Hypertensive emergency: diagnostic and therapeutic strategies

Abstract

Hypertensive emergencies are life-threatening conditions with end-organ damage caused by sudden increases in blood pressure that exceed 180/110-120 mmHg. Clinical conditions affecting the brain, arteries, retina, kidney and heart are encountered. The brain and cardiovascular system are most commonly affected. Ischemic stroke and acute pulmonary edema are the most common conditions. Some patients may experience end-organ damage independent of blood pressure values. This condition develops due to microangiopathy and deterioration of autoregulation that provides organ blood flow by damaging the vascular endothelium due to increased blood pressure. High blood pressure also increases end-organ damage in a vicious cycle by activating the renin-angiotensin-aldosterone system. This pathophysiology is important in treatment. As a general approach, rapid blood pressure reduction is not desired. Perfusion in end-organs that cannot adapt to autoregulation is impaired, and organ dysfunction deepens with ischemia and necrosis. In the general approach, a 10-20% decrease is targeted in the first hour, while a 5-15% decrease in blood pressure in the remaining 23 hours is sufficient. However, in ischemic stroke, blood pressure control is reduced according to both the treatment and the degree of pressure. If thrombolytic therapy is not to be given, if the blood pressure is not above 220/120 mmHg, no intervention is made. In aortic dissection, the aim is to reduce systolic blood pressure to 100-120 mmHg in a period of 20 minutes. In short, according to the target organ damage, short-acting intravenous antihypertensive drugs that can be treated stepwise and are selected according to the selected target values. In the selection of these drugs, options that may cause secondary damage to organ damage are avoided. Nitroprusside and nitroglycerin, which can increase central pressure, are not preferred primarily in ischemic stroke. Or, in adrenergic crisis, beta blockers can worsen blood pressure without sufficient alpha blockade. It should also be well known that such drugs have important side effects such as severe hypotension and cardiogenic shock.