Cardiac Complications of Hypertensive Emergency: Classification, Diagnosis and Management Challenges

Abstract

While mortality in patients with hypertensive emergency has significantly improved over the past decades, the incidence and complications associated with acute hypertension-mediated organ damage have not followed a similar trend. Hypertensive emergency is characterized by an abrupt surge in blood pressure, mostly occurring in people with pre-existing hypertension to result in acute hypertension-mediated organ damage. Acute hypertension-mediated organ damage commonly affects the cardiovascular system, and present as acute heart failure, myocardial infarction, and less commonly, acute aortic syndrome. Elevated cardiac troponin with or without myocardial infarction is one of the major determinants of outcome in hypertensive emergency. Despite being an established entity distinct from myocardial infarction, myocardial injury has not been systematically studied in hypertensive emergency. The current guidelines on the evaluation and management of hypertensive emergencies limit the cardiac troponin assay to patients presenting with features of myocardial ischemia and acute coronary syndrome, resulting in underdiagnosis, especially of atypical myocardial infarction. In this narrative review, we aimed to give an overview of the epidemiology and pathophysiology of hypertensive emergencies, highlight challenges in the evaluation, classification, and treatment of hypertensive emergency, and propose an algorithm for the evaluation and classification of cardiac acute hypertension-mediated organ damage.

Keywords: cardiac acute hypertension-mediated organ damage; classifications; diagnosis; epidemiology; hypertensive emergency; myocardial injury; pathophysiology.

Figure 1

Summary of the pathophysiologic processes in acute hypertension-mediated organ injury. ACS; acute coronary syndrome; AKI, acute kidney injury; aHMOD, acute hypertension-mediated organ damage; BP, blood pressure; HELLP, hemolysis, elevated liver enzymes, low platelets; NSAID, nonsteroidal anti-inflammatory drug; PRES, posterior reversible encephalopathy syndrome; RAAS, renin–angiotensin–aldosterone system; TMA, thrombotic microangiopathy; VSMC, vascular smooth muscle cell; * Not listed as acute hypertensive target organ damage in guidelines; † presence of retinal exudates, hemorrhage ± papilledema.

Figure 2

Algorithm for evaluation and classification of hypertensive emergencies. ^† Not listed as target organ damage in guidelines. ACS, acute coronary syndrome; AKI, acute kidney injury; aHMOD, acute hypertension-mediated organ damage; HELLP, hemolysis elevated liver enzymes or low platelets; PRES, posterior reversible encephalopathy syndrome; TMA, thrombotic microangiopathy. * Others—hemoglobin, platelet, lactic dehydrogenase, haptoglobin, creatinine, sodium, potassium, quantitative urinalysis for protein, urine sediments, ECG, chest X-ray, fundoscopy. Modified from van den Born et al. [5].