What is Hypertensive Emergency?
A hypertensive emergency refers to a sudden, significant increase in blood pressure that’s accompanied by signs of damage to organs targeted by this condition. These signs might show themselves as lung congestion, heart-related chest pain, problems with brain function, sudden kidney failure, tearing in the main artery from the heart, or seizures in pregnancy.
If the patient’s organ function sharply deteriorates, it’s crucial to quickly lower their blood pressure. However, in other situations, the approach should be to gradually reduce the blood pressure. This is to avoid causing problems in the brain due to a sudden drop in blood supply.
What Causes Hypertensive Emergency?
Various triggers can lead to extremely high blood pressure, often known as hypertensive emergencies. Most of the time, these emergencies happen in people who already have long-term high blood pressure. Two common causes of hypertensive emergencies are not taking prescribed high blood pressure medications consistently and using certain types of drugs that stimulate the body’s responses. These can cause a quick increase in blood pressure, exceeding the body’s natural ability to control it.
The specific blood pressure levels that are considered to be a hypertensive emergency can vary. They’re often stated as definite figures, but there isn’t universal agreement on what these levels should be, which makes them somewhat arbitrary. Instead of exact numbers, a more important indicator of a hypertensive emergency might be how quickly blood pressure rises above its normal range. This is why people without long-standing high blood pressure could show signs of a hypertensive emergency at much lower levels, while those with long-term high blood pressure could have extremely high levels but not experience immediate problems with their organs.
Risk Factors and Frequency for Hypertensive Emergency
About 30% of adults in America are estimated to have high blood pressure, also known as hypertension. Of these, 1% to 2% might experience a hypertensive crisis. This term includes both serious conditions known as hypertensive emergencies and hypertensive urgencies. The most common severe problems linked with a hypertensive crisis include acute lung fluid buildup (pulmonary edema), heart muscle damage due to lack of oxygen (cardiac ischemia), and emergencies related to the nervous system.
In the North American context, the availability of medication for hypertension has helped in reducing the number of hypertensive emergencies and has improved survival rates. However, if a hypertensive emergency is left untreated, it can be deadly.
- About 30% of adults in America have hypertension.
- Of these, 1% to 2% might experience a hypertensive crisis.
- This crisis can cause serious conditions like acute pulmonary edema, cardiac ischemia, and neurologic emergencies.
- Improvement in circumstances is seen in North America owing to available antihypertensive medications.
- They’ve helped reduce hypertensive emergencies and improve survival rates.
- But, if hypertensive emergencies aren’t treated, it might be fatal.
Signs and Symptoms of Hypertensive Emergency
For patients showing significantly high blood pressure, careful examination and history taking is important to figure out if it’s a real emergency situation. Symptoms to look out for include headache, dizziness, confusion or altered mental state, shortness of breath, chest pain, less urine production, vomiting, or vision changes. A sudden increase in blood pressure has to be probed to guide treatment strategies.
The physical exam findings will likely vary, as they depend on which organ is most affected. For instance, in case the heart is under stress, doctors may hear abnormal lung sounds, observe neck vein swelling or fluid accumulation in the limbs, or detect extra heart sounds. In cases where very rapid increase in blood pressure happens, as can be seen with misuse of certain substances, severe shortness of breath may be experienced even without any limb swelling due to rapid filling of lungs with fluid.
Brain function issues can lead to symptoms like confusion, blurred vision, lack of motor coordination or other cerebellar issues, difficulty with speech, or one-sided numbness or weakness. A thorough neurological examination, including a cranial nerve exam, strength and sensation tests, and tests for motor coordination and walking should be performed. An eye examination may reveal swelling of the eye nerve or hemorrhages shaped like flames or leakages.
Acute kidney failure could also show signs of fluid accumulation either in the lungs or in the body’s extremities.
Testing for Hypertensive Emergency
When dealing with potential high blood pressure emergencies, it’s important to consider the symptoms and signs that a patient presents with. If doctors suspect a serious high blood pressure emergency, they may order several lab tests. These can include metabolic panels (a range of blood tests), a urinalysis (a urine test), B-natriuretic peptide (a heart failure marker), and cardiac enzymes (proteins that can indicate heart issues).
An ECG – a test that checks your heart’s electrical activity – might be performed if there’s a suspicion of heart muscle damage due to insufficient blood supply. Depending on the symptoms, a head CT scan, which is a special type of X-ray that takes detailed pictures of your brain, might be suggested if the patient shows acute signs of neurological problems, like sudden severe headaches, confusion, or blurred vision.
If a patient is experiencing shortness of breath, a chest x-ray could be helpful. It can also indicate a widening of the mediastinum (the area between your lungs), which could suggest a potential aortic dissection – a serious condition where the large blood vessel branching off the heart tears. However, chest x-rays are not very sensitive for spotting this condition, so a CT angiography (a test that uses x-rays and dye to see how blood flows through your arteries) of the chest and abdomen may be necessary to either rule out or confirm an aortic dissection, as well as identify the extent of the tear in the artery.
Treatment Options for Hypertensive Emergency
In situations where there is a harmful and rapid rise in blood pressure, or a hypertensive emergency, rapid reduction of blood pressure is the key treatment strategy. The aim is to reduce blood pressure by about 20-25% in the first hour or two. Treatments that can quickly and easily adjust the blood pressure are preferable. Oral medications like clonidine and nifedipine aren’t used in emergency scenarios. Instead, intravenous treatments such as labetalol, esmolol, nicardipine, and nitroglycerin are usually effective.
The approach to treating high blood pressure differs depending on whether the patient has organ damage. If no organ damage is detected, blood pressure should be reduced gradually over several days. However, in the case of severe high blood pressure during pregnancy, immediate treatment is necessary. Pregnant women should be treated with nifedipine, methyldopa, or labetalol, but shouldn’t take ACE inhibitors or ARBs. Intravenous hydralazine or oral nifedipine can be used to lower blood pressure quickly during a crisis.
Sticking to current guidelines is important in these cases. First, anyone with a hypertensive emergency must be admitted to the hospital for continuous blood pressure monitoring. Next, they should be assessed for organ injury and started on the appropriate intravenous medications if needed. If the emergency is a life-threatening condition like an aortic dissection, blood pressure should be brought down to below 140 mmHg within the first hour. In adults without organ damage, the aim is to lower blood pressure by 25% within the first hour, then to 160/100 over the next several hours, and finally to bring it down gradually to normal levels over a span of two days.
What else can Hypertensive Emergency be?
When trying to understand a person’s health related issues, doctors must check for multiple conditions because various diseases can show similar symptoms. Depending on the situation, some of these conditions could be:
- Acute kidney injury (a sudden episode of kidney failure or damage)
- Aortic coarctation (a narrowing of the large blood vessel that supplies blood to the body)
- Aortic dissection (a serious condition in which the inner layer of the aorta tears)
- Chronic kidney disease (a long-term condition where the kidneys don’t work as well as they should)
- Eclampsia (a severe complication of pregnancy, causing seizures)
- Hypocalcemia (abnormally low levels of calcium in your blood)
- Hyperthyroidism (an overactive thyroid gland)
- Pheochromocytoma (a rare tumor of the adrenal glands)
- Renal artery stenosis (narrowing of the arteries that carry blood to the kidneys)
- Subarachnoid hemorrhage (a life-threatening type of stroke caused by bleeding into the space surrounding the brain)
By analyzing a patient’s symptoms and conducting appropriate medical tests, a doctor can more accurately identify the disease causing these symptoms.
What to expect with Hypertensive Emergency
In the past, medical emergencies related to high blood pressure were often linked with kidney problems, heart attacks, strokes, or even death. Fortunately, increased awareness and improved control of blood pressure have significantly reduced the mortality rate over the past 30 years. However, after the initial treatment, it’s crucial to maintain good blood pressure control to further reduce the risks.
Despite these improvements, the long-term outlook for patients with hypertension emergencies remains uncertain. A considerable number of these patients may experience heart-related complications or a stroke within a year.
Possible Complications When Diagnosed with Hypertensive Emergency
If a hypertensive emergency – a severe increase in blood pressure that can lead to a stroke – is not diagnosed or treated promptly, it can result in:
- Kidney failure
- Loss of vision
- Heart attack (medically referred to as MI)
- Stroke
Recovery from Hypertensive Emergency
It is suggested that a patient should be on bed rest until their blood pressure levels are under control. Also, it is typically advised to follow a low-salt diet and to work towards losing weight.
Preventing Hypertensive Emergency
The most effective way to avoid a serious high blood pressure emergency is to consistently take prescribed blood pressure-lowering medications. Regular high blood pressure cases can be overseen by your main health care provider. However, if a patient is taking more than three blood pressure medications and their blood pressure is still high, it’s recommended to get advice from a heart specialist, or cardiologist.
