Chest
Volume 118, Issue 1, July 2000, Pages 214-227
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Review
The Diagnosis and Management of Hypertensive Crises

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Severe hypertension is a common clinical problem in the United States, encountered in various clinical settings. Although various terms have been applied to severe hypertension, such as hypertensive crises, emergencies, or urgencies, they are all characterized by acute elevations in BP that may be associated with end-organ damage (hypertensive crisis). The immediate reduction of BP is only required in patients with acute end-organ damage. Hypertension associated with cerebral infarction or intracerebral hemorrhage only rarely requires treatment. While nitroprusside is commonly used to treat severe hypertension, it is an extremely toxic drug that should only be used in rare circumstances. Furthermore, the short-acting calcium channel blocker nifedipine is associated with significant morbidity and should be avoided. Today, a wide range of pharmacologic alternatives are available to the practitioner to control severe hypertension. This article reviews some of the current concepts and common misconceptions in the management of patients with acutely elevated BP.

Section snippets

Definitions

The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure has classified hypertension according to the degree of BP elevation.1 Stage 1 patients have a systolic BP of 140 to 159 mm Hg or a diastolic BP of 90 to 99 mm Hg. Stage 2 individuals have a systolic BP of 160 to 179 mm Hg or a diastolic BP of 100 to 109 mm Hg, whereas stage 3 includes a systolic BP pressure ≥ 180 mm Hg or a diastolic BP ≥ 110 mm Hg. Stage 3 hypertension has also been called

Epidemiology, Etiology, Pathogenesis

Hypertension is extremely common in the American population. Sixty million US inhabitants suffer from hypertension.1 The vast majority of these patients have essential hypertension. Moreover, a large number of affected individuals are unaware of their hypertension. Three quarters of those affected do not have their BP well controlled. Fewer than 1% of these patients will develop one or multiple episodes of hypertensive crises.18, 19

The incidence of hypertensive crises is higher among African

Clinical Manifestations

The manifestations of hypertensive crises are those of end-organ dysfunction. Table 2 lists those conditions that, when associated with severely elevated BP, are referred to as hypertensive crises/emergencies. Organ dysfunction is uncommon with diastolic BPs < 130 mm Hg, although it may occur.

It is important to recognize that the absolute level of BP may not be as important as the rate of increase.7, 9, 32, 33 For example, patients with long-standing hypertension may tolerate systolic BPs of

Initial Evaluation of the Patient with Hypertensive Crises

The key to successful management of patients with severely elevated BP is to differentiate hypertensive crises from hypertensive urgencies. This is accomplished by a targeted medical history and physical examination supported by appropriate laboratory evaluation.19 Prior hypertensive crises, antihypertensive medications prescribed, and BP control should be ascertained. Particular inquiry should include the use of monoamine oxidase inhibitors and recreational drugs (ie, cocaine, amphetamines,

Therapeutic Approach

Patients with hypertensive emergencies require immediate control of the BP to terminate ongoing end-organ damage, but not to return BP to normal levels.2, 3, 4, 5, 12, 13, 30 In patients with hypertensive urgencies, BP is lowered gradually over a period of 24 to 48 h, usually with oral medication. The elevated BP in patients with hypertensive emergencies should be treated in a controlled fashion in an ICU. Intraarterial BP monitoring is essential in all patients with hypertensive emergencies.

Clonidine

Clonidine is available as an oral and transdermal formulation. Oral clonidine (0.1 mg po every 20 min) has been used for the treatment of hypertensive urgencies.48, 49 The onset of action is within 30 min to 2 h, with a duration of action of 6 to 8 h. In a random, double-blind study, comparing the effects of oral nifedipine vs oral clonidine in 51 patients, clonidine was found to produce a more gradual decrease in BP than nifedipine.48 Sedation was observed in those patients taking clonidine.

Acute Aortic Dissection

IV antihypertensive treatment should be started in the emergency department in all patients (except patients with hypotension) as soon as the diagnosis of acute aortic dissection is suspected (Table 4).131 These patients must be admitted to an ICU as an emergency. Vascular pressures, urine output, mental status, and neurologic signs should be closely monitored for any deterioration owing to complications.

The aim of antihypertensive therapy is to lessen the pulsatile load or aortic stress by

Conclusion

The key to the successful management of patients with severely elevated BP is to differentiate hypertensive crises from hypertensive urgencies. Patients with hypertensive urgencies have severe hypertension (diastolic > 110 mm Hg), but without clinical evidence of acute end-organ damage. Rapid antihypertensive therapy is not warranted in these patients. Hypertensive crises constitute a distinct group of clinicopathologic entities associated with acute target organ injury. These patients require

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