What are the criteria for a hypertensive crisis?

From the Guidelines

Criteria for a Hypertensive Crisis

A hypertensive crisis is defined by severe elevations in blood pressure (>180/120 mmHg) associated with evidence of new or worsening target organ damage.

Key Characteristics

• Target organ damage includes conditions such as hypertensive encephalopathy, intracranial hemorrhage, acute ischemic stroke, acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina pectoris, dissecting aortic aneurysm, acute renal failure, and eclampsia 1.
• Symptoms depend on the organs affected and may include headache, visual disturbances, chest pain, shortness of breath, dizziness, and other neurological deficits 1.
• Acute manifestations of organ damage are critical for management and include conditions like acute onset of aortic dissection, myocardial ischemia, eclampsia, or heart failure 1.

Diagnosis and Management

• Diagnosis involves identifying severe blood pressure elevation along with signs of target organ damage, which may require immediate diagnostic workup and specific investigations based on presentation and clinical findings 1.
• Management typically involves immediate reduction of blood pressure (not necessarily to normal) to prevent or limit further target organ damage, often with intravenous therapy 1.
• Oral therapy is generally discouraged for hypertensive emergencies, emphasizing the need for more rapid and controlled blood pressure reduction 1.

Clinical Presentations

Specific clinical presentations of hypertensive emergencies include:

• Malignant hypertension: Severe blood pressure elevation associated with advanced bilateral retinopathy 1.
• Hypertensive encephalopathy: Severe blood pressure elevation associated with lethargy, seizures, cortical blindness, and coma in the absence of other explanations 1.
• Hypertensive thrombotic microangiopathy: Severe blood pressure elevation associated with hemolysis and thrombocytopenia in the absence of other causes and improvement with blood pressure-lowering therapy 1.

From the Research

Definition of Hypertensive Crisis

• A hypertensive crisis is defined as a systolic blood pressure >180 mm Hg or a diastolic blood pressure >120 mm Hg 2, 3
• It can be further classified as a hypertensive urgency or hypertensive emergency depending on end-organ involvement, including cardiac, renal, and neurologic injury 2, 4

Criteria for Hypertensive Urgency and Emergency

• Hypertensive urgency: severe hypertension with no or minimal end-organ damage 2, 4
• Hypertensive emergency: severely hypertensive patients with acute end-organ damage, such as cardiac, renal, or neurologic injury 2, 5, 3
• Examples of end-organ damage associated with hypertensive emergencies include cerebral infarction, acute pulmonary edema, hypertensive encephalopathy, and cerebral hemorrhage 5, 6

Clinical Presentation

• Hypertensive urgencies frequently present with headache, epistaxis, faintness, and psychomotor agitation 5
• Hypertensive emergencies frequently present with chest pain, dyspnea, and neurological deficit 5, 6
• Common signs and symptoms of hypertensive emergency include dyspnea, thoracic pain, and neurological deficit 6
• Common signs and symptoms of hypertensive urgency include headache, thoracic pain, and dyspnea 6

Management

• The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure 5, 3
• Immediate reduction in blood pressure is required only in patients with acute end-organ damage (i.e., hypertensive emergency) 2, 5, 3
• Patients with hypertensive emergencies are best treated in an intensive care unit (ICU) with titratable IV hypotensive agents 2, 5, 3
• Patients with hypertensive urgencies may be treated with oral antihypertensive agents as outpatients 2, 3