48 - Hypertensive Emergencies and Urgencies

Abstract

A hypertensive emergency is a major elevation in BP accompanied by progressive, acute target-organ damage, for example, acute coronary or cerebral ischemia, pulmonary edema, acute kidney injury, aortic dissection, or eclampsia. This condition, if untreated, historically carries a very high mortality rate and should be promptly treated with a short-acting, easily titrated, intravenous medication in a monitored setting. Although BP should be reduced within minutes to hours, the initial reduction in mean arterial pressure over the first few hours should be no more than 20% to 25% of baseline BP, to avoid hypoperfusion of vital organs. Once stable, patients should be investigated more thoroughly for a remediable cause of hypertension. Proper education and appropriate follow-up should be arranged to ensure continued and optimal management of hypertension as well as the other cardiovascular risk factors usually present. Often the result of inadequate treatment of preexisting hypertension, a hypertensive “urgency” is a major elevation of BP without evidence of progressive, acute target-organ damage. Such patients have cardiovascular risk intermediate between hypertensive emergencies and asymptomatic hypertension and may be treated as outpatients with one or more oral medication(s) to achieve BP control over days. More importantly, providing close follow-up in an ambulatory setting to achieve BP control, as well as proper education to avoid future “urgent” presentations is recommended. The major distinguishing feature of the true hypertensive emergency from the “hypertensive urgency” is the presence of ongoing acute target organ damage, not the degree of BP elevation itself.