, seizures and visual
disturbances including blindness. • Cerebral
infarction, hemorrhage and facial nerve palsy
may occur.
• Neuroimaging shows features of white matter
degeneration in the parieto-occipital area
(posterior leukoencephalopathy), which are
reversible with treatment.

21. • Retina

22. Grade 1 Generalised arteriolar constriction - seen as `silver wiring` and Vascular
tortuosities. Grade 2 + irregularly located, tight constrictions - `AV nicking` or `AV
Nipping` Grade 3 + with cotton wool spots and flame-haemorrhages Grade 4 + with
swelling of the optic disk (papillodema) only 8.6% had evidence of retinopathy
diagnosed with an ophthalmoscope