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How should we treat very high blood pressure until we distinguish between hypertensive emergency and urgency?

Hypertension Research volume 43, pages 470–472 (2020)Cite this article

Very high blood pressure (BP) is a prevalent and important problem in the emergency department (ED) [1]. For decades, it has been classified into hypertension emergencies (HTN-Es) or urgencies (HTN-Us).

  1. 1.

    Hypertensive EMERGENCIES. The Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 7 defines an HTN-E as a severe increase in BP (>180/120 mmHg) with evidence of impending/progressive target organ dysfunction. The JNC 7 cites the following types of HTN-Es: hypertensive encephalopathy, acute myocardial infarction (AMI), unstable angina pectoris, acute left ventricular (LV) failure with pulmonary edema, intracerebral hemorrhage, dissecting aortic aneurysm (AoD), and eclampsia [2]. The European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines listed the following HTN-Es: HTN (≥180/≥110 mmHg) with evidence of acute hypertension-mediated organ damage (HMOD) (previously known as target organ damage, TOD), such as to the eye (funduscopic changes, e.g, hemorrhages and/or papilledema), acute deterioration in renal function (AKI), acute AoD, acute myocardial ischemia, acute heart failure, sudden severe hypertension (HTN) due to pheochromocytoma, ingestion of sympathomimetics, severe HTN in pregnancy with or without or preeclampsia, HTN encephalopathy, acute intracerebral hemorrhage in patients with SBP ≥ 220 mmHg, and acute ischemic stroke with BP > 180/105 mmHg if patients are eligible for intravenous (i.v.) thrombolysis [3]. Hypertension Canada’s 2018 guidelines cite similar entities as HTN-Es: very high BP in the presence of hypertensive encephalopathy, intracerebral hemorrhage, acute ischemic stroke, acute coronary syndrome (ACS), acute LV failure, AKI, acute AoD, pre-eclampsia/eclampsia, and catecholamine-associated HTN. It is not clear whether the authors classify asymptomatic diastolic BP ≥ 130 mmHg as HTN-U or HTN-E [4]. HTN-Es are indications for instant hospitalization in an intensive care unit (ICU) for i.v. administration of a short-acting antihypertensive, continuous BP monitoring and careful dose titration [2, 3].

  2. 2.

    Hypertensive URGENCIES. “HTN-U” is severe HTN (upper levels of stage II HTN, e.g., 179/109 mmHg) accompanied by severe headache, epistaxis, shortness of breath, or pronounced anxiety but without clinical evidence of acute HMOD [2, 3]. Recommended treatment is an oral short-acting antihypertensive, given on an outpatient basis, followed by an observational period of a few hours [2, 3]. The reasons to choose peroral and not parenteral antihypertensive drugs for HTN-Us are the insufficient predictability of the effect and the frequently excessive BP reduction that occurs with i.v. administration [3, 5].

Hypertensive EMERGENCIES. The Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 7 defines an HTN-E as a severe increase in BP (>180/120 mmHg) with evidence of impending/progressive target organ dysfunction. The JNC 7 cites the following types of HTN-Es: hypertensive encephalopathy, acute myocardial infarction (AMI), unstable angina pectoris, acute left ventricular (LV) failure with pulmonary edema, intracerebral hemorrhage, dissecting aortic aneurysm (AoD), and eclampsia [2]. The European Society of Cardiology (ESC) and European Society of Hypertension (ESH) guidelines listed the following HTN-Es: HTN (≥180/≥110 mmHg) with evidence of acute hypertension-mediated organ damage (HMOD) (previously known as target organ damage, TOD), such as to the eye (funduscopic changes, e.g, hemorrhages and/or papilledema), acute deterioration in renal function (AKI), acute AoD, acute myocardial ischemia, acute heart failure, sudden severe hypertension (HTN) due to pheochromocytoma, ingestion of sympathomimetics, severe HTN in pregnancy with or without or preeclampsia, HTN encephalopathy, acute intracerebral hemorrhage in patients with SBP ≥ 220 mmHg, and acute ischemic stroke with BP > 180/105 mmHg if patients are eligible for intravenous (i.v.) thrombolysis [3]. Hypertension Canada’s 2018 guidelines cite similar entities as HTN-Es: very high BP in the presence of hypertensive encephalopathy, intracerebral hemorrhage, acute ischemic stroke, acute coronary syndrome (ACS), acute LV failure, AKI, acute AoD, pre-eclampsia/eclampsia, and catecholamine-associated HTN. It is not clear whether the authors classify asymptomatic diastolic BP ≥ 130 mmHg as HTN-U or HTN-E [4]. HTN-Es are indications for instant hospitalization in an intensive care unit (ICU) for i.v. administration of a short-acting antihypertensive, continuous BP monitoring and careful dose titration [2, 3].

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References

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Acknowledgements

This work has been supported by the Serbian Ministry of Education and Science, Belgrade, Serbia, grants No.175092 and No. III41018.

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Authors and Affiliations

  1. Department for Cardiovascular Diseases, Clinical Center Nis, Nis, Serbia

    Goran Koracevic

  2. Faculty of Medicine, University of Nis, Nis, Serbia

    Goran Koracevic & Dragan Djordjevic

  3. Clinic for Internal Diseases Intermedica, Nis, Serbia

    Dragan Lovic

  4. University Hospital Medical Center Bezanijska Kosa, Belgrade, Serbia

    Marija Zdravkovic

  5. Institute for Treatment and Rehabilitation Niska Banja, Niska Banja, Serbia

    Milovan Stojanovic & Dragan Djordjevic

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Koracevic, G., Lovic, D., Zdravkovic, M. et al. How should we treat very high blood pressure until we distinguish between hypertensive emergency and urgency?. Hypertens Res 43, 470–472 (2020). https://doi.org/10.1038/s41440-019-0393-5

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