There are several terms commonly used “Accelerated Hypertension”, “Hypertensive Emergency”, “Malignant Hypertension”. They all have a very similar definition (ESC/ESH, NICE, ACEP)

Patient has both:

1. Blood pressure: Systolic ≥180mmHg OR Diastolic ≥110mmHg (often >220/120mmHg)
2. End-Organ Damage: Retinal Changes, Encephalopathy, Heart Failure, Acute Kidney Injury, etc.

Mortality has improved in recent years with 5yr survival of 80% if treated. However, untreated average life expectancy is 24 months.

Investigation (All suspected cases):

• ECG
• Bloods: FBC, U&E
• Urine: Dip (protein and blood), Microscopy, Pregnancy (if childbearing age)
• Fundoscopy: is a critical part of the diagnostic workup – Digital Retinal Imaging is the method of choice currently

 

Further Investigations  (Specific Indications – not always in ED):

• Troponin (Suspected MI)
• BNP (Heart Failure)
• CXR (Pulmonary Oedema)
• CT Aorta (Suspected acute aortic disease e.g. aortic dissection)
• CT/MRI Brain (Nervous system involvement)
• Renal ultrasound (Renal impairment or suspected renal artery stenosis)
• Urine drug screen (Suspected methamphetamine or cocaine use)

Management

 

Hypertensive Emergency Treatment

Disease Specific IV therapies recommended by (ESC/ESH) – but liaise with local speciality teams as these patients will need admission

Clinical Indication	Target/Timing	First Line	Second Line
Malignant Hypertension	Several hours Reduce MAP by 20–25%	Labetalol/Nicardipine	Nitroprusside
Hypertensive Encephalopathy	Immediately Reduce MAP by 20–25%	Labetalol/Nicardipine	Nitroprusside
Acute Coronary Event	Immediately Reduce sBP <140mmHg	Nitroglycerine/Labetalol	Urapidil
Acute Cardiogenic Pulmonary Oedema	Immediately Reduce sBP <140mmHg	Nitroglycerine/Nitroprusside with Fruosemide	Urapidil with Furosemide
Aortic Dissection	Immediately Reduce sBP <120mmHg AND HR <60bpm	Nitroglycerine/Nitroprusside	Labetalol/Metopralol
Eclampsia, Severe Pre-Eclampsia/HELLP	Immediately Reduce sBP <160mmHg AND dBP <105mmHg	Labetalol/Nicardipine with Magnesium Sulphate	Consider Delivery

 

Non-Emergent Hypertension Treatment – NICE

• Oral therapy is normally sufficient
  • Calcium Channel Blockers are probably our 1st line in ED – as ACEi require renal monitoring
  • If already on extensive Antihypertensive therapy – Medical review will be required
  • If Adjusting/Starting oral antihypertensives there is no need for patient to wait in ED for BP to drop
• Life style advice is also useful
• Discharge for GP Follow-Up within 7 days

 

Phaeochromocytoma! (suspected cases require urgent medical review)

• Episodic symptoms (the 5 ‘Ps’):
  • Paroxysmal hypertension,
  • Pounding headache,
  • Perspiration,
  • Palpitations
  • Pallor
• Blood Pressure may be: Labile OR  Surges precipitated by drugs (e.g. β-blockers, metoclopramide, sympathomimetics, opioids, and tricyclic antidepressants)
• Skin inspection: cafe-au-lait patches of neurofibromatosis

Tests:

• CT/MRI
• Plasma or 24hr urinary fractionated metanephrines

Treatment:

• First Line Blood pressure managment α- adrenergic receptor blockers
  • Don’t use β-Blockers Alone (risk of hypertension)
• Surgical management is the ultimate treatment