What symptoms require immediate ED evaluation in a patient with uncontrolled hypertension?

Symptoms Requiring Immediate ED Evaluation in Uncontrolled Hypertension

Patients with uncontrolled hypertension should seek immediate emergency department evaluation if they experience symptoms indicating target organ damage such as severe headache, visual disturbances, chest pain, shortness of breath, or neurological deficits. 1

Definition of Hypertensive Emergency

A hypertensive emergency is characterized by:

• Severely elevated blood pressure (typically >180/120 mmHg) WITH evidence of acute target organ damage 1
• The rate of BP increase is often more important than the absolute value 1
• Distinguished from hypertensive urgency, which involves severely elevated BP without acute organ damage 1

Symptoms Requiring Immediate ED Evaluation

Neurological Symptoms

• Altered mental status, confusion, or lethargy 1
• Seizures 1
• Cortical blindness 1
• Focal neurological deficits (may indicate stroke) 1
• Severe headache (especially if sudden onset or different from previous headaches) 1, 2
• Dizziness with other concerning symptoms 1

Cardiovascular Symptoms

• Chest pain (may indicate acute coronary syndrome) 1, 2
• Shortness of breath or dyspnea (may indicate acute pulmonary edema) 1, 2
• Palpitations with other concerning symptoms 3

Visual Symptoms

• Blurred vision 1
• Visual disturbances or changes 1
• Double vision 1

Other Warning Signs

• Epistaxis (nosebleed) that is severe or difficult to control 2
• Nausea and vomiting (especially when accompanied by headache) 1, 3
• Significant anxiety or agitation with elevated BP 3, 2

Specific Hypertensive Emergency Presentations

Hypertensive Encephalopathy

• Characterized by severe hypertension with headache, confusion, seizures, visual disturbances 1
• May progress to coma if untreated 1
• Occurs in 10-15% of patients with malignant hypertension 1

Cardiovascular Emergencies

• Acute left ventricular failure with pulmonary edema 1
• Acute coronary syndrome/unstable angina 1
• Aortic dissection (characterized by tearing chest pain radiating to back) 1

Cerebrovascular Emergencies

• Intracerebral hemorrhage 1
• Ischemic stroke 1

Other Emergencies

• Acute kidney injury with oliguria 1
• Malignant hypertension with retinopathy (hemorrhages, exudates, papilledema) 1
• Thrombotic microangiopathy (hemolysis, thrombocytopenia) 1

Important Considerations

• The absence of symptoms does NOT rule out target organ damage 1
• Asymptomatic severe hypertension without evidence of acute target organ damage can typically be managed as an outpatient with oral medications 1
• Secondary causes can be found in 20-40% of patients presenting with malignant hypertension 1

Clinical Pitfalls to Avoid

• Do not rapidly lower blood pressure in asymptomatic patients as this may be harmful 1
• Do not use short-acting nifedipine for initial treatment of hypertensive emergencies as it can cause excessive BP reduction 1, 3
• Do not delay treatment in true hypertensive emergencies as this increases morbidity and mortality 4, 2
• Do not assume all severely elevated BP readings represent a hypertensive emergency - confirm with evidence of acute target organ damage 1

Remember that hypertensive emergencies require immediate hospitalization and parenteral therapy, while hypertensive urgencies can typically be managed with oral medications and close follow-up 3, 2.