Snapshot A 56-year-old woman with a history of hypertension presents to her primary care physician with a severe headache, blurry vision, and proteinuria. Her blood pressure was found to be 238/122 mmHg. Funduscopic exam is shown. Introduction Normal blood pressure - < 120/80 mmHg Pre-hypertension - 120-139/80-89mmHg Stage 1 hypertension - 140-159/90-99mmHg Stage 2 hypertension - > 160/100 mmHg Severe hypertension - > 180/100 mmHg without evidence of end organ damage can be subdivided as follows: asymptomatic severe hypertension - no risk factors present hypertensive urgency - risk factors present Hypertensive emergency/crisis - > 180/110 mmHg with evidence of end organ damage can be described as follows (not exclusive): malignant hypertension - usually includes kidney or eye damage hypertensive encephalopathy - includes nervous system dysfunction Presentation Symptoms patients present with wide range of symptoms including: oliguria chest pain focal neurologic deficits altered mental status delirium seizures headache shortness of breath nausea/vomiting may also be asymptomatic Physical exam BP > 180/110 mmHg, multiple measurements aid in making the diagnosis funduscopic exam papilledema flame hemorrhages cotton wool spots neurologic exam weakness paralysis paresthesias visual field changes cranial nerve deficits cardiac exam S3 jugular venous distention pulmonary exam crackles dullness at lung bases Evaluation Diagnostic testing is guided by the findings on history and physical exam, as well as the presence or absence of risk factors no symptoms and low risk urinalysis to screen for proteinuria no symptoms and moderate to high risk urinalysis to screen for proteinuria BMP to screen for changes in creatinine levels presence of chest pain, arrhythmias, or shortness of breath EKG if EKG is abnormal, or is changed from previous EKG's, order troponin I and CK-MB presence of focal neurologic changes non-contrast CT of the head Treatment Hypertensive urgency oral antihypertensives beta blockers metoprolol often used because of longer duration of action clonidine ACE inhibitors if oral medications are ineffective, may switch to IV formulations if patients are reliable and have good follow-up, they may be discharged without treatment to follow-up with their primary care physician Hypertensive emergency admission to ICU for blood pressure management goal is to reduce blood pressure by 10-20% within the first hour and another 5-15% within the next 24 hours (more rapid BP reduction may lead to stroke from a decrease in cerebral perfusion) exceptions to gradual BP reduction acute ischemic stroke - BP only treated if above 185/110 mmHg in patients who are candidates for reperfusion therapy and 220/120 mmHg in those who are not candidates for reperfusion therapy aortic dissection - SBP target 100-120 mmHg within 20 minutes IV antihypertensives - May be given as a single dose or as a continuous infusion nitroprusside - rapid acting and easily titratable nitroglycerine - has added benefit of relieving chest pain in patients with angina labetalol esmolol nicadipine hydralazine if signs of pulmonary edema or fluid overload are present to indicate heart failure add a diuretic, such as furosemide Prognosis, Prevention, and Complications Major risk of stroke if continued improper dosage or use of medications Must counsel patient on proper medication usage Schedule regular follow-up to maintain consistent BP control