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Clinical presentations of acute systemic hypertension may be classified into following three categories:

  1. Hypertensive emergency is characterized by elevated blood pressures with target organ dysfunction. Organ dysfunction is caused by persistent mechanical wall stress and endothelial injury leading to increased vascular permeability and fibrinoid necrosis within large arteries and arterioles of target organs such as brain, kidneys, heart, and lungs. Clinical manifestations of hypertensive emergency may include the following:

    • Chest pain associated with aortic dissection, acute pulmonary edema, or acute coronary syndrome.

    • Shortness of breath from acute pulmonary edema.

    • Acute neurologic symptoms such as altered mental status, focal motor or sensory deficits, headache, or visual disturbances. These can be associated with hypertensive encephalopathy, subarachnoid hemorrhage, intracranial hemorrhage, or acute ischemic stroke.

    • Peripheral edema secondary to acute renal failure or severe preeclampsia.

    • Sympathetic crisis due to sympathomimetic toxicity, adverse drug reactions and food–drug interactions, or pheochromocytoma.

  2. Hypertensive urgency is accompanied by profound blood pressure elevations without acute target organ dysfunction. Some clinicians recommend acute pharmacologic treatment for blood pressures of 180/120 mm Hg or greater, although the clinical benefits of such acute interventions are unclear.

  3. Chronic systemic hypertension is identified in patients with longstanding blood pressure elevations without obvious progression to acute target organ dysfunction. This diagnosis is defined by serial blood pressure measurements over several weeks. See Table 26-1.

Table 26-1

JNC7 Classification of Hypertension


Patients presenting with elevated blood pressure and accompanying acute symptoms often provide a history of hypertension. Many patients have coexisting medical conditions such as cardiovascular disease, renal dysfunction, cerebrovascular disease, diabetes, hyperlipidemia, chronic obstructive pulmonary disease, asthma, or renal artery stenosis. Secondary precipitants of acute hypertension may include pregnancy, sympathomimetic toxicity, adverse drug reactions, drug–drug interactions, or withdrawal from medications or recreational substances.

When a significantly elevated blood pressure is present, consider the possibility of hypertensive emergency in patients with any of the following signs and symptoms of target organ involvement:

  • Nervous system signs and symptoms such as headaches, visual changes, papilledema, retinal exudates, seizures, encephalopathy, focal motor or sensory deficits, vomiting, seizures, or confusion

  • Cardiovascular signs and symptoms such as chest pain, palpitations, dyspnea, rales, syncope, carotid bruits, new cardiac murmurs or gallops, asymmetric pulses, unequal blood pressures, pulsatile abdominal masses, or tearing pain radiating to the back or abdomen

  • Renal system signs and symptoms such as anuria, peripheral edema, or hematuria

Consider preeclampsia in pregnant or recently postpartum patients with hypertension, hyperreflexia, and peripheral edema. ...

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