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hypertensive crisis (malignant hypertension)

Etiology: see hypertension Clinical manifestations: 1) stage IV hypertension (very severe) a) systolic blood pressure > 210 mm Hg b) diastolic blood pressure > 120 mm Hg 2) target organ disease a) neurologic manifestations - altered mental status including coma - TIA, stroke - headaches, dizziness, vertigo, tremors - diplopia, diminished visual acuity - focal deficits: numbness, weakness, slurred speech, cranial nerve palsies b) cardiac manifestations - chest pain - dyspnea - pulmonary edema c) vascular manifestations - decreased peripheral pulses - bruits - abdominal, femoral, carotid d) retinal manifestations - papilledema - hemorrhages e) renal changes - hematuria - azotemia Laboratory: - urinalysis - serum creatinine Special laboratory: - funduscopy: optic disc swelling (papilledema) is a sign of increased intracranial pressure Management: 1) goal of initial treatment a) reduction of blood pressure by 25% in the 1st hour b) decrease to systolic blood pressure of 160 mmg Hg with diastolic blood pressure of 100-110 mm Hg in the next 2-6 hours [1] c) do not lower blood pressure rapidly to < 140/80 - adverse effects include: cerebral hypoperfusion & acute tubular necrosis (ATN) d) more rapid lowering of blood pressure may be attempted if there is evidence of: - pre-eclampsia, eclampsia, pheochromocytoma - acute organ injury - myocardial ischemia - left ventricular failure with pulmonary edema - intracranial hemorrhage & subarachnoid hemorrhage - lower systolic BP to < 140 mm Hg in the 1st hour [1] - aortic dissection - lower systolic BP to < 120 mm Hg in the 1st hour [1] 2) intravenous a) sodium nitroprusside or nitroglycerin drip b) esmolol* drip - contraindicated with sympathomimetic intoxication - contraindicated with acute heart failure* c) labetalol* drip - indicated when offending agent is alpha-adrenergic receptor agonist, i.e. cocaine* - benzodiazepine may be useful as adjunctive treatment in sympathomimetic intoxication (see toxidrome) - contraindicated with acute heart failure* d) hydralazine drip e) nicardipine* drip f) IV enalapril g) IV diazoxide 3) oral agents a) nifedipine* 10 mg every hr b) captopril 10 mg every hr - captopril less likely than nifedipine to cause excessive drop in blood pressure c) clonidine 0.1 mg every hr - do not use sublingual clonidine [1] 4) nitropaste 5) fenoldopam (Corlopam) 6) hospitalize for: a) blood pressure > 210/120 b) acute manifestations * use of labetalol in sympathomimetic intoxication is somewhat controversial * beta-blockers & calcium channel blockers contraindicated in patients with acute pulmonary edema due to acute heart failure [1] - use nitroglycerin, nitroprusside

Related

hypertensive urgency

General

hypertension (HTN, high blood pressure, HBP) hemodynamic instability (compromise) critical disease; critical illness; critically ill patient; critical condition

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Marik PE, Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care. 2011 Dec;17(6):569-80. PMID: 21986463
  3. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000 Jul 29;356(9227):411-7. Review. PMID: 10972386
  4. Johnson W, Nguyen ML, Patel R. Hypertension crisis in the emergency department. Cardiol Clin. 2012 Nov;30(4):533-43. Review. PMID: 23102030
  5. Calhoun DA, Oparil S. Treatment of Hypertensive Crisis. N Engl J Med 1990; 323:1177-1183 PMID: 2215596 https://www.nejm.org/doi/full/10.1056/NEJM199010253231706 - Varon J, Marik PE. Clinical review: the management of hypertensive crises. Crit Care 2003 Sep 17; 7:374. PMID: 12974970 Free PMC Article - NEJM Knowledge+ Question of the Week. Sept 18, 2018 https://knowledgeplus.nejm.org/question-of-week/15/
  6. NEJM Knowledge+ Question of the Week. July 16, 2109 https://knowledgeplus.nejm.org/question-of-week/1189/answer/A/
  7. Katz JN et al. Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe hypertension: the Studying the Treatment of Acute hyperTension (STAT) registry. Am Heart J 2009 Oct; 158:599 PMID: 19781420