Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

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

80–89

Stage 1

140–159

90–99

Stage 2

≥160

≥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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Chapter 57: Systemic Hypertension

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