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Chapter 57: Systemic Hypertension

Brigitte M. Baumann

INTRODUCTION AND EPIDEMIOLOGY

Hypertension affects approximately 40% of the U.S. population, and 1% to 6% of all ED patients present with severe hypertension.1-5 Of the latter, between one quarter and one half will have end-organ damage.2-5 Risk factors for the development of acute hypertensive events include obesity, cigarette smoking, older age, lack of access to health care, and noncompliance with antihypertensive medications.6

Chronic hypertension is categorized into three classifications: prehypertension, stage 1 hypertension, and stage 2 hypertension (Table 57-1).7

TABLE 57-1Categories of Blood Pressure in Adults*
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TABLE 57-1 Categories of Blood Pressure in Adults*
BP Category Systolic BP (mm Hg)   Diastolic BP (mm Hg)
Normal <120 and <80
Elevated 120–129 and <80
Hypertension      
Stage 1 130–139 or 80–89
Stage 2 ≥140 or ≥90

Abbreviation: BP = blood pressure.

*Data adapted from: 2017 High Blood Pressure Clinical Practice Guideline: Executive Summary, where BP is based on an average of ≥2 careful readings obtained on ≥2 occasions.7

Hypertensive crisis is an acute elevation of blood pressure, where the systolic blood pressure is >180 mm Hg and/or the diastolic blood pressure is >120 mm Hg. There are two forms of hypertensive crisis.

Hypertensive emergency is a hypertensive crisis (systolic blood pressure >180 mm Hg and/or diastolic blood pressure >120 mm Hg) with concomitant end-organ damage; the targeted end organs include the brain, heart, aorta, kidneys, or eyes (Table 57-2).7

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 preeclampsia, eclampsia Seizures, shortness of breath, headache, or vision abnormalities (blurred vision, flashing lights, scotomata) Proteinuria (no longer required for the diagnosis of preeclampsia), low platelet count, renal insufficiency, elevated liver enzyme levels, pulmonary edema
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

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