Chapter 26. Systemic and Pulmonary Hypertension

Classification of acute systemic hypertension into categories facilitates management:

1. Hypertensive emergency: elevated blood pressure (BP) associated with target organ dysfunction such as aortic dissection, acute pulmonary edema, acute coronary syndrome, acute renal failure, severe preeclampsia, hypertensive encephalopathy, subarachnoid hemorrhage, intracranial hemorrhage, acute ischemic stroke, and sympathetic crisis. Immediate recognition and treatment are required but therapeutic goals vary considerably.

2. Hypertensive urgency: a clinical presentation associated with severe elevations in blood pressure without progressive target organ dysfunction. The arbitrary numerical criterion of ≥180/110 mm Hg is often cited as an indication for treatment, when in fact the clinical benefit of such treatment is not well defined (see Emergency Department Care and Disposition section).

The clinician must ensure that the BP cuff size is appropriate for the patient's size; a small cuff relative to the arm size produces a falsely elevated reading.

Essential historic features include a prior history of HTN; noncompliance with BP medications; cardiovascular, renal, or cerebrovascular disease; diabetes; hyperlipidemia; chronic obstructive pulmonary disease or asthma; and a family history of HTN.

Precipitating causes such as pregnancy, illicit drug use (cocaine and methamphetamines), or decongestants should be considered. Patients should be asked about central nervous system symptoms (headaches, visual changes, weakness, seizures, and confusion), cardiovascular symptoms (chest pain, palpitations, dyspnea, syncope, pedal edema, or tearing pain radiating to the back or abdomen), and renal symptoms (anuria, edema, or hematuria). The patient should be examined for evidence of papilledema, retinal exudates, neurologic deficits, seizures, or encephalopathy; the presence of these findings may constitute a hypertensive emergency in the setting of elevated blood pressure. The patient also should be assessed for carotid bruits, heart murmurs, gallops, asymmetrical pulses or unequal blood pressures (coarctation vs aortic dissection), pulsatile abdominal masses, and pulmonary rales. Hypertensive encephalopathy is characterized by altered mental status in the setting of acute hypertension, and may be accompanied by headache, vomiting, seizures, visual disturbances, papilledema, or hematuria. In the pregnant (or postpartum) patient, the clinician should look for hyperreflexia and peripheral edema, suggesting preeclampsia.

Testing should be guiding by presenting symptoms, the most cost effective test is urinalysis. Renal impairment may present as hematuria, proteinuria, red cell casts, or elevations in blood urea nitrogen, creatinine, and potassium levels. An electrocardiogram may show ST- and T-wave changes consistent with coronary ischemia (see Chapter 18), electrolyte abnormalities, or left ventricular hypertrophy. A chest x-ray may help identify congestive heart failure (see Chapter 22), or aortic dissection (see Chapter 27). In patients with neurologic compromise, computed tomography of the head may show ischemic changes, edema, or blood (see Chapter 141). A urine or serum drug screen may identify illicit drug use. A pregnancy test should be done on all hypertensive women of childbearing potential.

Patients with hypertensive emergencies require O2 supplementation, cardiac monitoring, and intravenous access. After attention to the ABCs of resus-citation, the treatment goal is ...