The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All?

Abstract

Hypertensive emergencies (HE) represent high cardiovascular risk situations defined by a severe increase in blood pressure (BP) associated with acute, hypertension mediated organ damage (A-HMOD) to the heart, brain, retina, kidneys, and large arteries. Blood pressure values alone do not accurately predict the presence of HE; therefore, the search for A-HMOD should be the first step in the management of acute severe hypertension. A rapid therapeutic intervention is mandatory in order to limit and promote regression of end-organ damage, minimize the risk of complications, and improve patient outcomes. Drug therapy for HE, target BP, and the speed of BP decrease are all dictated by the type of A-HMOD, specific drug pharmacokinetics, adverse drug effects, and comorbidities. Therefore, a tailored approach is warranted. However, there is currently a lack of solid evidence for the appropriate treatment strategies for most HE. This article reviews current pharmacological strategies while providing a stepwise, evidence based approach for the management of HE.

Keywords: hypertension; hypertensive crisis; hypertensive emergency; hypertensive urgency; target organ damage; therapeutic approach.

Figure 2

Treatment of hypertensive emergencies according to the main acute hypertension mediated organ damage (A-HMOD). ACS—Acute coronary syndrome; ACPE—Acute cardiogenic pulmonary oedema; AAS—Acute aortic syndrome; M-HTA—Malignant hypertension; TMA—Thrombotic microangiopathy; BP—Blood pressure; SBP—Systolic blood pressure; DBP—Dyastolic blood pressure; HR—Heart rhythm; MAP—Mean arterial pressure.

Figure 1

Diagnostic algorithm of possible hypertensive emergencies. BP—blood pressure; ECG—electrocardiography; ACS—Acute coronary syndrome; ACPE—Acute cardiogenic pulmonary oedema; AAS—Acute aortic syndrome; M-HTA—Malignant hypertension; CK—Creatine kinase; CK-MB—Creatine kinase-MB; CT—Computer tomography; MRI—Magnetic resonance imaging. According to Table 1 and Figure 2.