From the Guidelines
Hypertension can lead to significant end organ damage if left untreated or poorly controlled, affecting primarily the heart, brain, kidneys, eyes, and blood vessels, and thus, effective blood pressure control is essential to prevent or slow progression of end organ damage. The primary organs affected by hypertension include:
- Heart: left ventricular hypertrophy, heart failure, coronary artery disease, and arrhythmias
- Brain: increased risk of stroke, transient ischemic attacks, vascular dementia, and cognitive impairment
- Kidneys: hypertensive nephropathy, characterized by proteinuria, reduced glomerular filtration rate, and eventual chronic kidney disease
- Eyes: hypertensive retinopathy with arteriolar narrowing, hemorrhages, exudates, and in severe cases, papilledema
- Blood vessels: atherosclerosis, arterial stiffness, and peripheral arterial disease
These complications occur due to mechanical stress on vessel walls, endothelial dysfunction, oxidative stress, and activation of the renin-angiotensin-aldosterone system 1. Effective blood pressure control with antihypertensive medications (such as ACE inhibitors, ARBs, calcium channel blockers, diuretics, and beta-blockers) to targets below 130/80 mmHg is essential to prevent or slow progression of end organ damage 1. Regular monitoring of organ function through tests like echocardiography, renal function tests, urinalysis, fundoscopy, and cognitive assessments helps detect early damage and guide treatment adjustments 1.
In cases of hypertensive emergencies, defined as severe elevations in BP (>180/120 mm Hg) associated with evidence of new or worsening target organ damage, immediate reduction of BP is necessary to prevent or limit further target organ damage 1. The type of acute organ damage is the principal determinant of the drug of choice, target BP, and timeframe in which BP should be lowered 1.
It is crucial to classify patients according to their total cardiovascular risk, taking into account the coexistence of different risk factors, organ damage, and disease, to guide treatment decisions and maximize cost-efficacy of the management of hypertension 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Definition and Classification of Hypertensive Crises
- Hypertensive crises are categorized as either hypertensive emergencies or urgencies depending on the degree of blood pressure elevation and presence of end-organ damage 2.
- A systolic blood pressure (BP) > 180 mm Hg or a diastolic BP > 120 mm Hg is considered a "hypertensive crisis" 2.
- Hypertensive emergency is typically defined as a blood pressure greater than 180/120 mmHg leading to end-organ damage 3.
End-Organ Damage in Hypertension
- End-organ damage can occur due to acute elevation in blood pressure, even before achieving the blood pressure threshold 3.
- Examples of end-organ damage include cardiovascular, cerebrovascular, or renal damage 4.
- The risk of immediate complications or organ damage is less likely to occur in hypertensive urgencies, but the ultimate prognosis, if untreated, is poor 5.
Treatment of Hypertensive Emergencies
- Therapeutic intervention should be a short-acting, easily titratable, intravenous antihypertensive medication based on the type of end-organ damage, pharmacokinetics, and comorbidities 3.
- Immediate reduction in blood pressure is required only in patients with acute end-organ damage (i.e., hypertensive emergency) 2.
- Patients with hypertensive emergencies are best treated in an intensive care unit (ICU) with titratable IV hypotensive agents 2.
Management of Hypertension
- Angiotensin-converting enzyme (ACE) inhibitors are recommended as first-choice therapy for patients with cardiovascular disease, but angiotensin receptor blockers (ARBs) may be considered as an alternative due to their equal outcome efficacy and fewer adverse events 6.
- The primary goal of intervention in a hypertensive crisis is to safely reduce blood pressure 2.