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Chapter 57: Systemic Hypertension

Brigitte M. Baumann

INTRODUCTION AND EPIDEMIOLOGY

Hypertension affects approximately 30% of the U.S. population, and 1% to 6% of all ED patients will present with severe hypertension.1,2,3,4,5 Of the latter, between a third and one half will have end-organ damage.2,3,4,5 Risk factors for the development of hypertensive crisis include obesity, cigarette smoking, and older age.6

Chronic hypertension is categorized into three classifications: prehypertension, stage 1 hypertension, and stage 2 hypertension7 (Table 57-1).

TABLE 57-1JNC7 Classification of Hypertension
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TABLE 57-1 JNC7 Classification of Hypertension
Class Systolic BP (mm Hg) Diastolic BP (mm Hg)
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 140–159 or 90–99
Stage 2 ≥160 or ≥100

Abbreviations: BP = blood pressure; JNC7 = Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Hypertensive emergency is an acute elevation of blood pressure (≥180/120 mm Hg) associated with end-organ damage; the targeted end organs include the brain, heart, aorta, kidneys, or eyes7 (Table 57-2). Acute hypertensive emergencies are more common in chronic hypertensive patients who fail to adhere to their antihypertensive therapy regimens and those who are unable to access outpatient health care.6

TABLE 57-2Hypertensive Emergencies
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TABLE 57-2 Hypertensive Emergencies
Diagnostic Category Signs and Symptoms Evidence of Acute End-Organ Damage
Acute aortic dissection

Chest pain, back pain

Unequal blood pressures (>20 mm Hg difference) in upper extremities

 Abnormal CT angiogram of chest and abdomen/pelvis or transesophageal echocardiogram of the aorta
Acute pulmonary edema Shortness of breath Interstitial edema on chest radiograph
Acute myocardial infarction Chest pain, nausea, vomiting, diaphoresis Changes on ECG or elevated levels of cardiac biomarkers
Acute coronary syndrome Chest pain, nausea, vomiting, diaphoresis Clinical diagnosis, changes on ECG, or elevated levels of cardiac biomarkers
Acute renal failure May have systolic or diastolic abdominal bruit Elevated serum creatinine level, proteinuria
Severe pre-eclampsia, HELLP syndrome, eclampsia Seizures Proteinuria, hemolysis, elevated liver enzyme levels, low platelet counts
Hypertensive retinopathy Blurred vision Retinal hemorrhages and cotton-wool spots (Figure 57-1), hard exudates, and sausage-shaped veins
Hypertensive encephalopathy Altered mental status, nausea, vomiting, headache May see papilledema or arteriolar hemorrhage or exudates on funduscopic examination, may note cerebral edema with a predilection for the posterior white matter of the brain on MRI
Subarachnoid hemorrhage Headache, focal neurologic deficits Abnormal CT of the brain; red blood cells on lumbar puncture
Intracranial hemorrhage Headache, new neurologic deficits Abnormal CT of the brain
Acute ischemic stroke New neurologic deficits Abnormal MRI or CT of the brain
Acute perioperative hypertension Bleeding unresponsive to direct pressure Clinical diagnosis; manifestations of other hypertensive emergencies
Sympathetic crisis* Anxiety, palpitations, tachycardia, diaphoresis Clinical diagnosis in the setting ...

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