What symptoms are concerning for hypertensive urgency?

Symptoms Concerning for Hypertensive Urgency

Severe headache, visual disturbances, chest pain, dyspnea, neurologic symptoms, dizziness, epistaxis, and severe anxiety are the key symptoms concerning for hypertensive urgency when accompanied by severely elevated blood pressure (typically >180/120 mmHg) without evidence of acute target organ damage. 1

Differentiating Hypertensive Urgency from Emergency

Hypertensive Urgency

• Severely elevated BP (typically >180/120 mmHg)
• No evidence of acute target organ damage
• Common symptoms include:
  • Severe headache
  • Visual disturbances (without retinal hemorrhages/papilledema)
  • Shortness of breath (without pulmonary edema)
  • Epistaxis (nosebleed)
  • Severe anxiety
  • Dizziness
  • Palpitations
  • General malaise and feeling of illness 2

Hypertensive Emergency

• Severely elevated BP with evidence of acute target organ damage
• Requires immediate BP reduction to prevent progressive organ failure 1, 3
• Specific presentations indicating emergency rather than urgency:

Neurological Signs

• Altered mental status
• Lethargy
• Seizures
• Cortical blindness
• Coma 1, 3

Ocular Signs

• Advanced bilateral retinopathy
• Retinal hemorrhages
• Cotton wool spots
• Papilledema 1

Cardiovascular Signs

• Acute left ventricular failure
• Pulmonary edema
• Acute coronary syndrome
• Unstable angina 1

Vascular Signs

• Aortic dissection
• Signs of thrombotic microangiopathy 1

Renal Signs

• Acute renal failure 2

Clinical Approach to Suspected Hypertensive Urgency

1. Measure BP accurately - Confirm elevated readings (typically >180/120 mmHg)

2. Assess for symptoms - Look specifically for:

   • Headache (often severe)
   • Visual changes (without retinopathy)
   • Chest discomfort (without acute coronary syndrome)
   • Shortness of breath (without pulmonary edema)
   • Anxiety
   • Epistaxis

3. Rule out target organ damage - Critical step to differentiate urgency from emergency:

   • Perform fundoscopic examination (look for hemorrhages, exudates, papilledema)
   • Assess neurological status (mental status, focal deficits)
   • Check for signs of heart failure (pulmonary edema)
   • Evaluate for signs of aortic dissection

Important Considerations

• The severity of hypertensive urgency is determined not only by the absolute BP level but by the magnitude and rapidity of the BP increase 2
• Patients with previously normal baseline BP may develop symptoms at lower thresholds (such as in eclampsia) 2
• Common causes include medication non-compliance, inadequate therapy, endocrine disorders, renal disease, and substance use 2
• Approximately 25% of patients in busy urban emergency departments present with severe hypertension 1

Common Pitfalls to Avoid

• Mistaking urgency for emergency: Failing to thoroughly assess for target organ damage can lead to inappropriate management
• Reducing BP too rapidly: Even in urgency, BP should be reduced gradually over 24-48 hours, not minutes to hours 2, 4
• Using inappropriate medications: Short-acting nifedipine is no longer considered acceptable for initial treatment 1
• Inadequate follow-up: Patients treated for hypertensive urgency require close monitoring and follow-up care 4

Remember that the key distinction between hypertensive urgency and emergency is not the absolute BP level but the presence or absence of acute target organ damage, which determines the treatment approach and setting.