What to do in hypertensive crisis ?: Hypertensive urgency and hypertensive emergency


This article explains crisis associated with high blood pressure namely hypertensive urgency and hypertensive emergency. Since both of them are medical emergencies, a hypertensive patient should follow strict preventive measures and never neglect symptoms in order to avoid complications.

Introduction

Hypertension is a very commonly seen disorder in today's era. If it is kept under control by following proper treatment plan prescribed by the concerned doctor then one may neither has to face any crisis related to it nor has to land in an emergency situation of any kind. If care is not taken then one has to go through hypertensive crisis which is an umbrella term for both the terms hypertensive urgency and hypertensive emergency. It is also known as acute hypertension and is a medical emergency which means it can only be corrected or brought under control by a team of doctors in the hospital. A hypertensive crisis is nothing but high blood pressure crisis in which blood pressure level rises quickly and severely to a very high level and can cause a stroke. It occurs when blood pressure readings show 180/110 or even higher. In hypertension, organ damage takes place slowly over a period of several years. However, in hypertensive crisis, organ damage can be seen quickly within a short duration. Both hypertensive emergency and hypertensive urgency require medical attention cause these conditions can be life threatening.

Hypertensive urgency

Patient is known to have high blood pressure when systolic pressure is less than 180 and diastolic pressure is less than 120. When blood pressure rises, patient shows certain symptoms and these symptoms makes him seek medical support. Sometimes, patient does not show any symptoms but still has very high blood pressure. His elevated blood pressure is discovered incidentally. Hypertensive urgency is a condition in which patient has elevated levels of blood pressure without any symptoms. Patient suffering from it neither shows any organ failure nor is suffering from any fatal condition but can show the same if his blood pressure is not brought under control. Since he does not display any symptoms, it becomes difficult to diagnose that his blood pressure is highly elevated. In absence of diagnosis, treatment seems almost impossible.

Examples

  • Accelerated hypertension,
  • Perioperative hypertension,
  • Marked hypertension associated with congestive heart failure, transient ischemic attacks etc.


Symptoms

Elevated blood pressure level without damage to organs and absence of life-threatening events is the main symptom of hypertensive urgency. Apart from this, following symptoms may or may not be present in patients-
  • Severe headache
  • Difficulty in breathing
  • Bleeding from nose
  • Severe headaches


Treatment of hypertensive urgency

Blood pressure is lowered within 24 to 48 hours. There is no need to quickly bring down elevated levels of blood pressure as the main aim of treatment is to prevent complications as most of the patients do not show any symptoms. Patient is hospitalized and kept under close monitoring. He is kept in calm environment, preferably in quite and dark room. Blood pressure is brought down slowly by giving oral medications and abruptness is avoided to prevent brain damage or brain death which usually happens when blood pressure is brought down quickly leading to cutting off supply to brain. Some may argue that hospitalization is not mandatory, but still it is the best precautionary measure to take in order to prevent further complications. If patient is already on anti-hypertensive drugs then some changes will be made in the course of treatment. Usually treatment is started with low dose of drugs and incremental doses are given as and when needed. At the onset of treatment, heavy doses are avoided to prevent rapid fall in blood pressure. Excess reduction in b.p. is prevented in individuals who are at high risk of suffering from hypotensive complications like age old individuals, patients suffering from atherosclerotic heart disease, intracranial disease, peripheral vascular disease etc. Mean arterial pressure should not come down for more than 25% in 24 hours. Certain specific drugs which are given are ACE inhibitor like captopril, calcium channel blocker like nicardipine, nifedipine, central symphatolytic drug like clonidine etc.

Hypertensive emergency

It is also known as malignant hypertension. It is a condition in which patient displays a very high blood pressure along with acute impairment of one or more than one organ system and damage is irreversible. Systolic blood pressure is 180 or more and diastolic is 120 or more. Organs commonly affected are kidneys, brain, heart etc. Patient shows swelling in the brain, rupture of blood vessels, kidney diseases or failure etc. End-organ damage may be new or progressive. This condition is often associated with life-threatening complications.

Symptoms

  • blurred vision and other disturbances in eye sight,
  • Nausea and vomiting
  • Headache with confusion
  • Disturbed appetite
  • Dizziness or weakness
  • Pain in chest
  • dyspnea
  • Severe anxiety
  • Altered mental status like sleepiness, forgetfulness
  • Vertigo
  • Seizures
  • Edema or swelling


Risks associated

Symptoms displayed during hypertensive emergency indicates which end-organ dysfunction may be present.
  • Chest pain suggests ischemia, unstable angina
  • Dyspnea indicates congestive heart failure and pulmonary edema
  • If patient shows confusion, visual disturbances and other neurological symptoms then it is presence of hypertensive encephalopathy
  • Back pain suggests aortic dissection


Other organ damages seen are-

  • Cardiovascular end-organ damage may include acute pulmonary edema, aortic dissection, myocardial infarcton, acute left ventricular failure
  • Stroke which occurs due to bleeding in the brain
  • Heart attack
  • Heart failure
  • Retinopathy
  • Eclampsia during pregnancy
  • Microangiopathic hemolytic anemia
  • Kidneys may suffer from acute renal failure, hematuria, proteinuria
  • Brain may suffer from increased intracranial pressure, cerebral hemorrhage, cerebral infarction, intracranial hemorrhage, hypertensive encephalopathy


Treatment of hypertensive emergency

Treatment is customized based on extent of irreversible organ damage that has taken place in a patient. Usually patient is kept in ICU and blood pressure is tried to lower smoothly and not abruptly. During first hour of onset of treatment, mean arterial pressure is lowered by 10% and an additional only 15% is reduced in next 2 to 3 hours. If instead of smooth lowering of b.p., abruptly it is tried to lower down then patient may suffer from heart or cerebrovascular hypo-perfusion, renal ischemia etc. IV saline is administered to restore intravascular volume along with vasodilator drugs. IV blood pressure drugs are administered to prevent further damage to organs. Anti-hypertensive agents like intravenous sodium nitroprusside injection is given for immediate effect. In less severe cases, oral drugs are given like captopril, clonidine, prazosin etc.

In resistant malignant hypertension, non-pharmacological treatment becomes essential. This is because of end stage kidney failure. Treatments like laparoscopy, nephrectomy, renal artery embolization come to help. If patient shows neurological symptoms then ECG, urine analysis and head CT scan are done. Serum BUN and creatinine level are determined. In case of pregnant women, hypertensive emergency should be treated as quickly as possible to eliminate the risk of maternal end-organ damage. In intracerebral hemorrhage, hypertension should be treated only when blood pressure is more than 180/105 mm Hg whereas mean arterial pressure should be maintained below 130 mm/Hg. In cardiac emergency, patient should be treated with nitroglycerine. If there is no risk of cardiac failure then beta-blockers can be used to teat hypertension.

What to do in hypertensive crisis?

There is not much that an individual can do during hypertensive crisis i.e., in hypertensive urgency or hypertensive emergency. Procedures involved are all medical related and thus one has to call for medical help as soon as symptoms occur so that one can save oneself from undergoing life threatening situations and damage to organs. Preventive measures on the other hand definitely keep hypertensive crisis at bay and thus taking care of body by keeping blood pressure withing normal range will be of great help.

Following are the preventive measures one can follow

  • If a patient is diagnosed with hypertension and even if it is of mild severity, he should continue taking his medications and pay regular visit to doctor for follow ups. This kind of treatment plan will prevent risk of hypertensive urgency.
  • Monitor blood pressure regularly at home and do it accurately in a sitting position. Do it twice a day. Once in the morning and once in the evening and keep a record of all the readings obtained. Any drastic changes if seen then consult doctor immediately.
  • Proper medication should be taken for other health related problems especially, diabetes, thyroid disorders, adrenal problems etc. These conditions interfere with hypertension and can worsen it leading to crisis.
  • Excess weight has a large impact on blood pressure and can cause hypertension. Thus, body has to maintain a normal weight. Any excess amount of weight if present should be lost in a healthy way by following a healthy diet.
  • Follow a healthy life style. Eat as much healthy as possible. Eat lots of fruits, vegetables, whole grains, lean proteins etc. Decrease sodium and fat intake and increase intake of potassium. Healthy changes will improve hypertension and decrease elevated levels of blood pressure naturally. Avoid alcohol or at least moderate drinking should be adopted. Do not smoke because smoking increases b.p.


Conclusion

Hypertensive crisis cannot be taken lightly as it is associated with significant morbidity and mortality. Early diagnosis and proper medical treatment is essential to prevent a person from going through trauma of life-threatening events and organ failures or damages. If an individual experiences severe rise in blood pressure along with other symptoms then he should immediately consult doctor and should not hesitate to seek medical help cause timely treatment can save life and also save him from going through end-organ damage or fatal events.


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