1. HYPERTENSIVE CRISES

2. DEFINITIONS: Hypertension: Hypertensive Urgency:
Stage I: /90-99
Stage II: >160/100
Hypertensive Urgency:
Systolic BP >180 or Diastolic BP >120 in the absence of end-organ damage

3. DEFINITIONS CONTINUED:
Hypertensive Emergencies:
SBP >180 OR DBP>120 in the presence of end-organ damage
Malignant Hypertension: End-organ damage--eyes, kidneys, brain (hemorrhage/infarct) affected
Hypertensive encephalopathy: Cerebral edema leading to neurological symptoms

4. SIGNS AND SYMPTOMS: Hypertensive Urgency:
Can be completely asymptomatic
Some symptoms include:
Severe headache
Shortness of breath
Epistaxis.
Severe anxiety
Signs:
Elevated BP on consecutive readings

5. S&S CONTINUED Hypertensive Emergencies Symptoms:
nausea, vomiting (cerebral edema)
Chest Pain
SOB
Blurry vision
Confusion
Loss of consciousness

6. SIGNS
Papilledema, Retinal hemorrhages, exudates.
Malignant nephrosclerosis with AKI, proteinuria, hematuria.
Cerebral edema causing seizures and coma
Pulmonary Edema.
Myocardial Infarction.
Hemorrhagic Stroke, lacunar infarcts.

7. TREATMENT OPTIONS Hypertensive Urgency:
Goal: Reduce BP to <160/100 over several hours to day
Elderly at high risk of ischemia from rapid reduction of BP, therefore slower reduction in BP in this patient population
Previously treated hypertension:
Increase dose of existing med or add another med
Reinstitution of med in non-compliant patients

8. TREATMENT CONTINUED Hypertensive Urgency continued:
Previously untreated hypertension:
Slow reduction of BP (one to two days): Amlodipine, Metoprolol XL, lisinopril .
Initiation of two agents or a combination with thiazide diuretic in patients with B.P of > 200/100.

9. TREATMENT CONTINUED Hypertensive Emergency:
Goal: Lower Diastolic BP to approximately over 2-6 hours; max initial fall not to exceed 25%
More aggressive decrease can lead to ischemic stroke and myocardial ischemia
If focal neurological sx presentobtain MRI to r/o acute stroke (rapid BP correction contraindicated)
Parenteral antihypertensives (IV Drip) recommended over oral agents in hypertensive emergency

10. TREATMENT
Recommended parenteral antihypertensive agents (IV drip) for Hypertensive Emergencies and admission to ICU
Nitroprusside (cautious about cyanide toxicity), Nicardipine, and Labetalol.
Once BP controlled, switch to oral anti-hypertensives and follow-up closely

13. SUMMARY Hypertensive Crises are common
Differentiate Hypertensive Urgency from Emergency on the basis of end-organ damage
Can treat hypertensive urgency with oral antihypertensive, but parenteral medications required for hypertensive emergencies
25% reduction in diastolic BP over 2-6 hours for hypertensive emergencies
To start Oral antihypertensive and follow-up closely.