Overview
A short-term sharp rise in blood pressure, accompanied by a series of serious symptoms, even life-threatening clinical phenomenon
The main manifestation is rapid increase in blood pressure, accompanied by headache, chest tightness, nosebleed, etc.
Rapid rise in blood pressure in a short period of time leading to
Treatment to lower blood pressure as soon as possible
Definition
Hypertensive crisis refers to a short-term sharp rise in blood pressure, with systolic blood pressure >180mmHg and/or diastolic blood pressure >120mmHg, which can be accompanied by a series of serious symptoms and even life-threatening clinical phenomena.
It includes hypertensive emergencies and hypertensive subemergencies, and the difference between the two is that hypertensive emergencies have target organ damage such as brain, heart and kidney [1-3].
Classification
Hypertensive emergencies and hypertensive sub-emergencies can be categorized according to their severity.
Hypertensive emergencies: patients with primary or secondary hypertension have a sudden and significant increase in blood pressure under the effect of certain triggers, accompanied by progressive cerebral, cardiac, renal and other important target organ insufficiency.
Hypertensive subacute: the blood pressure rises significantly, but there is no clinical manifestation of target organ damage.
Causes
Causes
The main etiologic factors of hypertensive crisis include:
Discontinuation of antihypertensive drugs or failure to take antihypertensive drugs as prescribed.
Administration of drugs that affect the metabolism of antihypertensive drugs (nonsteroidal anti-inflammatory drugs, steroids, immunosuppressants, gastric mucosal protectants, etc.).
Taking sympathomimetic toxic drugs (cocaine, lysergic acid diethylamide, amphetamines, etc.).
Severe trauma, surgery.
Acute and chronic pain.
Acute infections.
Acute urinary retention.
Emotional agitation, nervousness, panic attacks.
Poor control of concomitant risk factors (e.g., smoking, obesity, hyperlipidemia, and diabetes).
Pathogenesis
On the basis of common etiologies and various triggers, abnormalities in neurohumoral regulation, including hyperactivation of the sympathetic nervous system, activation of the renin-angiotensin aldosterone system, and increased release of vasoconstrictor-active substances (renin, angiotensin, etc.), lead to contractile spasms of the small arteries throughout the body, and a sharp rise in arterial blood pressure in a short period of time [4-5].
Symptoms
Main Symptoms
Patients may have symptoms caused by a marked increase in blood pressure, such as headache, chest tightness, nosebleeds and irritability, and hypertensive emergencies may present with target organ complications such as cerebral, cardiac and renal.
Complications
Hypertensive emergency in hypertensive crisis may be accompanied by complications of progressive cerebral, cardiac, renal and other target organ insufficiency.
Acute coronary syndrome
Manifestations include acute chest pain, chest tightness, radiating shoulder and back pain, pharyngeal constriction, irritability, sweating, and palpitations.
Acute aortic dissection
Tearing-like chest pain, with different ranges of vessels affected may have corresponding clinical manifestations, such as with the loss of peripheral pulse, oliguria, anuria.
Acute heart failure: shortness of breath, coughing up pink foamy sputum, sitting breathing, sweating, cyanosis, and wet rales in both lungs.
Acute cerebral infarction: aphasia, facial paralysis, tongue paralysis, hemiplegia, hemiparesis, impaired consciousness, epileptic seizures.
Acute cerebral hemorrhage: headache, projectile vomiting, may be accompanied by different degrees of consciousness disorder, hemiparesis, aphasia, dynamic onset, often progressive aggravation.
Subarachnoid hemorrhage: severe headache, nausea, vomiting, neck and back pain, impaired consciousness, convulsions, hemiparesis, aphasia.
Acute renal insufficiency: oliguria, edema, azotemia, and even uremia.
Pre-eclampsia and eclampsia: pregnant women with elevated blood pressure, proteinuria or edema between the 20th week of pregnancy and the first week after delivery, which may be accompanied by headache, dizziness, blurred vision, epigastric discomfort, nausea, etc. Patients with eclampsia suffer from convulsions or even coma.
Hypertensive encephalopathy: acute onset of severe headache, nausea and vomiting, impaired consciousness (blurred awareness, drowsiness, or even coma), and commonly progressive retinopathy [6].
Medical treatment
Department of Medicine
Emergency department
Regardless of a history of hypertension, sudden onset of severe headache, chest pain, and impaired consciousness suggests immediate consultation in the emergency department or calling 120 emergency.
Cardiovascular Medicine
If the general public finds elevated blood pressure during a doctor’s visit or physical examination, they should pay attention and go to the Department of Cardiovascular Medicine for diagnosis and treatment.
Patients with high blood pressure should go to the Cardiovascular Medicine Department for review and adjustment of antihypertensive medication if they find that their blood pressure is not well controlled during daily monitoring.
Preparation
Consultation: Registration, Preparation of Information, Frequently Asked Questions
Tips for seeking medical treatment
Seek emergency medical attention immediately, preferably accompanied by family members.
Preparation List
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
Is there dizziness, headache, nausea, vomiting?
Is there acute chest pain, chest tightness, radiating shoulder and back pain, throat tightness, irritability, sweating, palpitations?
Is there tearing chest pain, loss of pulse, oliguria, anuria?
Is there shortness of breath, coughing up pink foamy sputum, telangiectasia, sweating, cyanosis?
Is there aphasia, facial paralysis, tongue paralysis, hemiplegia, hemiparesis, impaired consciousness, epileptiform seizures?
Is there severe headache, projectile vomiting, nausea, neck and back pain, impaired consciousness, hemiparesis, aphasia?
Is there severe headache, nausea, vomiting, neck and back pain, impaired consciousness, convulsions, hemiparesis, aphasia.
Is there oliguria, edema?
Does the pregnant patient have elevated blood pressure, proteinuria, edema, headache, dizziness, blurred vision, epigastric discomfort, nausea, convulsions, coma?
When did the symptoms appear and how long did they last? Are there fluctuations of relief, aggravation, etc.?
Medical History Checklist
Any previous history of hypertension, medication and usual blood pressure control?
Any history of cardiovascular disease such as diabetes, hyperlipidemia, coronary heart disease, etc.?
Any history of kidney disease such as chronic nephritis?
Any history of neurological diseases such as stroke?
Checklist
Test results of the last six months, which can be brought to the doctor’s office
Laboratory tests:
General tests: electrolytes, blood gas analysis.
Kidney-related tests: urine test (urine routine, urine sediment, urine microalbumin), kidney function.
Heart-related tests: brain natriuretic peptide, troponin, etc.
Imaging examination and other auxiliary examinations:
Cardiopulmonary examination: X-ray chest film, electrocardiogram, echocardiogram, CT angiography of chest and abdomen.
Brain examination: cranial CT/ MRI.
Renal examination: adrenal CT/MRI, renal artery ultrasound.
Medication List
Medications used in the last 3 months, if available in boxes or packages, carry with you to the doctor’s office
Antihypertensive drugs: nifedipine, captopril, chlorosartan, etc.
Drugs that affect the metabolism of antihypertensive drugs:
NSAIDs: aspirin, indomethacin, acetaminophen, etc.
Steroids: hydrocortisone, methylprednisolone, dexamethasone, etc.
Immunosuppressants: cyclophosphamide, methotrexate, cyclosporine, etc.
Gastric mucosal protective agents: cimetidine, omeprazole, pantoprazole, etc.
Sympathomimetic toxic drugs: cocaine, lysergic acid diethylamide, amphetamine, etc.
Diagnosis
Diagnosis is based on
Medical history
History of primary hypertension, renal disease, endocrine disease, cardiovascular lesions, cranial disease, sleep apnea syndrome, and hypertension in pregnancy.
Presence of precipitating factors such as failure to use antihypertensive medication in a timely manner or to take antihypertensive medication as prescribed, administration of medications that affect the metabolism of antihypertensive medication or sympathomimetic toxicity, severe trauma, surgery, acute or chronic pain, acute infections, acute urinary retention, emotional excitement, stress, panic attacks, and poor control of concomitant risk factors (e.g., smoking, obesity, hyperlipidemia, and diabetes mellitus).
Clinical Symptoms
Symptoms
Patients may have symptoms caused by a marked increase in blood pressure, such as headache, chest tightness, nosebleeds, and irritability.
Hypertensive emergencies may present with signs of target organ insufficiency of the brain, heart, and kidneys, including severe headache, nausea, projectile vomiting, impaired consciousness (confusion, drowsiness, coma), hemiparesis, and aphasia.
Shortness of breath, coughing pink foamy sputum, telangiectasia, profuse sweating, cyanosis; chest pain, chest tightness, radiating shoulder and back pain, pharyngeal constriction, palpitation; oliguria, anuria, and edema.
Physical signs
Measurement of blood pressure: blood pressure rises sharply; significantly different blood pressure in both upper arms should be alerted to the possibility of aortic coarctation.
Circulatory system examination: focus on the determination of heart failure, such as observing whether the jugular vein is angry, auscultating the lungs to see whether there are double pulmonary wet rales, auscultating the heart to see whether there is a pathological third heart sound or prancing horse rhythm, auscultating the abdominal aorta and renal artery to see whether there is a pathological murmur.
Neurological examination: acute cerebral infarction, acute cerebral hemorrhage, subarachnoid hemorrhage and other cranio-cerebral complications can be seen as altered state of consciousness (blurred consciousness, drowsiness, or even coma), meningeal irritation signs (cervical ankylosis, Kirschner’s sign, Barthelson’s sign), changes in visual field and pathological signs (Babinski’s sign).
Funduscopic examination: Hypertensive urgency is seen in funduscopy with new onset of hemorrhage, exudation, and optic papillary edema.
Laboratory tests
Urinalysis
Assess the degree of renal impairment.
Including urine routine, urine sediment, microalbuminuria. Urine specific gravity decreases in renal impairment, and microalbuminuria, erythrocytes, and occasionally tubular patterns may be present.
Renal function
Can assess the degree of renal function impairment.
May assist in determining the severity of renal complications in hypertension.
Electrolytes
To assess for electrolyte disturbances.
Hyperkalemia and metabolic acidosis may be seen in hypertensive crisis with acute renal insufficiency.
Blood gas analysis
Purpose: To assess the degree of hypoxia in hypertensive crisis with shortness of breath.
Significance of the test: In severe hypoxia, the partial pressure of arterial oxygen, arterial oxygen saturation can be seen to fall, as well as the decrease of blood pH and other manifestations of acidosis.
Brain natriuretic peptide
Purpose: To assess cardiac function.
Significance: Brain natriuretic peptide level can be significantly increased in hypertensive crisis complicated with heart failure.
Troponin
Test Objective: To evaluate myocardial damage.
Significance: Hypertensive crisis with acute coronary syndrome may have significantly elevated troponin levels.
Imaging
Chest X-ray
It is mainly used to evaluate cardiac and large vessel disease in hypertensive crisis patients.
In hypertensive patients, aortic dilatation and enlargement of the left heart may be seen. In patients with heart failure, cardiac enlargement is more pronounced, and there are signs of pulmonary hemorrhage. Widening of the mediastinum is seen in those with concomitant aortic coarctation.
Remove metal objects from the body before performing X-rays; protect unexamined areas, such as the gonads.
Cranial CT/MRI
Primarily used to evaluate brain injury in hypertensive crisis.
Early stage of cerebral hemorrhage can be seen as a well-defined high-density shadow on CT, and MRI is more diagnostic for acute cerebral infarction.
Remove any metal objects from the body before the examination; keep still during the examination, otherwise artifacts will be produced.
Echocardiography
To assess cardiac function, including systolic function, diastolic function, and left ventricular ejection fraction in patients with hypertensive crisis.
In patients with concomitant heart failure, cardiac enlargement and decreased left heart ejection fraction are seen.
Try to eliminate nervousness to avoid rapid heartbeat affecting the image display; adjust the body position as prescribed by the doctor during the examination.
Chest and abdomen CT
It is mainly used to evaluate whether the patients with hypertensive crisis are complicated with aortic coarctation.
Complicated aortic coarctation can be seen in the thoracic and abdominal aortic endothelial dissection, which is the gold standard for confirming the diagnosis of aortic coarctation.
Remove any metal objects from the body before the examination; remain still during the examination as artifacts may occur.
Adrenal CT or MRI
Primarily used to evaluate for occupancy and hyperplasia on the adrenal glands.
Patients with aldosteronism and hypertensive crisis caused by pheochromocytoma may have nodules, tumors, and thickening on the adrenal glands.
Remove metal objects from the body before the examination; keep still during the examination, otherwise artifacts will be produced.
Renal Artery Ultrasound
To assess the presence of renal artery stenosis.
Renal artery plaques, malformations, or stenosis may be seen in patients with hypertensive crisis due to renal artery stenosis.
Electrocardiogram
To assess for arrhythmias in patients with hypertensive crisis.
ST-segment changes and T-wave abnormalities may be seen in patients with acute coronary syndrome or aortic coarctation.
Differential Diagnosis
Thyroid crisis
Similarity: Both patients may have severe systemic symptoms such as vomiting, palpitations, sweating and coma.
Differences: In thyroid crisis, there is a history of hyperthyroidism, blood pressure is not obviously elevated, and laboratory tests show a significant increase in the concentration of thyroid hormones in the blood and serious water and electrolyte disorders.
Pheochromocytoma crisis
Similarity: both of them may present with rapid increase of blood pressure, headache, excessive sweating, accompanied by damage to target organs such as brain, heart and kidney.
Differences: The sudden rise of blood pressure in pheochromocytoma crisis is due to the release of large amount of catecholamines into the blood, and the blood and urine catecholamines are more than two times of the normal high limit. The blood pressure may fluctuate, and is usually accompanied by a series of symptoms caused by a sharp increase in catecholamines.
Treatment
Treatment objective: reduce blood pressure as soon as possible to avoid further damage to target organs and improve the prognosis.
Treatment principles: monitor blood pressure and vital signs; remove or correct the triggers and causes of the sudden rise in blood pressure; slowly lower the blood pressure to 160/100mmHg within 24-48 hours for sub-acute hypertension, and within a few hours for acute hypertension.
General treatment
Quiet rest.
Cardiac monitoring.
Open intravenous access.
Oxygen, keep the airway open, mechanical ventilation if necessary.
Sedation and analgesia: diazepam, morphine, etc.
Maintain water-electrolyte balance.
Antihypertensive treatment
Acute coronary syndrome
Antihypertensive goal: blood pressure control below 130/80mmHg, but maintain diastolic blood pressure >60mmHg.
Commonly used drugs: nitroglycerin, metoprolol, uradil, etc.
Acute aortic coarctation
Antihypertensive goal: under the premise of ensuring adequate perfusion of organs, rapidly reduce blood pressure and maintain systolic blood pressure at 100-120mmHg, and control ventricular rate at ≤60 beats/minute.
Commonly used drugs: diltiazem, uradil, labetalol, sodium nitroprusside, etc.
Acute heart failure
Antihypertensive goal: the reduction of mean arterial pressure within the initial 1 hour is not more than 25% of the pre-treatment level, target systolic blood pressure <140 mm Hg, but not less than 120/70 mm Hg.
Commonly used drugs: sodium nitroprusside, nitroglycerin, uradil, valsartan, captopril, etc.
Acute cerebral infarction
Blood pressure lowering target: Thrombolytic patients blood pressure is recommended to reduce the mean arterial pressure by 15% within 1 hour, and the blood pressure is controlled at <180/110mmHg; non-thrombolytic patients should be cautious in lowering blood pressure, when the systolic blood pressure＞220mmHg or diastolic blood pressure＞120mmHg, or the combination of other target organ damage can be controlled to lower blood pressure, and the mean arterial pressure will be lowered by 15% within the first 24 hours, but the systolic blood pressure shouldn’t be lower than 160 mmHg.
Commonly used drugs: labetalol, nicardipine, sodium nitroprusside.
Acute cerebral hemorrhage
Hypotensive target: when blood pressure rises sharply in hypertensive encephalopathy, reduce the mean arterial pressure by 20%-25% in the first hour, and the initial hypotensive target is 160~180/100~110mmHg.
Commonly used drugs: labetalol, nicardipine, sodium nitroprusside.
Subarachnoid hemorrhage
Antihypertensive goal: It is recommended that blood pressure be maintained at about 20% above the basal blood pressure, and systolic blood pressure can be maintained at 140~160mmHg after aneurysm surgery.
Commonly used drugs: nicardipine, nimodipine, uradil, labetalol.
Pre-eclampsia and eclampsia
Antihypertensive goal: control blood pressure <160/110mmHg, when there is organ function damage blood pressure control at <140/90mmHg, but to avoid lowering blood pressure too quickly to affect fetal blood supply.
Commonly used drugs: nicardipine, labetalol, hydralazine, magnesium sulfate, uradil.
Hypertensive encephalopathy
Blood pressure lowering target: When the blood pressure of hypertensive encephalopathy rises sharply, the average arterial pressure should be lowered by 20%~25% in the first hour, and the initial lowering target should be 160~180/100~110 mmHg.
Commonly used drugs: labetalol, nicardipine, sodium nitroprusside.
Hypertension sub-acute
Antihypertensive goal: Slowly reduce blood pressure to 160/100 mmHg within 24~48 hours.
Commonly used drugs: nifedipine controlled-release tablets, amlodipine benzenesulfonate tablets, metoprolol and other long-acting antihypertensive drugs [7-10].
Prognosis
Cured
Untreated
If hypertensive crisis is left untreated, the clinical manifestations will progressively deteriorate, leading to failure of the heart, brain, kidneys and other important organs, or even death.
After treatment
Timely and correct management of hypertensive crisis can alleviate the condition in a short period of time, prevent progressive or irreversible target organ damage, and reduce mortality.
Hazard
Hypertensive emergencies change rapidly and easily lead to damage of important target organs such as brain, heart and kidney, including hypertensive encephalopathy, acute cerebral infarction, cerebral hemorrhage, subarachnoid hemorrhage, acute left heart failure, acute aortic coarctation, acute renal insufficiency, eclampsia and other critical complications.
Hypertensive subacute conditions are prone to develop into hypertensive emergencies if left untreated.
Daily
Daily Management
Dietary management
Reasonable diet, advocate high quality protein, low fat diet.
Reduce sodium intake, daily sodium intake should be controlled below 5g.
Control high-calorie food, such as fatty meat and fried food.
Life Management
Control body weight.
Exercise regularly and reduce sedentary time.
Quit smoking and stay away from second-hand smoke.
Try to stop drinking.
Reduce mental stress, maintain psychological balance and avoid great joy and sorrow.
Disease monitoring
Control blood pressure within a reasonable range.
Long-term, smooth and effective control of blood pressure at a normal level, it is recommended to use antihypertensive drugs under the guidance of a doctor, do not stop or change the drugs by yourself.
Regularly measure and record your own blood pressure. If your blood pressure is not well controlled (the general target blood pressure is <140/90mmHg), seek medical advice promptly.
Prevention
Control high-risk factors, including rational diet, weight reduction, smoking and alcohol cessation, regular exercise, and maintaining psychological balance, to prevent hypertension at source.
Actively treat the appropriate triggers and causes to avoid recurrent episodes.
Avoid and remove the triggers, strictly follow the doctor’s instructions for antihypertensive treatment, and be careful with drugs that raise blood pressure or interact with antihypertensive drugs.