What are Emergency Treatment of Hypertension?

Hypertension:

Introduction:

Blood pressure: Blood pressure is necessary to circulate blood, oxygen (O₂), and nutrients to body organs and remove carbon dioxide (CO₂) and waste products. Without blood pressure shock, circulatory collapse and death would result. The systolic blood pressure (SBP) measures the pressure when the heart’s ventricles are contracting (systole). Diastolic blood pressure (DBP) is a measure of the heart at rest (diastole).

Hypertension is defined as either a sustained systolic blood pressure of greater than 140 mm Hg or a sustained diastolic blood pressure of greater than 90 mm Hg. Hypertension results from increased peripheral vascular arteriolar smooth muscle tone, which leads to increased arteriolar resistance and reduced capacitance of the venous system.

BP classification	Systolic (mmHg)	Diastolic (mmHg)
Normal	<120	<80
Prehypertension	120-139	80-89
Hypertension stage 1	140-159	90-99
Hypertension stage 2	160 or higher	100 or higher
Hypertensive crisis	Higher than 180	Higher than 120

A hypertensive emergency is present when severe hypertension is associated with acute end-organ damage. Examples include hypertensive encephalopathy, acute pulmonary edema, aortic dissection, and rebound after abrupt withdrawal of antihypertensive medications. Organ damage associated with the hypertensive emergency may include:

Changes in mental status, such as confusion
Bleeding into the brain (stroke)
Heart failure
Chest pain (unstable angina)
Fluid in the lungs (pulmonary edema)
Heart attack
Aneurysm (aortic dissection)
Eclampsia (occurs during pregnancy)

Causes for hypertensive emergencies:

Vasculitis
Erythropoietin
Hyperaldosteronism
Pheochromocytoma
Renovascular hypertension
Acute glomerulonephritis
Non -adherence to antihypertensive medication
Too-rapid withdrawal from antihypertensive medications
Autonomic dysreflexia in the presence of spinal cord injury
Use of sympathomimetic drugs such as cocaine, amphetamines

Hypertension Risk Factors:

Age (men older than 55 years; women older than 65 years)
Diabetes mellitus
Family history of heart disease
Metabolic syndrome
Obesity
Tobacco usage
Decreased physical activity
Dyslipidemia
Diet high in salt and saturated fats
Excessive alcohol consumption
Cushing’s syndrome, sleep apnea

Symptoms of Hypertensive Emergency:

Symptoms of a hypertensive emergency include:

headache or blurred vision
Increasing confusion
Seizure
Increasing chest pain
Increasing shortness of breath
Swelling or edema (fluid buildup in the tissues

Diagnosing Hypertensive Emergency:

Specific tests will be performed to monitor blood pressure and assess organ damage, including:

Regular monitoring of blood pressure
Eye exam to look for swelling and bleeding
Blood and urine testing

Treatment:

In a hypertensive emergency, the first goal is to bring down the blood pressure as quickly as possible with intravenous (IV) blood pressure medications to prevent further organ damage.

Medications used in hypertensive emergencies are:

Drugs	Brand name	Route	Dose	Onset of action	Duration of action	Adverse effects
Vasodilators:
Hydralazine	Apresoline	IV, IM infusion	IV: 10–20 mg IM: 10–40 mg	IV: 10 min IM: 20 min	IV: 1–4 hrs IM: 2–6 hrs	loss of appetite (anorexia), Nausea, vomiting, diarrhea, fast heart rate, chest pain
Nitroglycerin	Nitromist, Rector	Sublingual, Transdermal, Intravenous	5–200 mcg/min	2–5 min	5–10 min	Headache, dizziness, weakness, fast heart rate, Nausea, vomiting, flushing
Sodium nitroprusside	Nitropress	IV infusion	0.25–10 mcg/kg/min	Few seconds	1–2 min	Severe hypotension, Flushing, Palpitations, Shortness of breath, Headache, Dizziness
Calcium Channel Blockers:
Clevidipine	Cleviprex	IV infusion	1–6 mg/hour	1–4 min	5–15 min	· Agitation, decreased urine output, hostility, lethargy, loss of consciousness, muscle twitching, seizures (convulsions)
Nicardipine	Cardene	IV infusion, Oral	5–15 mg/ hour	5–10 min	2–6 hours	Headache, upset stomach, dizziness, flushing, numbness, fast heartbeat, muscle cramps
β-Blockers:
Esmolol	Brevibloc	IV infusion	25–300 mcg/kg/min	1–2 min	10–20 min	slow heartbeats, swelling in your hands or feet, wheezing, chest tightness, swelling, bruising
Metoprolol	Lopressor, Toprol XL.	IV infusion	5–15 mg	5–20 min	2–6 hours	Dizziness, depression, Nausea, dry mouth, stomach pain, gas or bloating, heartburn,
Labetalol	Normodyne, Trandate	IV infusion	20 mg may repeat escalating doses of 20–80 mg	2–5 min, peak 5–15 min	2–6 hr Up to 18 hr	dizziness, tingling scalp or skin, lightheadedness, excessive tiredness, headache, stuffy nose
ACE Inhibitors:
Enalapril	Vasotec	IV infusion	1.25 mg	15–30 min	12–24 hour	hypotension, dizziness, fever, constipation, decreased sexual desire, sun sensitivity
α-Antagonist:	1.
Phentolamine	2. OraVerse, Regitine	IV infusion	1–5 mg	Seconds	15 min	orthostatic hypotension, cardiac arrhythmias, weakness, flushing

Conclusion:

The treating clinician needs to rapidly assess target-organ damage to differentiate hypertensive emergency from hypertensive urgency. In addition, the clinician must consider whether a patient qualifies as an exception to the general treatment principles of hypertensive crisis (compelling condition). Once the treatment goal is selected, medication is chosen based on treatment goals, presenting target-organ damage, pharmacokinetics and pharmacodynamics parameters of each medicine, Blood pressure variability (BPV) profiles, and clinical data. Each patient will qualify for continuous monitoring to assess for the achievement of target goals and avoidance of overaggressive, unintentional correction. Furthermore, close monitoring is required to evaluate for adverse effects from the medications selected.