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HYPERTENSIVE EMERGENCIES: Emergency Department Evaluation and Management OCTOBER 2008 Volume 3 Charles V COLLABORATE | INVESTIGATE | EDUCATE HYPERTENSIVE EMERGENCIES: Emergency Department Evaluation and Management OCTOBER 2008 VOLUME 3 Charles V. Pollack, Jr., MA, MD, FACEP, FAAEM, FAHA Dear Colleagues: Christopher J. Rees, MD Department of Emergency Medicine Hypertension remains one of the most common disease processes in patients presenting to the Emergency Department (ED). While Pennsylvania Hospital sometimes symptomatic and associated with end organ damage University of Pennsylvania such as hypertensive encephalopathy, hemorrhagic stroke, acute Philadelphia, PA coronary syndrome, heart failure, and renal insufficiency, many patients present without symptoms. Emergency physicians and Objectives: hospitalists should understand the appropriate classification of patients with hypertension, the pathophysiology of this disease 1. Describe the distinctions among hypertensive “crisis,” “urgency,” process, and appropriate treatment strategies. In this EMCREG- and “emergency” International Newsletter, Charles V. Pollack, Jr. MD and Christopher 2. Discuss the general approach to acute severe hypertension in the ED J. Rees, MD of Pennsylvania Hospital and the University of 3. Explain the limitations of typically used parenteral Pennsylvania discusses hypertension and parenteral medications antihypertensive agents in the ED used for treatment of these patients in the ED, including the Velocity 4. Summarize the potential role of clevidipine in ED management trial. This paper serves as a companion to the Hypertension of hypertensive emergency Consensus Panel publication as a supplement in the March 2008 Annals of Emergency Medicine and the EMCREG-International Newsletter published earlier this year by Drs. Judd Hollander and Introduction Anna Marie Chang. Hypertension is an extremely common Through collaboration with colleagues from a variety of specialties, illness, affecting 50 to 75 million people patients with hypertension can receive optimal therapy when in the US, many of whom are unaware that they even have hypertension.1-3 It is the presenting to an acute care setting such as the ED. For patients At some point in their receiving parenteral therapy, the natural transition of the patient most common primary medical diagnosis with hypertensive emergency through the ED to the intensive care in the US.4 Familiarity does not, however, lives, 1% of patients with unit or step-down bed involves careful collaboration between the equate to treatment success; some two- hypertension will have a emergency physician and hospitalists. It is our hope you will find thirds of hypertensive patients fail to hypertensive emergency. this EMCREG-International Newsletter helpful in the care of your achieve adequate control of their blood patients with hypertension. pressure (BP).2,3 Poor BP control often –––––––––––– prompts emergency department (ED) visits. About 5% of ED Sincerely, At some point in their lives, 1% of patients patients have at least with hypertension will have a hypertensive “emergency,” defined as severely elevated one blood pressure (BP) blood pressure associated with target reading that is severely 1,2,5 organ dysfunction. elevated, although Meanwhile, about 5% of ED patients have most do not have a at least one BP reading that is severely hypertensive emergency. elevated, although most do not have a Peer Reviewer for Commercial Bias: Douglas M. Char, MD; Associate Andra L. Blomkalns, MD W. Brian Gibler, MD Professor, Emergency Medicine; Program Director, Emergency Medicine Director of CME, President, Residency Program; Director, Emergency Cardiac Evaluation Unit. EMCREG-International EMCREG-International Washington University, St. Louis, MO Hypertensive Emergencies: Emergency Department Evaluation and Management OCTOBER 2008 VOLUME 3 EM E RG E NCY MEDICINE CARDIAC RE S E ARCH AND EDUCATION GROUP hypertensive emergency (HE).6 Patients often present to the encephalopathy, acute hemorrhagic or ischemic stroke, ED for unrelated issues, only to be found to have severely acute papilledema, acute pulmonary edema, aortic elevated BP. Other patients present with complaints dissection, acute renal failure with or without hematuria, clearly referable to a BP derangement. The incidence of and eclampsia. It is essential to realize that most patients hypertensive emergency is disproportionately higher in the who present to the ED with severe hypertension do not elderly, male, and African-American populations.7,8 Rapid have a hypertensive emergency. recognition, evaluation, and treatment of hypertensive emergencies are necessary to prevent permanent or Hypertensive urgency is defined as “those situations worsened target organ damage. There are essentially associated with severe elevations in BP without 4 no evidence-based guidelines for treating hypertensive progressive target organ dysfunction.” Some authors use emergencies in general, although there are guidelines the term hypertensive crisis to include both hypertensive for the management of BP in stroke, aortic dissection, emergencies and hypertensive urgencies. This may not and eclampsia. The most recent periodic review by the be fruitful as the term “crisis” is often used to justify an Joint National Committee (JNC) on Prevention, Detection, acute intervention, which is not always necessary in the Evaluation, and Treatment of High Blood Pressure (JNC 7, ED when severe hypertension is detected. 2003) offers little in the form of evidence-based guidance Another important term in this discussion is autoregulation. on the management of hypertensive urgencies, defined as In normotensive people, there is ordinarily a broad range severe elevations of BP without target organ damage, or of pressures through which arteries and arterioles can emergencies in general.4 dilate and constrict to maintain normal and consistent perfusion. Chronic hypertension causes arterial walls Definitions to accommodate chronically excessive pressures. This autoregulation limits the vessels’ ability to respond The JNC 7 describes hypertension using a baseline BP of appropriately to acute decreases or increases in BP. 115/75 mm Hg, reporting that the risk of cardiovascular When BP abruptly increases, regardless of stimulus, disease (CVD) doubles with each incremental increase larger arteries reflexively vasoconstrict in an effort to of 20/10 mm Hg. JNC 7 defines blood pressure and limit pressure reaching the tissues, which would interfere hypertension categories as follows: with normal cellular activity. In this situation, an acute lowering of BP by a clinician seeking to re-achieve a Normal: <120/80 mm Hg “normal” BP will reduce the blood flow to tissue without Pre-hypertension: 120-139/80-89 mm Hg prompt compensatory vessel dilation, which can lead to Hypertension: Stage 1: 140-159/90-99 mm Hg ischemia of end-organ tissue. Therefore, it is important Hypertension: Stage 2: > 160/100 mm Hg when treating hypertensive emergencies, to not decrease BP either too rapidly or by too great of an amount. Hypertensive emergencies almost always fall into stage 2, although some patients, especially younger individuals, can have hypertensive emergencies at much lower BP Causes of Hypertensive Emergencies levels than those with chronic hypertension. The JNC 7 The most common origin of hypertensive emergency is an publication defines hypertensive emergency as “a severe abrupt increase in BP in patients with chronic hypertension, elevation in blood pressure (usually >180/120 mm Hg) most often as a result of medication noncompliance.3 complicated by evidence of impending or progressive Other relatively common causes of hypertensive target organ dysfunction.”4 Clinical manifestations of emergency include stimulant intoxication, including target organ damage usually involve derangements cocaine, methamphetamine, and phencyclidine as well as in the neurologic, cardiac, or renal systems. While withdrawal syndromes from the anti-hypertensives such as the myocardium is the most common target organ clonidine and beta blockers. Less common causes include damaged by hypertension with a clinical manifestation pheochromocytoma and adverse drug interactions with as acute coronary syndrome (ACS)3, other examples of monoamine oxidase inhibitors (MAO-I). target organ dysfunction include, but are not limited to, Page 2 Hypertensive Emergencies: Emergency Department Evaluation and Management EM E RG E NCY MEDICINE CARDIAC RE S E ARCH AND EDUCATION GROUP OCTOBER 2008 VOLUME 3 Clinical Syndromes of Hypertensive Evaluation of the Patient with Emergencies Hypertensive Emergency Cardiac manifestations of hypertensive emergencies All patients with severely elevated BP should undergo usually present with either ACS or acute cardiogenic a thorough history and physical examination in the pulmonary edema. Central nervous system syndromes ED. A complete past medical history with attention to usually manifest as subarachnoid hemorrhage, hypertension is obviously important. A review of all the intraparenchymal hemorrhage, cerebral infarction, patient’s medications which includes review of dosages, or hypertensive encephalopathy. Hypertensive length of use, compliance, and last time taken should encephalopathy is often more difficult to diagnose and is be obtained. The patient must be questioned about in the differential not only with the other three syndromes recreational drug use, as several drugs of abuse, such as noted, but also with substance abuse. Hypertensive cocaine, amphetamines, and phencyclidine, can cause encephalopathy is potentially fully reversible
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