IntroductionHypertensive crisis is a condition when patient experiences sudden spike in blood pressure and this can even turn into a life-threatening event. It is also known as acute hypertension. It is so severe that it can immediately result in a stroke. It involves two conditions. One is hypertensive urgency and the other one is hypertensive emergency. Hypertensive urgency is a condition in which symptoms are almost absent in most of the individuals. Even the ones who are suffering from it do not know about it and this condition is discovered in them accidentally. End-organ damage or life-threatening events have not taken place, but these conditions may develop in them at any time. In case of hypertensive emergency, patient shows various symptoms and undergoes one or more than one end-organ damage. In both the conditions, patient is kept under close monitoring and blood pressure is brought down slowly to avoid any brain damage. End-organ damage which has taken place is usually irreversible and treatment is provided as per the organ affected. Since it is a medical condition, treatment too is mainly performed in a hospital by a team of doctors. Hypertensive patients should take care to prevent worsening of symptoms by following a preventive care.
Causes of hypertensive crisisMedicines
Pathophysiology of hypertensive crisisDuring onset of hypertensive emergency, there will be failure of normal autoregulation. Systemic vascular resistance rises almost all of a sudden i.e., there is an abrupt rise and this itself is the triggering factor seen along with sudden rise in blood pressure. This will cause underlying secondary hypertension to complicate. Endothelium secretes nitric oxide and prostacylin . This modulates vascular tone. In this way, endothelium plays a major role. Another important factor is activation of rennin-angiotensin system. It gets activated when walls of blood vessels stretch on sudden spike of b.p. Endothelium will also face injury due to endothelial decompensation in case of shut down of vasodilatory response. There will be further increase in blood pressure. This cycle continues where resistance and damage of endothelium continue side by side. If the cycle is not stopped then homeostatic failure leading to brain and local autoregulation failure begin. Also leads to end-organ damage and myocardial infarction. Endothelial injury is mainly caused due to sudden spike in blood pressure followed by fibrinoid necrosis. Vascular damage can cause deposition of platelets and fibrin. There will be failure of normal autoregulatory function. Consequently, ischemia develops and there will be further release of vasoactive entities. This completes the vicious cycle.
Diagnosis of Hypertensive crisisIt is very important to differentiate between hypertensive urgency and hypertensive emergency because both the conditions require different treatment procedures. Thus, diagnosis becomes a crucial step. Diagnosis will mainly include taking history, performing physical examinations, blood tests, other tests like electrocardiogram and chest radio graph etc. These tests will help to different the two hypertensive crisis events as well as diagnose the possible end-organ damage that has taken place and the treatment required for the same.
HistoryDoctor will ask certain questions to the patient or to the attender accompanying patient to record a detailed case history. It will determine nature and severity of hypertensive crisis. Some of the questions asked will be as follows -
Patient will be asked about symptoms he is suffering from because symptoms are suggestive of end-organ damage patient is going through.
Physical examinationBlood pressure is measured in both arms of the patient. This is because in case if patient is suffering from aortic dissection; there will be discrepancy of almost 20mm systolic b.p. in between arms. Blood pressure should also be measured in both standing as well as in supine position. This will determine volume status. Patients who are suffering from hypertensive emergency may present themselves with depletion of intravascular volume. This condition is also known as pressure natriuresis. Head and neck examinations should be done thoroughly. Papilledema, hemorrhages, exudates, retinopathy etc are all indications that patient is suffering from hypertensive emergency. Auscultation is determined for murmurs. If patient is suffering from aortic dissection then he will show diastolic murmur along with aortic insufficiency. If patient is suffering from ischemia then he will show mitral regurgitation. Systolic or diastolic abdominal bruit means renovascular disease and presence of rales indicate vascular congestion, pulmonary edema etc. Atherosclerotic disease in smokers means patient is undergoing renal artery stenosis. Focal neurologic indications are signs of hemorrhagic stroke. Tremor indicates hypertensive encephalopathy.
ConclusionHypertensive crisis or acute hypertension is a medical emergency and require immediate medical treatment. Otherwise it may result in an end-organ damage of one or more organs and life-threatening events may take place in the body of the patient. It involves both hypertensive urgency as well as hypertensive emergency and most of the times it is used as a umbrella term for both these conditions. Proper diagnosis is essential which helps to determine whether patient is suffering from hypertensive urgency or hypertensive emergency which is also known as malignant hypertension. Both crisis require different treatments. History, physical examinations, lab tests and other diagnostic tests will essentially determine the cause as well as the crisis. Proper treatment given at right time can save life as well as prevent further organ damage. Know more about What to do in hypertensive crisis: Hypertensive urgency and hypertensive emergency to learn about various medical procedures involved in the emergency treatment as well as preventive measures to keep hypertensive crisis at bay.