Hypertensive emergency vs asymptomatic elevated blood pressure (hypertensive urgency). Management of emergencies, urgencies, and outpatient elevated blood pressures.

1. Hypertensive Emergencies
& Managing HTN
Prepared by Myiesha Taylor MD FAAEM
EM Attending 4.6.21

2. A 47-year-old African American male presents to the
ED complaining of a laceration to his finger he
sustained while cooking.
His tetanus is up to date, the bleeding is controlled,
and you successfully repair the uncomplicated
laceration.
Prior to discharge, you review the patient’s vital
signs and find a blood pressure of 190/115. The
patient has no complaints.
What needs to be done about this elevated
blood pressure?
The Case Vignette:

3. Is this a Hypertensive EMERGENCY or Urgency?

4. Hypertensive Urgency
(severe asymptomatic HTN)
Minimally or asymptomatic patients
without evidence of end organ
damage with markedly elevated
blood pressure
● typically >180s/110s
● They may present with headache,
shortness of breath, epistaxis, or anxiety
but often are asymptomatic.*

5. Hypertensive Emergency
Definition: end-organ damage due to hypertension
Blood pressure is generally >180/120 (usually > 220/130), but
presence of end-organ damage defines disease (not absolute blood
pressure number)
Is rare
Elevated blood pressure with evidence of end-organ
damage.
Heart - acute coronary syndrome and myocardial
infarction
Aortic - dissection
Renal - evidence of worsening functioning or failure
Pulmonary - edema
Neurological - mental status changes (encephalopathy) or
evidence of stroke (infarction or bleeding)
Pregnancy - eclampsia

6. Hypertensive Emergency
Not based on a number!!
It is based on evidence of END
ORGAN DAMAGE!!

7. Malignant Hypertension
A patient with malignant hypertension always
has retinal papilledema (as seen in the image
below), as well as flame-shaped hemorrhages
and exudates.
Other clinical features of malignant
hypertension may include encephalopathy,
confusion, left ventricular failure, intravascular
coagulation, and impaired renal function, with
hematuria and weight loss.
The pathologic hallmark of malignant hypertension is fibrinoid necrosis of the arterioles,
which occurs systemically, but specifically in the kidneys. These patients develop fatal
complications if untreated, and more than 90% will not survive beyond 1-2 years.
- always has papilledema, hemorrhages/exudates

8. Indicators of End-Organ Damage
Altered mental status - seizures, infarction,
intracranial hemorrhage, encephalopathy
Shortness of breath - congestive heart failure
Chest pain - acute myocardial infarction, EKG
changes
Neurologic deficit - aortic dissection (can
present as neurologic deficit, chest pain, or
back pain); stroke
Ophthalmologic - vision changes, retinal
changes/hemorrhages, exudates, and
papilledema
Diminished kidney function - oliguria,
elevated serum creatine, UA evidence of kidney
damage

9. Pertinent History & Focused Physical Exam
Double check the BP (ensure proper cuff size,
check both extremities, take multiple readings with
the patient calm)
BP discrepancy in the upper extremities
could indicate aortic dissection
Past medical history of high-risk conditions?
Medication history and compliance.
Social History - drug use (both illicit such as
cocaine and methamphetamines, and OTC such as
sympathomimetic medications. Acute stressors.
Fundoscopic exam and visual fields
Chest exam - evidence of pulmonary edema
Extremity exam - evidence of edema (CHF)
Abdominal masses (aortic disease)

10. Diagnostic Testing
● Clinical judgement and risk-factors inform the decision of necessary work-up.
If risk-factors, concerning historical points, or physical exam findings suggest possible end organ
damage, further evaluation is appropriate.
○ Renal - UA (proteinuria/hematuria/cells/casts), CMP
○ Vascular - CBC with peripheral smear to r/o microangiopathic anemia. Aortic
ultrasound or CT scan of the chest/abdomen/pelvis.
○ Cardiopulmonary - EKG, CXR, cardiac enzymes, BNP, ECHO
○ Neuro - Head CT
○ Beta HCG - rule-out pregnancy
○ Utox
○ Endocrine considerations - Thyroid & parathyroid disease, pheochromocytoma,
mineralocorticoid excess, Cushing disease, SLE, pregnancy)
* isolated HA does not warrant a HCT as this has not been shown to be a risk factor
for end-organ CNS damage.
“a headache is not a hypertensive emergency unless the
patient looks so bad that you are rushing her to CT”

11. Treatment for HTN Urgency
Rapidly lowering blood pressure in the
emergency department is usually unnecessary in
asymptomatic patients and may be harmful.
Reducing severely elevated blood pressure
below the autoregulatory zone too quickly
can result in markedly decreased perfusion
to the brain and eventually ischemia or
infarction.
Outpatient treatment is generally acceptable,
with appropriate follow-up. If it is unclear
whether the patient will comply with follow-
up, a short hospital stay may be needed.
Initiating treatment for asymptomatic
hypertension is optional with appropriate
follow-up.
Tx in ischemic strokes (and if the provider lowers
the BP too aggressively precipitating a stroke):
The problem with ischemic strokes is they will
generally have an ischemic penumbra
surrounding the core of the stroke. This is an area
that’s at risk for death; thus, having an elevated
blood pressure is beneficial at minimizing the
stroke size through collateral circulation.

13. Treatment of HTN
EMERGENCY
Admit adults with a hypertensive emergency to an
ICU for continuous monitoring of BP and target
organ damage, as well as for parenteral
administration of an appropriate medication.
For adults with a compelling condition (aortic
dissection, severe preeclampsia/eclampsia, or
pheochromocytoma crisis), lower SBP to below 140
mm Hg during the first hour and to below 120 mm
Hg in aortic dissection.
For adults without a compelling condition, reduce
the SBP to a maximum of 25% within the first
hour; then, if the patient is clinically stable, lower
the BP to 160/100 -110 mm Hg over the next 2-6
hours, and then cautiously to normal over the
following 24-48 hours.

15. Treatment of HTN EMERGENCY - the drugs
1. B-blockers: Labetolol is useful for most hypertensive emergencies (preferred in aortic
dissection and ESRD). Give a 20mg slow IV push, then double the dose q10 min, up to
300mg. Be cautious in patients with asthma or COPD, and hepatic failure. Esmolol has
quicker onset/offset, and may be safer in patients with mildly reactive airways.
2. Vasodilators: Nitroglycerin is great for ACS and pulmonary edema, but arterio-dilates
only at high doses. Therefore for CHF patients, use higher doses to produce afterload
reduction. Nitroprusside dilates both arteries and veins, but generates cyanide w/
prolonged use of high doses as it breaks down. Starting dose is 0.3–0.5mcg/min, and max
dose is 2 mcg/min (less in renal pts). Hydralazine also dilates arteries, but has less
predictable effects, and raises HR. Phentolamine (an a1 blocker) arterio-dilates to
counteract catecholamines (i.e. cocaine, pheochromocytoma).
3. Calcium channel blockers: Dihydropyridine CCBs lower blood pressure by vasodilation
(amlodipine, nifedipine, and nicardipine). The phenylalkylamine class of CCBs mainly
have negative inotropic and negative chronotropic effects (diltiazem and verapamil).
Clevidipine, a dihydropyridine CCB, is administered IV for rapid and precise BP
reduction. [25] It is rapidly metabolized in the blood and tissues and does not accumulate
in the body. Initiate IV infusion of clevidipine at 1-2 mg/hour; titrate the dose at short
intervals (ie, 90 seconds) initially by doubling the dose.
Parenteral (IV):
● Labetalol
● Esmolol
● Nitroglycerin
● Nitroprusside
● Nicardipine
● Clevidipine
● Fenoldopam
● Hydralazine

17. Treatment of HTN EMERGENCY
**Use the drug you are most familiar with, if the clinical context is appropriate.
Aortic dissection: labetalol or esmolol. Followed by vasodilator. If contraindications to
b-blocker, do diltiazem.
Congestive Heart Failure (CHF): high dose nitroglycerin to achieve arterial dilatation.
Give up to 6 sublingual doses while IV drip is being prepared. Non-invasive positive
pressure. BP can be very high, so verify and monitor by an arterial line in the right radial
artery.
Pre-eclampsia is BP >160 /110, along with proteinuria (or low platelets, elevated LFT or
Cr) or pulmonary, liver, cerebral or visual symptoms, in a patient >20 weeks pregnant.
Moms LoveHealthyNewborns:
Use Methyldopa, Labetalol, Hydralazine, or Nifedipine for hypertensive pregnant women.
Eclampsia is the same, but with seizures.
Labetalol plus Mg+, although hydralazine (5mg IV slow push over 1-2 minutes,
repeat 5-10mg prn) can be used as a second line. Give 2g/hr IV Mg+ for seizure
prophylaxis.
*Goal is still only 25% BP reduction, and consult OB as delivery is the definitive
treatment

18. The drugs - when and how
Cardiovascular emergencies - labetalol, nicardipine, nitroprusside (with beta-blocker), esmolol, and morphine sulfate. Rapid
BP reduction is also indicated in cardiovascular emergencies, such as aortic dissection, acute coronary syndrome, and acute heart
failure. Beta blockers are the recommended antihypertensive agents in patients with hypertension and thoracic aortic disease.
However, avoid beta-blockers if there is aortic valvular regurgitation or suspected cardiac tamponade. Rapidly lower the SBP to below
120 mm Hg. Beta blockade should precede vasodilator administration, if needed for BP control or to prevent reflex tachycardia.
Maintain the SBP below 110 mm Hg, unless signs of end-organ hypoperfusion are present. The preferred treatment includes a
combination of narcotic analgesics (morphine sulfate), beta blockers (labetalol, esmolol), and vasodilators (nicardipine, nitroprusside).
CCBs (verapamil, diltiazem) are an alternative to beta blockers.
Hypertensive encephalopathy - reduce the MAP 25% over 8 hours. Labetalol, nicardipine, esmolol are the preferred
medications; nitroprusside and hydralazine should be avoided.
Acute ischemic stroke - labetalol and nicardipine. Withhold antihypertensive medications unless the SBP is above 220 mm Hg or
the DBP is over 120 mm Hg, unless patient is getting tPA.
For acute coronary syndrome - beta blockers and nitroglycerin are the preferred drugs. Reduce the BP by 20%-30% of baseline. Note that thrombolytics are
contraindicated if the BP is above 185/100 mm Hg. Be careful with nitrates and Viagra-type drugs on board. In acute heart failure, the preferred medications are IV
nitroglycerin or sublingual nitroglycerin and IV enalapril. In hypertensive adults with reduced ejection fraction (HFrEF) nondihydropyridine CCBs (verapamil, fendiline,
diltiazem) are not recommended for treatment in this patient population.
Acute intracerebral hemorrhage - the preferred medications are labetalol, nicardipine, and esmolol; avoid nitroprusside and hydralazine. The treatment is based
on clinical/radiographic evidence of increased intracranial pressure (ICP). If there are signs of increased ICP, maintain the MAP just below 130 mm Hg (or SBP < 180 mm Hg)
for the first 24 hours after onset.
Cocaine toxicity/pheochromocytoma - Diazepam, phentolamine, and nitroglycerin/nitroprusside are the preferred drugs. However, avoid beta-adrenergic
antagonists before administering phentolamine. Hypertension and tachycardia from cocaine toxicity rarely require specific treatment. Alpha-adrenergic antagonists
(phentolamine) are the preferred agents for cocaine-associated acute coronary syndromes. Pheochromocytoma treatment guidelines are similar to that of cocaine
toxicity.

19. Use the Mean Arterial Pressure to guide your treatment
MAP is what the automated BP cuff is actually measuring.
MAP may be most closely related to the risk of hypertensive
emergency.
MAP is preferred in guiding therapy. The best way to titrate
antihypertensive drugs in a logical fashion is to target a specific MAP.

20. Take home points regarding HTN Urgency/Emergency
Hypertensive urgency is an acute, severe elevation in blood pressure without signs or symptoms of end-organ damage.
Proposed blood pressure levels indicating hypertensive urgency are arbitrary and not associated with short-term morbidity and
mortality.
Hypertensive urgency is common in the outpatient setting. In the absence of symptoms of target organ damage, most patients can be
safely treated in the outpatient setting. Referral to the ED was associated with increased use of health care resources but not better
outcomes.
Focus on symptoms of end-organ damage in the patient's history, including chest pain, shortness of breath, headache,
neurologic deficits, and vision changes.
If a maintenance dose of an oral antihypertensive is initiated, the patient may be sent home without waiting for normalization of
blood pressure. Over weeks to months, the dosage and selection of medications may be modified to achieve desired goals.
Caution is advised in pregnant patients with hypertension. Preeclampsia can ensue at lower blood pressure levels than
expected in other hypertensive emergencies.
Treat the patient, not the number. Rapidly bringing down blood pressure in a patient without end-organ damage may result
in relative hypoperfusion and harm the patient rather than help.
In patients with asymptomatic markedly elevated blood pressure, routine ED medical intervention is not required. Patients
with asymptomatic markedly elevated blood pressure should be referred for outpatient follow-up.

22. Case Resolution
The patient reports he has been told in the past he
has had high blood pressure by his doctor, but has
not seen by his primary care provider (PCP) in over
one year.
You discuss with the patient the need for the
patient to follow up with his doctor for repeat
blood pressure measurement and give appropriate
discharge instructions regarding both wound care
and elevated blood pressure.
The patient returns ten days later for suture
removal and reports he has seen his doctor and
was started on medication for his hypertension.

23. Managing
HTN
outpatient
(Guideline
Algorithm)

24. Managing
HTN
outpatient
(Guideline
Algorithm)