As a junior doctor, you will often be called about patients with raised blood pressure (BP) in secondary care. This differs from chronic hypertension in primary care for which the treatment is summarised expertly by NICE. Here we look at the assessment and management of hypertension in acute care, with a focus on hypertensive emergencies & BP control in special situations (e.g. acute stroke).

Hypertensive Emergencies

These are situations where urgent treatment is needed to prevent life-threatening events.

These include:

• Malignant hypertension: a recently increased BP >180/110 mmHg resulting in end-organ damage (neurological, cardiovascular and renal). Features of damage include papilloedema/flame haemorrhages on fundoscopy, disseminated intravascular coagulation, encephalopathy (lethargy/somnolescence, vomiting, seizures, cortical blindness), acute heart or kidney failure
• Severe hypertension with associated clinical conditions that need urgent BP control: acute aortic dissection, acute myocardial ischaemia, acute heart failure
• Pregnant women with severe hypertension or pre-eclampsia

Hypertensive Urgency

This is where BP can be reduced more gradually

• BP >180/110 mmHg without any end-organ damage

Hypertension

Aetiology

Although, primary hypertension is the most common up to 15% of patients may have secondary hypertension. Consider this in patients

• With hypertension in childhood or below 40 years old particularly with moderate hypertension
• Acutely worsening hypertension (if normally known to chronically stable)
• Resistant hypertension
• All patients with malignant hypertension or hypertensive urgency
• Features of an endocrine cause, CKD, OSA or family history of pheochromocytoma

European Society of Hypertension Guidelines

In addition to the above don’t forget drug causes: oral contraceptive pill, NSAIDs, corticosteroids, tricyclic antidepressants, illicit stimulants (amphetamines, cocaine, ecstasy) & diet pills.

Initial Assessment

• ABCDE. Don’t forget to compare bilateral pulse quality
• Repeat the BP with bilateral measurements for dissection or coarctation. A lying and standing BP is particularly useful in the elderly; orthostatic hypotension could mean aggressive control may lead to increased falls. You should aim to treat the standing BP)
• Focussed history for hypertensive emergencies
  • Neurological: confusion, headaches, seizures, nausea, visual changes, focal neurology: speech, dizziness, visual field defects, weakness or sensation disturbance
  • Cardiovascular: chest pain, dizziness or syncope, breathlessness
  • Renal: whether they’re passing urine & haematuria
  • Pregnancy
• Focussed history for secondary causes
  • Medications & drugs
  • Family history
  • OSA: Sleep quality, snoring & day time somnolence
  • Endocrine: Sweating, palpitations, weight gain/loss, polyuria, weakness, oedema & other thyroid features
• Cardiovascular risk factors (means controlling it thoroughly is even more important)
• Examination
  • Neurological & Cardiovascular examination
  • Fundoscopy
  • Abdominal exam – enlarged kidneys or renal bruit
  • Consider if the patient looks cushingoid, has features of thyroid disease,
• Investigations
  • The main purpose is to identify end-organ damage. ECG, U&Es and a urine dip should always be done for these patients. Consider an echocardiogram to look for left ventricular hypertrophy and/or heart failure
  • Tests for any secondary causes can usually be done later e.g. renal ultrasound & endocrine tests
  • Consider the investigations as advised by the European Society of Hypertension:

European Society of Hypertension Guidelines

Management

Most patients will have hypertensive urgency (or less severe hypertension)

• Note that treatment for this may be guided by the underlying cause e.g. in pregnancy many medications are contraindicated
• Treat this as per NICE guidelines with the usual CCB or ACEI. Often Ramipril 1.25-2.5mg or Amlodipine 5mg is used to slowly reduce BP over days. You might want to reduce BP to ≤160/100 mmHg over the first few hours if the patients at very high risk of imminent cardiovascular events
• Wherever possible increase their current antihypertensives before introducing new agents

Escalate hypertensive emergencies to the (medical) registrar and/or critical care

• These patients need close possibly invasive monitoring of BP e.g. arterial line
• IV therapy may be required with close cardiovascular & neurological monitoring to avoid organ hypoperfusion (as they have altered BP autoregulation)
• They need urgent treatment of end-organ damage with referrals to relevant specialists (e.g. ophthalmology, renal)
• Usually, the aim is to reduce BP by about 20-25% (see below)

European Hypertension Guidelines

Special situations:

• In an acute ischaemic stroke, reflex mechanisms aim to maintain perfusion to borderline ischaemic areas (penumbra) by increasing BP. Therefore BP should not be lowered unless extremely high (systolic > 220 mmHg, diastolic > 120 mmHg) or other conditions require urgent control (see “hypertensive emergencies” above). Therefore discuss all hypertension in stroke patients with seniors before initiating treatment
• In spontaneous intracranial haemorrhage, very aggressive control may be required in severe hypertension to prevent haematoma expansion. IV antihypertensives may be used. However, there’s some conflicting evidence therefore seek expert opinion.

References and Further Reading

• Patient.info: Hypertensive Emergencies
• UpToDate: Evaluation & Treatment of Hypertensive Emergencies in Adults
• UpToDate: Management of Severe Asymptomatic Hypertension
• ESC/ESH Guidelines on Hypertension
• Oxford Medicine: Hypertension in Special Situations
• BP management in acute stroke
• Eyewiki: Hypertensive retinopathy