Severe Asymptomatic Hypertension

Patient presents with hypertensive crisis. No subjective complaints. Denies headache, visual disturbance, lightheadedness, nausea, epistaxis, dyspnea, chest pain, palpitations, oliguria. No h/o coronary artery disease, heart failure, CVD, chronic kidney disease, DM, obstructive sleep apnea, EtOH/stimulant abuse. BP >180/>110. RR, SPO2 WNL. No neurologic deficits, JVD, arrhythmia, new onset heart murmur, pulmonary rales on exam.

• Repeat blood pressure 30 minutes after initial measurement

• Blood pressure remains elevated

  • Obtain CMP and compare results to previous labs: Admit to hospital if changes suggest end organ damage, e.g. AKI, AST or ALT > 2x upper limit of normal

  • Outpatient treatment for patients without evidence end organ damage:

    • No h/o HTN: Start home BP monitoring and f/u in 2-4 weeks

    • H/o HTN: Adjust hypertensive medications

Severe HTN with Mild Symptoms

Pt with h/o HTN presents with hypertensive crisis. Reports new onset headache, lightheadedness, nausea, epistaxis, shortness of breath, palpitations, anxiety. BP >180/>110.

• Repeat BP 30 min after initial BP measurement

• Obtain BMP, U/A to assess for end-organ injury; compare with previous labs

• Treatment

  • Agent

    • No h/o asthma, HF, heart block, bradycardia: Administer labetalol 20 mg IV

    • Labetalol contraindicated: Administer hydralazine 10 mg IV

  • Re-evaluate

    • Symptoms improve with short acting HTN Rx: Start/adjust HTN Rx and f/u in 1 week

    • Symptoms do not improve with short acting HTN Rx and no indication of end-organ damage on labs; start/adjust hypertensive tx and f/u in 1 week

    • Concerns about medication adherence and/or evidence of pulmonary rales, JVD, arrhythmia, new onset heart murmur, neurologic deficits: Admit for inpatient management

Notes

• CCASP guidelines

• Systolic > 240 mmHg or diastolic > 130 mmHg may benefit from hospitalization

• End organ damage

  • There is no consensus or guidelines for the definition of end-organ damage criteria in severe hypertension. AKI is commonly considered a marker for end-organ ischemia and the KDIGO definition is provided below. LFT and urine criteria were adopted from preeclampsia management that also assess for end-organ damage.

  • AKI is defined as any of the following:

    • Increase in serum creatinine (SCr) by ≥ 0.3 mg/dl within 48 hours

    • Increase in SCr to ≥ 1.5 times baseline within previous 7 days

    • Urine volume < 0.5 ml/kg/h for 6 hours