The diagnosis and treatment of hypertensive crises

Abstract

Hypertension (HTN) is one of the most common chronic medical conditions, affecting nearly 72 million people in the United States. A systolic blood pressure (BP) > 180 mm Hg or a diastolic BP > 120 mm Hg is considered a "hypertensive crisis." Hypertensive crises are categorized as either hypertensive emergencies or urgencies depending on the degree of BP elevation and presence of end-organ damage. The primary goal of intervention in a hypertensive crisis is to safely reduce BP. Immediate reduction in BP is required only in patients with acute end-organ damage (ie, hypertensive emergency). This requires treatment with a titratable shortacting intravenous (IV) antihypertensive agent, while severe HTN with no acute end-organ damage (ie, hypertensive urgency) is usually treated with oral antihypertensive agents. Patients with hypertensive emergencies are best treated in an intensive care unit (ICU) with titratable IV hypotensive agents. Rapid-acting IV antihypertensive agents are available, including clevidipine, labetalol, esmolol, fenoldopam, nicardipine, and sodium nitroprusside. Newer agents such as clevidipine have considerable advantages compared with other available agents in the management of hypertensive crises. Sodium nitroprusside is an extremely toxic drug, and its use in the treatment of hypertensive emergencies should be avoided. Likewise, nifedipine, nitroglycerin, and hydralazine should not to be considered first-line therapies in the management of hypertensive crises because these agents are associated with significant toxicities and/or side effects.