Acute Severe Hypertension in Out Patient Clinic

What is Hypertensive emergency?

• BP – 180/110 to 120 mm Hg
• Associated with acute Target Organ Damage (TOD)

What is Hypertensive Urgency?

• BP – 180/110 to 120 mm Hg
• Absence of acute TOD

How to identify Target Organ damage (TOD)?

• TOD associated with signs and symptoms and listed below

Brain	Stroke Intra cranial hemorrhage Encephalopathy
Heart	Acute Coronary Syndrome Acute Heart Failure
Eye	Hemorrhages Exudates Papilledema
Kidney	Acute Kidney Injury
Large vessels	Aortic Dissection
Small vessels	Micro Angiopathic Hemolytic Anemia

What is the difference between Hypertensive Emergency vs Urgency?

	Emergency	Urgency
Level of BP (mm Hg)	180/110 to 120	180/110 to 120
Target organ damage	Present	Absent
Setting	Acute rise of BP	Chronic BP elevation
Hospitalization	Needed – ICU	Not needed – OPD
Morbidity & Mortality	Increased	Not increased
Medicines	Intra venous	Oral

Causes of Acute Severe Hypertension in out patient setting

• Drug non-compliance
• Dietary sodium indiscretion
• Over-the-counter drugs, NSAIDs, Steroids
• Anxiety or panic
• Acute stroke/Heart failure
• Renal disease

Causes of Acute Severe Hypertension in-patient setting

• Withholding of antihypertensive medications
• Urinary retention
• Pain
• Intravenous fluids

When to suspect secondary hypertension?

Despite treatment of hypertension if BP remains high during follow up

What is the importance of cerebral blood flow auto regulation?

• Chronic uncontrolled hypertension patients have normal cerebral flow despite high BP levels. This prevents development of cerebral edema.
• If BP is controlled rapidly this leads to cerebral hypoperfusion and should not be done.

How to manage Hypertensive Urgency?

• Most managed as out patient
• Guideline directed management of hypertension
• Out patient visit within next 5 days
• Intra venous medicines for BP control are discouraged
• Symptoms related to hypertension like headache, atypical chest pain or epistaxis is present
• Choose rapid acting drugs such as clonidine, labetalol, captopril, prazosin etc.
• Avoid Nifedipine sub lingual because of unpredictable BP reductions causing cardio vascular event
• BP medicines to be administered every 30 minutes till BP controlled
• Patient to be sent home after BP stabilizes below 160-180/100-110

How to manage Hypertensive Emergency?

• To be admitted into intensive care unit.
• Intra venous medicines needed
• Choice of the agent depends on TOD