What are the clinical signs of a hypertensive (high blood pressure) emergency?

From the Guidelines

Hypertensive emergency is characterized by severely elevated blood pressure (typically >180/120 mmHg) with evidence of acute target organ damage, and immediate blood pressure reduction is necessary to prevent or limit further target organ damage 1. The clinical signs of a hypertensive emergency include:

• Severe headache, blurred vision or other visual disturbances, confusion or altered mental status, chest pain, shortness of breath, and seizures
• Papilledema, retinal hemorrhages, or exudates on fundoscopic examination
• Neurological manifestations such as focal deficits, encephalopathy, or coma
• Cardiovascular signs including acute heart failure with pulmonary edema, acute coronary syndrome, or aortic dissection (presenting with tearing chest or back pain)
• Renal involvement manifesting as acute kidney injury with oliguria or anuria
• Microangiopathic hemolytic anemia with schistocytes on blood smear may be present in malignant hypertension These signs are associated with a high 1-year death rate (>79%) and median survival of 10.4 months if left untreated 1. The management of hypertensive emergencies requires immediate reduction of blood pressure using IV medications like labetalol, nicardipine, clevidipine, or nitroprusside in an intensive care setting, with the goal of reducing blood pressure by 20-25% in the first hour 1. It is essential to identify and address the underlying cause of the hypertensive emergency while monitoring for complications. Hypertensive emergency differs from hypertensive urgency, which has severely elevated blood pressure without acute end-organ damage and can be managed less aggressively 1.

From the FDA Drug Label

Rapid Decreases of Blood Pressure Caution must be observed when reducing severely elevated blood pressure A number of adverse reactions, including cerebral infarction, optic nerve infarction, angina, and ischemic changes in the electrocardiogram, have been reported with other agents when severely elevated blood pressure was reduced over time courses of several hours to as long as 1 or 2 days The desired blood pressure lowering should therefore be achieved over as long a period of time as is compatible with the patient's status.

The clinical signs of a hypertensive emergency are not explicitly stated in the provided drug label. However, it can be inferred that a hypertensive emergency may be characterized by:

• Severely elevated blood pressure that requires immediate attention
• Cerebral infarction
• Optic nerve infarction
• Angina
• Ischemic changes in the electrocardiogram It is essential to note that these signs are associated with the risks of rapid blood pressure reduction rather than being direct indicators of a hypertensive emergency. 2

From the Research

Clinical Signs of Hypertensive Emergency

The clinical signs of a hypertensive emergency include:

• Elevated blood pressure (higher than 180 mm Hg systolic or higher than 120 mm Hg diastolic) 3, 4, 5
• Acute organ damage, such as:
  • Neurological damage (e.g. stroke) 6, 7, 5
  • Cardiac damage (e.g. myocardial infarction, heart failure) 4, 6, 5
  • Renal damage 6, 7
  • Obstetric complications (e.g. preeclampsia, eclampsia) 4
• Presence of acute target organ disease, such as acute left ventricular dysfunction or acute intracranial events 7

Management of Hypertensive Emergency

Management of hypertensive emergency involves:

• Immediate lowering of blood pressure (about 10-25% within the first hour) in an intensive care setting 6, 5
• Use of parenteral antihypertensive therapy, such as nitroprusside, fenoldopam, or nicardipine 4, 6
• Close monitoring of blood pressure and organ function 3, 4, 6
• Consideration of secondary causes of hypertension after transfer from the intensive care unit 6