Clinical Management of Hypertensive Urgency in an Urgent Care Setting Urgent message: Effective management of patients presenting to urgent care with acute high blood pressure starts w ith differentiat- ing between hypertensive emergency and hypertensive urgency and ends with appropriate treatment and counseling. Sanjeev Sharma, MD, Christy Anderson, PharmD, Poonam Sharma, MD, and Donald Frey, MD Introduction Pressure (JNC 7) classifies hy- rgent care physicians rou- pertension as shown in Table tinely encounter patients 1. Four categories of blood with high blood pres- pressures are described, the Usure, but management— most significant being Stage particularly for those pa- 2, defined as pressures tients with precarious eleva- >160/100 mmHg. While the tions—remains controversial. JNC 7 does not define a blood Alternative options involve pressure limit for hyperten- the use of various drug-ther- sive urgency or emergency, apy modalities in the urgent the report classifies “severe el- care setting with close obser- evation” in blood pressure as vation, or initiation of oral >180/120 mm HG. medication and releasing the The World Health Organ- patient to home with specif- ization (WHO), Interna- ic instructions. tional Society of Hyperten- The consequences of inap- sion (IHS), and European propriate treatment can be Society of Hypertension disastrous, and include my- Inc Researchers, / Photo © Brian Evans (ESH) all classify hyperten- ocardial infarction, stroke, sion as shown in Table 2. In and death. this system, there are six blood pressure categories, with the highest being Stage 3 at >180/110 mmHg. Classification of Hypertension Historically, systolic blood pressure (SBP) >179 and di- Hypertension can be classified in various ways. The Sev- astolic blood pressure (DBP) >109 has broadly been enth Report of the Joint National Committee on Preven- considered to be a “hypertensive crisis.”1 These pressures tion, Detection, Evaluation, and Treatment of High Blood are further sub-classified as either hypertensive emer- www.jucm.com JUCM The Journal of Urgent Care Medicine | April 2009 11 MANAGEMENT OF HYPERTENSIVE URGENCY IN AN URGENT CARE SETTING gency or hypertensive urgency. Table 1: JNC-7 Classification of Hypertension Hypertensive emergency exists if there are signs of acute end-organ damage Category SBP/DBP (mm Hg) such as encephalopathy, myocardial Optimal <120/80 infarction, unstable angina, pulmonary Prehypertensive 121–139 /80–89 edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, and Stage 1 hypertension 140–159/ 90–99 aortic dissection. As there is no ab- Stage 2 hypertension >160/>100 solute pressure measurement to define hypertensive emergency, it is identi- fied by the physical signs of acute end- Table 2: WHO, ISH, & ESH Classification of Hypertension organ damage. Consequently, patients with a low baseline pressure can pres- Category SBP/DBP (mm Hg) ent with “normal” or mildly elevated Optimal <120/80 pressure and be considered to have a Normal 120-129/80-84 true hypertensive emergency. Patients with markedly elevated High normal 130-139/85-89 blood pressure but who lack these signs Stage 1 hypertension 140–159/90–99 are determined to be in hypertensive ur- Stage 2 hypertension 160-179/100-109 gency.1 Some clinicians classify hyper- Stage 3 hypertension >180/110 tensive urgency as “elevated blood pressure (diastolic pressure usually >120 mm Hg) that is not associated with new or progres- nosed hypertensive individuals. They actually ex- sive end-organ damage”.2 hibit normal pressures in their regular environment. In hypertensive urgency, there is a risk of imminent The goal in hypertensive emergency is to rapidly and end-organ damage, but such damage has not yet oc- carefully control the blood pressure to prevent fatal curred. Particularly susceptible patients often have pre- and irreversible end-organ damage. Action is usually existing conditions, e.g., renal insufficiency, congestive taken in minutes up to a few hours as per the clinical sit- heart failure, coronary artery disease, CNS disorders, or uation, and intravenous medicines are usually em- retinal changes. ployed. The aim may not be to reduce the blood pres- One to two percent of all hypertensive patients may sure into the normal range in certain clinical scenarios present with hypertensive emergency or crisis at some such as stroke. point of their lives.1 In hypertensive urgency, blood pressure can be con- Other terminologies used in these instances include: trolled safely over period of hours or days in the outpa- Ⅲ Acute hypertensive episode, which is defined as: tient setting. – Stage 3 hypertension –systolic pressure 180 mmHg Etiology – and diastolic pressure 110 mmHg The etiology of hypertensive urgency is not well under- with no signs or symptoms of evolving or impending stood. Most such patients have pre-existent hyperten- target-organ damage. sion,3 and non-adherence with antihypertensive med- Ⅲ Transient hypertension, which is the presence of ications near the time of the episode is seen in about high blood pressure in association with other con- 50% of them.4 Illicit drug usage is also reported to be a ditions such as anxiety, alcohol-withdrawal, sudden risk factor for the development of hypertensive emer- medication cessation, and toxic levels of some sub- gency.5 Other causes of both urgency and emergency are stances. In this case, treatment is aimed at the un- shown in Table 3. derlying cause. Ⅲ White-coat hypertension, or anxiety- related high blood Pathophysiology pressure readings seen only in a physician’s office, During the hypertensive episode, there is an abrupt in- with otherwise normal blood pressure. This is a sur- crease in the systemic vascular resistance due to humoral prisingly common finding, especially in newly diag- vasoconstriction. This may be the triggering event.6 www.jucm.com JUCM The Journal of Urgent Care Medicine | April 2009 15 MANAGEMENT OF HYPERTENSIVE URGENCY IN AN URGENT CARE SETTING Increased blood pressure causes en- Table 3: Etiologic Causes of Hypertensive Urgency/Emergency dothelial damage by increasing the en- dothelial permeability and local activa- tion of the clotting cascade (platelet Essential Hypertension and fibrin deposition), resulting in fib- Renal •Renal artery stenosis rinoid necrosis and intimal prolifera- •Glomerulonephritis tion. The endothelium is then unable Vascular •Vasculitis to compensate or auto-regulate for –hemolytic-uremic syndrome –thrombotic thrombocytopenia purpura changes in blood pressure. A vicious cy- cle ensues with further increases in re- Pregnancy- •Preeclampsia sistance and endothelial damage. related •Eclampsia High blood pressure also increases Pharmacologic •Sympathomimetics the stretch on the vessel wall which ac- •Clonidine withdrawal tivates the renin-angiotensin system. •Beta-blocker withdrawal This plays an important part in severely •Cocaine elevated blood pressures. •Amphetamines The combined process of endothelial Endocrine •Cushing’s syndrome damage, loss of auto-regulation, acti- •Conn’s syndrome vated renin-angiotensin system, de- •Pheochromocytoma crease in vasodilators (nitric oxide, •Renin-secreting adenomas prostacycline), and sustained blood •Thyrotoxicosis pressure elevation can lead to tissue is- Neurologic •Central nervous system trauma chemia and end-organ damage. Major •Intracranial mass organ systems involved include the central nervous, cardiovascular, renal, Autoimmune •Scleroderma renal crisis and gravid uterus.7, 8 Single-organ involvement is found in approximately 83% of patients presenting with hy- The physical exam should begin with measuring the pertensive emergencies. Dual-organ involvement is blood pressure in both arms, using an appropriately found in 14% of cases, and multi-organ involvement (>3 sized cuff. Smaller cuffs can falsely elevate blood pressure organ systems) is found in approximately 3% of patients readings in obese patients, and vice versa. The physical presenting with a hypertensive emergency.9 exam should also include a supine and standing blood pressure, as well as a measurement in the neck to assess Clinical Presentation for signs of elevated jugular venous pressure. A proper history and physical examination help a physi- Next, pulses should be assessed in all extremities, cian to differentiate between hypertensive urgency and and auscultation performed on the lungs (for signs of emergency. A focused history should be taken to rule out pulmonary edema), the renal arteries (for bruits), and end-organ damage, the signs and symptoms of which the heart (for murmurs or gallops). are shown in Table 4. A focused neurologic and fundoscopic assessment The history should include any previous history of should be done to rule out a cerebrovascular accident. high blood pressure, antihypertensive medications used Lateralizing signs are uncommon in hypertensive en- and adherence to medication regimens, over-the- cephalopathy and are more suggestive of a stroke. Other counter and illicit drug use (cocaine, amphetamines, de- studies which may be employed to help rule out a hy- congestants, stimulants, oral contraceptives, and pertensive emergency include electrocardiogram, chest NSAIDs), and the presence of previous end-organ dam- x-ray, urinalysis, complete blood count, evaluation of age (e.g. renal, cardiac, or cerebrovascular). electrolytes, and serum tests for renal function. Common symptoms related to hypertensive emer- In a patient with severely elevated blood pressure, gencies are chest pain