hypertensive crisis (malignant hypertension)
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Etiology
see hypertension
Clinical manifestations
- stage IV hypertension (very severe)
- systolic blood pressure > 210 mm Hg
- diastolic blood pressure > 120 mm Hg
- target organ disease
- neurologic manifestations
- altered mental status including coma
- TIA, stroke
- headaches, dizziness, vertigo, tremors
- diplopia, diminished visual acuity
- focal deficits: numbness, weakness, slurred speech, cranial nerve palsies
- cardiac manifestations
- vascular manifestations
- decreased peripheral pulses
- bruits - abdominal, femoral, carotid
- retinal manifestations
- renal changes
- neurologic manifestations
Laboratory
Diagnostic procedures
- funduscopy: optic disc swelling (papilledema) is a sign of increased intracranial pressure
Management
- goal of initial treatment
- reduction of blood pressure by 25% in the 1st hour
- decrease to systolic blood pressure of 160 mmg Hg with diastolic blood pressure of 100-110 mm Hg in the next 2-6 hours[1]
- do not lower blood pressure rapidly to < 140/80
- adverse effects include: cerebral hypoperfusion & acute tubular necrosis (ATN)
- more rapid lowering of blood pressure may be attempted if there is evidence of:
- pre-eclampsia, eclampsia, pheochromocytoma
- acute organ injury
- lower systolic BP to < 140 mm Hg in the 1st hour[1]
- aortic dissection
- lower systolic BP to < 120 mm Hg in the 1st hour[1]
- intravenous
- sodium nitroprusside or nitroglycerin drip
- esmolol* drip
- contraindicated with sympathomimetic intoxication
- contraindicated with acute heart failure*
- labetalol* drip
- indicated when offending agent is alpha-adrenergic receptor agonist, i.e. cocaine*
- benzodiazepine may be useful as adjunctive treatment in sympathomimetic intoxication (see toxidrome)
- contraindicated with acute heart failure*
- hydralazine drip
- nicardipine* drip
- IV enalapril
- IV diazoxide
- oral agents
- nifedipine* 10 mg every hr
- captopril 10 mg every hr
- captopril less likely than nifedipine to cause excessive drop in blood pressure
- clonidine 0.1 mg every hr
- do not use sublingual clonidine[1]
- nitropaste
- fenoldopam (Corlopam)
- hospitalize for:
- blood pressure > 210/120
- acute manifestations
* use of labetalol in sympathomimetic intoxication is somewhat controversial
* beta-blockers & calcium channel blockers contraindicated in patients with acute pulmonary edema due to acute heart failure[1]
More general terms
Additional terms
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Marik PE, Rivera R. Hypertensive emergencies: an update. Curr Opin Crit Care. 2011 Dec;17(6):569-80. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21986463
- ↑ Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000 Jul 29;356(9227):411-7. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/10972386
- ↑ Johnson W, Nguyen ML, Patel R. Hypertension crisis in the emergency department. Cardiol Clin. 2012 Nov;30(4):533-43. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23102030
- ↑ Calhoun DA, Oparil S. Treatment of Hypertensive Crisis. N Engl J Med 1990; 323:1177-1183 PMID: https://www.ncbi.nlm.nih.gov/pubmed/2215596 https://www.nejm.org/doi/full/10.1056/NEJM199010253231706
Varon J, Marik PE. Clinical review: the management of hypertensive crises. Crit Care 2003 Sep 17; 7:374. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12974970 Free PMC Article
NEJM Knowledge+ Question of the Week. Sept 18, 2018 https://knowledgeplus.nejm.org/question-of-week/15/ - ↑ NEJM Knowledge+ Question of the Week. July 16, 2109 https://knowledgeplus.nejm.org/question-of-week/1189/answer/A/
- ↑ Katz JN et al. Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe hypertension: the Studying the Treatment of Acute hyperTension (STAT) registry. Am Heart J 2009 Oct; 158:599 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19781420