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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: a Narrative Review

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Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: a Narrative Review brain sciences Review Hypertensive Crisis in Acute Cerebrovascular Diseases Presenting at the Emergency Department: A Narrative Review Mariagiovanna Cantone 1 , Giuseppe Lanza 2,3,* , Valentina Puglisi 4, Luisa Vinciguerra 4, Jaime Mandelli 5, Francesco Fisicaro 6 , Manuela Pennisi 6, Rita Bella 7 , Rosella Ciurleo 8 and Alessia Bramanti 8 1 Department of Neurology, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy; [email protected] 2 Department of Surgery and Medical-Surgical Specialties, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy 3 Department of Neurology IC, Oasi Research Institute—IRCCS, Via Conte Ruggero, 73, 94018 Troina, Italy 4 Department of Neurology and Stroke Unit, ASST Cremona, Viale Concordia, 1, 26100 Cremona, Italy; [email protected] (V.P.); [email protected] (L.V.) 5 Department of Neurosurgery, Sant’Elia Hospital, ASP Caltanissetta, Via Luigi Russo, 6, 93100 Caltanissetta, Italy; [email protected] 6 Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia, 89, 95123 Catania, Italy; drfrancescofi[email protected] (F.F.); [email protected] (M.P.) 7 Department of Medical and Surgical Sciences and Advanced Technologies, University of Catania, Via Santa Sofia, 78, 95123 Catania, Italy; [email protected] 8 IRCCS Centro Neurolesi Bonino-Pulejo, S.S. 113, Via Palermo C/da Casazza, 98123 Messina, Italy; [email protected] (R.C.); [email protected] (A.B.) * Correspondence: [email protected] or [email protected]; Tel.: +39-095-3782448 Abstract: Hypertensive crisis, defined as an increase in systolic blood pressure >179 mmHg or diastolic blood pressure >109 mmHg, typically causes end-organ damage; the brain is an elective and Citation: Cantone, M.; Lanza, G.; early target, among others. The strong relationship between arterial hypertension and cerebrovascular Puglisi, V.; Vinciguerra, L.; Mandelli, diseases is supported by extensive evidence, with hypertension being the main modifiable risk factor J.; Fisicaro, F.; Pennisi, M.; Bella, R.; for both ischemic and hemorrhagic stroke, especially when it is uncontrolled or rapidly increasing. Ciurleo, R.; Bramanti, A. However, despite the large amount of data on the preventive strategies and therapeutic measures Hypertensive Crisis in Acute that can be adopted, the management of high BP in patients with acute cerebrovascular diseases Cerebrovascular Diseases Presenting at the Emergency Department: A presenting at the emergency department is still an area of debate. Overall, the outcome of stroke Narrative Review. Brain Sci. 2021, 11, patients with high blood pressure values basically depends on the occurrence of hypertensive 70. https://doi.org/10.3390/brainsci emergency or hypertensive urgency, the treatment regimen adopted, the drug dosages and their 11010070 timing, and certain stroke features. In this narrative review, we provide a timely update on the current treatment, debated issues, and future directions related to hypertensive crisis in patients Received: 29 November 2020 referred to the emergency department because of an acute cerebrovascular event. This will also focus Accepted: 4 January 2021 greater attention on the management of certain stroke-related, time-dependent interventions, such as Published: 7 January 2021 intravenous thrombolysis and mechanic thrombectomy. Publisher’s Note: MDPI stays neu- Keywords: ischemic stroke; hemorrhagic stroke; cerebrovascular events; arterial hypertension; tral with regard to jurisdictional clai- hypertensive crisis; management; drugs ms in published maps and institutio- nal affiliations. 1. Introduction Copyright: © 2021 by the authors. Li- 1.1. Arterial Hypertension censee MDPI, Basel, Switzerland. Arterial hypertension is the main risk factor for cardio- and cerebrovascular diseases This article is an open access article in Western countries [1–6]. It is estimated that the majority of patients presenting at the distributed under the terms and con- emergency department (ED) with hypertensive crisis, defined as an increase in systolic ditions of the Creative Commons At- blood pressure (SBP) higher than 179 mmHg or diastolic blood pressure (DBP) higher tribution (CC BY) license (https:// than 109 mmHg [7], have had poor control of the arterial BP in the previous months. creativecommons.org/licenses/by/ 4.0/). Brain Sci. 2021, 11, 70. https://doi.org/10.3390/brainsci11010070 https://www.mdpi.com/journal/brainsci Brain Sci. 2021, 11, 70 2 of 28 Epidemiological data also show that only 17.4% of patients with arterial hypertension achieve adequate BP control [8,9]. In recent years, progress has been made in understanding the pathophysiology of hypertension and its complications. In particular, solid evidence has demonstrated that BP control significantly reduces morbidity and premature mortality [10–13]. However, the control rates remain rather low and still far from being satisfactory worldwide. In neurological practice, a history of hypertension or uncontrolled BP commonly occurs at stroke onset, which is also associated with adverse clinical outcomes, early recurrent events, and high mortality [14]. Nowadays, several strategies, based both on healthy lifestyle and pharmacological treatment, are highly effective and well tolerated in the reduction of high BP values. Nevertheless, despite the amount of data on the impact of hypertension in stroke and the need for prevention, the management of BP during the acute phase of both ischemic and hemorrhagic stroke remains an area of debate. Moreover, the relationship between BP and cardiovascular events means the distinction between normal BP and hypertension in still somewhat based on arbitrary cut-off values. As shown in several clinical trials [15–17], hypertension is defined as the level of BP at which the benefits of treatment, achieved with lifestyle or pharmacological interventions, unequivocally overcome the risks of the treatment itself. This evidence provides the basis for the definition of hypertension and for the classification of BP severity [8]. Traditionally,hypertension has been defined as an SBP ≥140 mmHg or DBP ≥90 mmHg [8]. These values are supported by several randomized, controlled trials demonstrating the beneficial effects of treating patients with the above-mentioned values. However, the latest report of the American College of Cardiology and the American Heart Association (AHA) Task Force [18] has significantly modified these threshold values by defining hyperten- sion as a BP higher 130/80 mmHg and by considering normal BP as values lower than 120/80 mmHg. Moreover, within the hypertension classes, the task force also identified two stages, i.e., stage 1, defined as SBP 130–139 or DBP 80–89 mmHg; and stage 2, defined as BP ≥140/90 mmHg. Finally, the quantification of the total cardiovascular risk, i.e., the probability of an individual developing a cardiovascular event during a defined time interval, is a relevant part of the risk stratification and subsequent therapeutic choice for patients with arterial hypertension [18]. 1.2. Hypertensive Emergency and Hypertensive Urgency The guidelines of the European Society of Cardiology (ESC) on the management of hypertension and subsequent revisions [8,19] have provided the most used recommen- dations for the diagnosis and treatment of hypertension, although they did not consider the difference between hypertensive emergency (HE) and hypertensive urgency (HU). In this framework, the classification of the Joint National Committee on Prevention, Detec- tion, Evaluation, and Treatment of High Blood Pressure seems to be more accurate [7] by providing distinct definitions of HE and HU. HE is characterized by a severe BP increase (generally > 180/120 mmHg) and is associ- ated with acute organ damage, which includes acute cerebrovascular events, hypertensive encephalopathy, aortic dissection, myocardial infarction, unstable angina, acute congestive heart failure with pulmonary edema, hemolysis, increase in liver enzymes and low platelet count (HELLP syndrome), eclampsia, acute renal failure, and microangiopathic hemolytic anemia. Overall, hypertensive crises represent approximately 0.5% of all cases presenting at the ED [20]. A hypertensive crisis can develop in a previously normal subject or can complicate an underlying hypertension. Any medical, neurological, or psychiatric disorder causing a sudden rise of BP can result in an HE. Notably, a preexisting hypertension can reduce the probability of HE through some adaptive vascular modifications that seem to protect organs from constantly high BP values [21,22]. Conversely, in HU organ damage is not present or it is minimal, or is not clearly evident. Examples of HU, in which BP values are equal to or greater than grade 2 (SBP 160–179 mmHg or DBP 100–109 mmHg), are Brain Sci. 2021, 11, 70 3 of 28 severe migraine, epistaxis, dyspnea, or severe anxiety [23,24]. Therefore, it is evident that a differentiation between HE and HU is crucial for management and optimal therapeutic approaches. Moreover, unlike HE, HU can be resolved spontaneously or within 24–48 h by using oral or intramuscular medications [25]. However, in the common scenario of BP > 180/120 mmHg at the ED, an acute hyper- tension may be classified as either HE or HU, since it is difficult to differentiate them based on BP values only, without clinical evidence of organ damage. The relatively paucity of data regarding this distinction is reflected in the fact that the 2014 Eighth
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