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Managing Acute Severe Hypertension

December 16, 2019

Written by Clay Smith

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We need to know hypertension (HTN) and be expert in not only management of hypertensive emergency but urgency as well. Here is a quick review for you.

Why does the matter?
We see elevated BP all the time in the ED. We often see asymptomatic patients referred for BP elevation from clinics from those who should know better. This is a review article with several best practices. Make sure to review our prior post on the latest AHA HTN guidelines.

Under pressure…
The key take home points were:

  • Acute severe HTN with end organ damage is called hypertensive emergency and should be managed in the hospital with IV medications. What is end-organ damage?

    • Brain: stroke, ICH, PRES

    • Eye: retinal hemorrhage, exudate, papilledema

    • CV: ACS, heart failure, aortic dissection

    • Renal: AKI

    • Microvascular: microangiopathic hemolytic anemia and “malignant HTN”

  • This next point is so important, I am going to quote it in full.
    “Acute severe hypertension without acute target-organ damage (hypertensive urgency) is not associated with adverse short-term outcomes and can be managed in the ambulatory setting.”
    To recap, HTN urgency does not impact short-term outcomes and can be managed in clinic. Generally, these patients should not be referred to the ED. They need oral medication started (or restarted) and close follow up.

  • Stopping previously prescribed medication is the most common reason for HTN urgency.

  • Due to autoregulation in patients with chronic HTN, the pace of BP lowering should be slow – 25% max in the first hour.

  • The type of IV medication for HTN emergency should be guided by the type of end organ damage. Here is a simplified way to think about this. For the brain, use nicardipine. For the heart or vessels, use nitroglycerin.

    • Nicardipine – Use for diffuse microvascular injury (malignant HTN), HTN encephalopthy, ICH, or ischemic stroke.

    • Nitroglycerin – Use for ACS, CHF, or aortic dissection (add esmolol for dissection).

    • Goal decrease for most patients is usually 20-25% in hour one; a SBP of 160 is not a bad general target over hours 2-6. Dissection should target 120.

Acute Severe Hypertension. N Engl J Med. 2019 Nov 7;381(19):1843-1852. doi: 10.1056/NEJMcp1901117.

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What are your thoughts?