This document discusses the classification, clinical manifestations, investigations, and management of hypertensive crises. It distinguishes between hypertensive urgency, which involves severe but asymptomatic elevations in blood pressure, and emergency, which involves elevations with associated end-organ damage. Common symptoms include headache, fatigue, confusion, and chest pain. Investigations include blood tests, electrocardiograms, urinalysis, and imaging. Treatment depends on the situation but generally aims to lower blood pressure by 10-15% within the first hour using intravenous medications such as nitroglycerin, nitroprusside, or labetolol. Oral agents like captopril may also be used but reductions should be more gradual. The

1. Hypertensive Urgency and Emergency
The Approach
By Dr Nurul Athirah
MO KK Tandek

2. The Basic (JNC 7)*
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
Risk of CV event increase with 20/10mmHg
Dm and kidney dss < 130/<80mmHg
Treatment determine by highest blood pressure
*
T

3. Hypertensive crisis
→ Urgency Severe elevations(>180/>120mmHg) of
BP without target end-organ damage
→ Emergency Severe elevations of BP with target
end- organ damage or dysfunction. Younger pts may
have lower BP

4. Preeclampsia / Eclampsia
A syndrome;
-preeclampsia : HTN+ proteinuria + pulmonary
edema + proteinuria > 20w POG without seizures
- eclampsia : .... with seizures

6. Clinical manifestations
●Fatigue
●Headache
●Restless
●Confuse
●Visual disturbance
●Seizure
●Dyspnoe
●Tachy/bradycardia
●Pedal edema
●Chest pain
●Dizziness
●nausea,vomitting

11. 3. Investigations
i. Bloods
-RP, LFT, lipid profile
cardiac bloods
ii. ECG
-LVH, ischemia, MI , arrythmia
iii. UFEME
- hematuria or proteinuria
iv. radiologic
- CXR ; pulmo edema/
mediastinal widening or (v)
- CT ( if mental status/
altered neurological status)

12. General principle
1.1 H'emergency
– BP control accomplished within few hours (reduce
risk of permanent damage/ death)
-diastolic 100-110mmHg adequate for first 24hr
-use IV antihypertensive
1.2.H'urgency
-BP control , slow with oral aHTN (24-48hr), to a
diastolic 100-110mmHg
-excesive decrease should be avoided (minimise risk
of cerebral hypoperfusion/ coronary insuff)

13. JNC7 guidelines
- Reduce SBP by 10-15% , and not more than
25% within the first hour
-if pt is stable, to 160/ 100-110mmHg over 2 –
6hours
-in case of aortic dissection ; reduce SBP at at
least 120mmHg within 20minutes
-too rapid reduction will reduce tissue perfusion
( ischmemia , infarction)

14. An aortic dissection
is a tear in the inner
layer of the aortic wall,
which allows blood to
enter into the wall
of the aorta (AHA)

18. 1.1 Oral antihypertensive agents
( only for urgent / not rapid reductions)
- combinations therapy necessary when diastolic
> 110mmHg
ACEi ; captopril 12.5 to 25mg (w/wo diuretics
BB ; atenolol 50-100mg or labetolol 200-400mg
(with / wo diuretics) or,
CCB can also be used.

19. Drugs of choice
i. CAD (coronary artery disease) and HF (heart
failure) ; IV NTG or nitroprusside
ii. Pulmonary edema ; IV frusemide, IV
nitroprusside, or ACEi/ ARB
iii. HTN in pregnancy ; MgSO4, hydralazine or
labetolol
iv. stroke ; BB, CCB, diuretic or ACEi/ ARB

20. Common drugs used in our settings
1. Captopril (ACEi)/ 25mg poonset 15-30mins,duration action6-
8hours ; effect the renin-angiotensin (inhibit angiotensin I → II)
**Ag II regulates BP
2. Labetolol (combined alpha , beta adrenergic inhibitor). Controls
reflex tachcyardia as BP drops. Does not effect cardiac/ renal
3. Nifedipine (CCB) ; dilate coronary artery, and relaxation of
peripheral arterioles smooth muscle, reduce peripheral vascular
resistance. Onset 5-10mins , peak15-30mins, duration 6-8hrs
4. Mgso4 (inorganic salt) ; replace Mg , decrease nerve impulse to
muscles
5. Nitroglycerin ; rx acute cardiac ischemia. direct vasodilator ,
reduce preload and cardiac output

21. Having difficulties ?
- ?incomplete history
-?complex comorbidities
Rx – choose aHTN with limited side effects
and broad applicability , with limited renal /
cardiac/ hepatic contraindications

24. Sources
1. Sarawak Handbook of Medical
Emergencies 3rd edition
2.Hypertensive emergencies : acute care
evaluation and management ; emergency
medicine cardiac research and emergency
group ( dec 2008, vol 3)
3. American Heart Association (AHA)