What is Hypertensive Urgency?
Hypertensive urgency refers to a significant increase in blood pressure without damage to target organs – such as the lungs, heart, brain, or kidneys. Specific numbers have been suggested to identify this condition, including upper blood pressure above 180 or lower blood pressure above 110. But these are just suggested numbers and haven’t been directly connected with immediate risks of disease or death. As such, some have suggested using the term ‘hypertensive urgency’ only for patients with very high blood pressure and notable risk factors for worsening organ damage like heart failure or chronic kidney disease.
Yet, it’s important to note hypertensive urgencies are linked with a higher chance of bad heart-related events in the long run. Therefore, they need a careful approach, one that is centered on improving blood pressure control, reducing factors that excessively heighten blood pressure, and ensuring regular check-ins with primary care providers.
What Causes Hypertensive Urgency?
There are many different reasons why blood pressure might become, all of a sudden, very high. Not taking blood pressure medications as prescribed, using certain drugs known as sympathomimetics—drugs that mimic the actions of the fight-or-flight hormone adrenaline—and problems with the thyroid gland, are just some of the possible causes of dangerously high blood pressure, known as hypertensive urgencies. Even things like anxiety and pain can trigger acute spikes in blood pressure, necessitating a distinctive treatment approach.
Additionally, elevated blood pressure could be a result of inaccurate measurements due to poor equipment or the wrong method while taking these measurements. Therefore, it’s important to assess and make adjustments if the equipment or technique employed is creating incorrect blood pressure readings.
On a similar note, an inaccurate high blood pressure reading could be due to a condition known as pseudohypertension. This occurs when arteries become hard or clogged with calcium and don’t easily compress when taking blood pressure with an inflating cuff. This could be a potential cause of high blood pressure readings and should be considered in patients who are experiencing high blood pressure despite intense treatment efforts, but do not show signs of damage to their body due to the high blood pressure.
Risk Factors and Frequency for Hypertensive Urgency
About 30% of American adults, which equates to approximately 1.3 billion people worldwide, have high blood pressure. Among those with high blood pressure, between 1% and 2% will experience a severe increase in their blood pressure levels, also known as a hypertensive crisis, during their lifetime. The lack of studies on these severe blood pressure spikes is likely due to the difficulty in determining whether a patient’s symptoms are related to their blood pressure or another cause.
The risks for a sudden increase in blood pressure include weight problems, being female, having heart disease, diabetes, smoking, and, importantly, not taking blood pressure medications as prescribed. Males, older individuals, and people of Afro-Caribbean origin are more likely to suffer a hypertensive crisis.
- About 30% of American adults have high blood pressure, or hypertension.
- This condition affects over 1.3 billion individuals worldwide.
- Between 1% and 2% of people with hypertension will experience a hypertensive crisis in their lives.
- Few studies exist on sudden severe increases in blood pressure due to the difficulty in identifying the causes.
- Risk factors for sudden blood pressure spikes include obesity, being female, having a history of heart disease, diabetes, smoking, and not taking prescribed blood pressure medications.
- Males, older people, and people of Afro-Caribbean origin are more susceptible to a hypertensive crisis.
Signs and Symptoms of Hypertensive Urgency
When examining a patient with extremely high blood pressure, it’s crucial to look out for signs that could show the patient is at risk of damage to crucial body parts. Doctors should look out for symptoms such as headaches, dizziness, difficulty breathing, chest discomfort, vomiting, or changes in vision.
The check-up initiates with an accurate blood pressure reading, using a correctly fitted cuff, placed on the patient’s exposed upper arm. If an appropriate cuff isn’t available, a wrist measurement can be done, however, it should be cautiously interpreted because it doesn’t have as much supporting data compared to other methods. It’s important to assess blood pressure in both a standing and lying position (to check for low blood volume). Also, the blood pressure should be measured in both arms, since a noticeable difference could suggest a severe condition known as aortic dissection.
Various other signs should also be inspected thoroughly. Signs of heart failure, such as increased pressure in the veins of the neck, abnormal lung sounds, or abnormal heart sounds, could hint that the patient may be facing a severe high blood pressure emergency. It’s also key to perform a detailed neurological exam, including tests of the parts of the brain involved in coordination, to rule out any brain damage. Furthermore, examining the back of the eye (fundoscopy) and identifying swelling of the optic disc (papilledema) could signify a critical condition that requires more aggressive treatment.
The patient’s medical and medication history plays a pivotal role in understanding and managing the high blood pressure crisis. This includes the severity and duration of the patient’s preexisting hypertension, their adherence to blood pressure-lowering medication, the use of over-the-counter medicines such as decongestants, and any history of illegal drug usage, like cocaine. It’s also important to ask about any history of dysfunction in critical organs, particularly the kidneys and brain. In women, knowing the date of their last menstrual period is crucial, as high blood pressure affects 10% of pregnancies.
Testing for Hypertensive Urgency
When a patient experiences hypertensive urgencies (a sudden increase in blood pressure), there isn’t a standard routine to evaluate this. The aim is to check if the surge in blood pressure has caused any harm to important organs like the heart or kidneys.
If your doctor suspects that damage may have occurred, they may recommend some lab tests or imaging. These can include tests to check your metabolic function, a urine test, an electrocardiogram (ECG) to check your heart, a chest X-ray, or a brain CT scan.
Your doctor will also likely test your electrolyte levels, blood urea nitrogen, and creatinine levels to check how well your kidneys are functioning. They may use a test called a ‘dipstick urinalysis’ to check if there is blood or excess protein in your urine. Furthermore, they may inspect your urine under a microscope to search for red blood cells.
A complete blood count and an analysis of a smear of your blood may also be performed to rule out a condition called microangiopathic anemia which can occur due to high blood pressure. Depending on your situation, you might also require a pregnancy test, tests to check for drugs, and tests to check your hormone levels.
Imaging tests like X-rays or scans are only ordered if the clinical signs indicate they are necessary. For instance, a chest X-ray or ECG might be ordered if you have symptoms like chest pain or shortness of breath that suggest you might have fluid in your lungs. If you have neurological symptoms like confusion or severe headache, you may need a brain CT scan.
Extra care is needed for patients who are at high risk of rapidly developing damage to vital organs, such as those with chronic heart failure, kidney disease, coronary artery disease, or a history of stroke. In these patients, doctors will have a lower threshold to order lab tests, ECGs, or imaging studies, even if the signs are not very clear.
Pregnant patients with high blood pressure need special attention. This is because they can develop a condition known as preeclampsia, even if the blood pressure increases are not as high as in hypertensive emergencies. Especially, if a pregnant woman has no history of high blood pressure but begins to complain of symptoms like headaches, vision changes, or abdominal pain, your doctor will likely want to perform lab tests. The tests may include a complete blood count, liver function tests, and an enzyme test called lactic dehydrogenase.
Treatment Options for Hypertensive Urgency
While visiting an emergency department, between 3% to 45% of adults may experience at least one instance of high blood pressure. However, only a small fraction of these patients will need emergency treatment. It’s important to remember the fundamental principle when providing emergency care for patients with high blood pressure: you must treat the whole patient, not just their blood pressure numbers.
The foremost objective for healthcare providers in the emergency department is to determine which patients with briefly elevated blood pressure show signs of health complications – these complications are also known as “end-organ damage” that might need immediate treatment. People who come to the hospital with severely heightened blood pressure but no symptoms of complications should start blood pressure-lowering treatments. They should also follow up with their primary healthcare provider regularly over time, to gradually reduce their blood pressure.
The goal in handling cases of extremely high blood pressure, or hypertensive urgency, is to make sure that the patient’s blood pressure remains within safe levels over the long term. Encouraging these patients to regularly take their medications and have frequent check-ins with their primary care doctor is crucial. Rapidly lowering blood pressure in patients who show no symptoms or signs of health complications has not proven beneficial and can potentially lead to health risks, particularly in patients who have chronically high blood pressure. However, starting these patients on oral medications to slowly lower blood pressure over 24 to 48 hours can be beneficial. What’s most important is that they have a follow-up appointment with their doctor within a week to ensure blood pressure control and adjust medications as needed.
Severe increases in blood pressure in pregnant women should be immediately managed to prevent health complications. Women with high blood pressure who are pregnant, or plan to become pregnant, should transition to certain specific treatments such as nifedipine, methyldopa, and labetalol during their pregnancy.
When using medicine to lower blood pressure, the best approach will depend on which organ might be at risk. In emergencies, certain drugs can effectively lower blood pressure quickly. Sodium nitroprusside is one such medication often prescribed in these situations, and it acts quickly. However, patients receiving it should be closely monitored. Labetalol is another drug that can be highly beneficial in managing high blood pressure emergencies, particularly in cases of acute dissection or end-stage kidney disease. Similar to sodium nitroprusside, patients taking labetalol need to be carefully monitored to make sure blood pressure is being adequately controlled.
There are other medications, such as fenoldopam and clevidipine, used in situations with high blood pressure in emergencies. The medication dosage will be adjusted depending on the patient’s response to the initial dose.
What else can Hypertensive Urgency be?
When a physician is trying to diagnose hypertensive urgency, a condition where blood pressure becomes very high and needs to be lowered quickly, several other conditions need to be considered because they may present similar symptoms. These include:
- Anxiety disorders
- Apnea (difficulty breathing)
- Cocaine-related heart muscle damage
- Heart failure
- Overactive thyroid (Hyperthyroidism)
- Thickening of heart muscle (Hypertrophic cardiomyopathy)
- Heart attack (Myocardial infarction)
- Overproduction of the hormone aldosterone by the adrenal glands (Primary aldosteronism)
- Bleeding in the brain (Hemorrhagic stroke)
- Reduced blood supply to the brain (Ischemic stroke)
What to expect with Hypertensive Urgency
People with a condition known as hypertensive urgency are more likely to experience health problems and a higher risk of death in the long run. Research shows that about 9% of these individuals might not survive past a year. Hypertension, if not managed well, can drastically increase the risk of dying and is often referred to as a silent killer, due to its stealthy progression.
The long-term outlook for people with hypertensive urgencies or emergencies isn’t very promising. A study that looked at 670 adults with extremely high blood pressure found that 57.5% had hypertensive emergencies. Among these, 98% had to be admitted to the hospital, while 23.2% of those with hypertensive urgency were hospitalized as well.
Of those admitted, the median survival time was quite low. Patients with hypertensive emergencies related to the brain and nervous system (neurovascular emergencies) survived around 14 days, while those with heart-related emergencies (cardiovascular emergencies) survived around 50 days.
Possible Complications When Diagnosed with Hypertensive Urgency
People with a severe, quick increase in blood pressure, known as hypertensive urgency, need proper treatment. If they don’t get it, their condition may worsen into a hypertensive emergency, which can cause severe damage to important organs in the body. This important prompt treatment will help avoid serious long-term health issues related to high blood pressure that aren’t well managed. These issues can include:
- Heart attack
- Stroke
- Heart failure
- Kidney failure
- Eye damage due to high blood pressure (hypertensive retinopathy)
- Dementia
- Abnormal bulge in an artery (aneurysms)
Preventing Hypertensive Urgency
Patients experiencing a sudden spike in their blood pressure (a condition known as hypertensive urgency) are often recommended to adopt certain lifestyle adjustments:
- Lower the use of salt (sodium) in their diet
- Avoid the consumption of alcohol
- Eat foods that are high in fiber, like vegetables and fruits
- Maintain regular physical activity or exercise
- Stay away from drinks that contain caffeine
- Stop smoking
- If overweight, work on reducing weight
These changes help to stabilize blood pressure levels, protecting the heart and other organs from further damage.
