High blood pressure is a chronic condition, and the damage it causes to blood vessels and organs generally

occurs over years.

However, it is possible for blood pressure to rise quickly and severely enough to be considered a hypertensive
crisis. To reduce morbidity and mortality in this situation, early evaluation of organ function and blood pressure
elevations at these levels is critical to determine the appropriate management.

Hypertensive crises can present as hypertensive urgency or as a hypertensive emergency.

If, while monitoring your blood pressure, you get a systolic reading of 180 mm Hg or higher OR a diastolic
reading of 110 mm HG or higher, wait a couple of minutes and take it again. If the reading is still at or above that
level, you should seek immediate emergency medical treatment for a hypertensive crisis. If you can't
access the emergency medical services (EMS), have someone drive you to the hospital right away.

Hypertensive Urgency

Hypertensive urgency is a situation where the blood pressure is severely

elevated [180 or higher for your systolic pressure (top number) or 110 or higher for your diastolic
pressure (bottom number)], but there is no associated organ damage. Those experiencing hypertensive
urgency may or may not experience one or more of these symptoms:

Severe headache

Shortness of breath

Nosebleeds

Severe anxiety

Treatment of hypertensive urgency generally requires readjustment and/or additional dosing of oral
medications, but most often does not necessitate hospitalization for rapid blood pressure reduction. A
blood pressure reading of 180/110 or greater requires immediate evaluation, because early evaluation of
organ function and blood pressure elevations at these levels is critical to determine the appropriate
management.

Hypertensive Emergency

A hypertensive emergency exists when blood pressure reaches levels that are damaging organs. Hypertensive
emergencies generally occur at blood pressure levels exceeding 180 systolic OR 120 diastolic, but can occur at
even lower levels in patients whose blood pressure had not been previously high.

The consequences of uncontrolled blood pressure in this range can be severe and include

Stroke

Loss of consciousness

Memory loss

Heart attack
 Damage to the eyes and kidneys

Loss of kidney function

Aortic dissection

Angina (unstable chest pain)

Pulmonary edema (fluid backup in the lungs)

Eclampsia

If you get a blood pressure reading of 180 or higher on top or 110 or higher on the bottom, and are having
any symptoms of possible organ damage (chest pain, shortness of breath, back pain,
numbness/weakness, change in vision, difficulty speaking) do not wait to see if your pressure comes
down on its own. Seek emergency medical assistance immediately. Call 9-1-1. If you can't access the
emergency medical services (EMS), have someone drive you to the hospital immediately.

http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPr
essure/Hypertensive-Crisis_UCM_301782_Article.jsp#.V2pBG1R97Mw

Discussion

The present study provides an estimate of the prevalence of hypertensive crises in an

emergency department during 1 year. This accounts for only 3% of the total patients but
approximately one fourth (27%) of the urgencies-emergencies. To our knowledge, this last
finding has never been reported before and indicates that hypertensive crises represent an
important and common event in emergency medicine and require appropriate resources for
their diagnosis and treatment. Data on the incidence of hypertensive crises in the general or
hypertensive population would be most interesting from the epidemiological viewpoint, but to
our knowledge they are not available in the literature and unfortunately cannot be estimated
from the present study. Using the operational classification of hypertensive crises in urgencies
and emergencies proposed by the Joint National Committee1 we found that hypertensive
urgencies are more frequent than hypertensive emergencies (76% and 24%, respectively).
Although hypertensive emergencies represent only one fourth of hypertensive crises, they are
by definition characterized by end-organ damage so that the medical staff devotes a lot of
time and effort to these patients. Other reports on this topic could enable us to compare the
data from various areas of the same country or different countries.

As far as the time of presentation of hypertensive crises is concerned, as previously noted, we

found two peaks during the day (at 9 AM and 7 to 8 PM) and one peak during the year
(January). The peaks during the day do not represent the time at which the crises occurred,
owing to the variability of the latency period between the appearance of symptoms and
arrival at the Emergency Department either by their own choice or having been sent by their
doctor (transport time). On the other hand, the circadian and circannual rhythms of
hypertensive crises are unknown, even though the Framingham Study showed that sudden
cardiac death had a circadian variation with a peak at 7 to 9 AM.12

In our series of patients presenting with a hypertensive crisis, 60% were women (Table 1).
This high percentage of women is also present in hypertensive urgencies and probably
reflects the larger number of women than men present in hypertensive
populations.13 However, this excess disappears in hypertensive emergencies (Figure), which
suggests that hypertensive men are more susceptible than hypertensive women to end-organ
damage. In addition, postmenopausal age seems to increase the susceptibility to end-organ
damage.
 Approximately one fourth of the patients presenting with hypertensive crises had unknown
hypertension (Table 1), indicating that a hypertensive crisis occurs most commonly in
patients with known hypertension. These data confirm a previous report14 that suggested that
often hypertensive patients did not take medication as prescribed or received inadequate
therapy. Furthermore, the proportion of our patients with unknown hypertension is higher in
hypertensive urgencies (28%) than emergencies (8%). Another interesting result of the
present study deals with the frequency of signs and symptoms of hypertensive urgencies and
emergencies and the pattern of end-organ damage in hypertensive emergencies. We found
headache and epistaxis to be the most frequent signs at presentation in hypertensive
urgencies (22% and 17%, respectively), whereas chest pain, dyspnea, and neurological deficit
were the most frequent signs in hypertensive emergencies (27%, 22%, and 21%) (Table 4).
Furthermore, the most frequent end-organ damage associated with hypertensive emergencies
were cerebral infarction, acute pulmonary edema, and hypertensive encephalopathy (24%,
23%, and 16%, respectively); cerebral hemorrhage accounted for only 4.5% (Table 3). The
clinical pattern of presentation of hypertensive crises had never been studied before and is of
some interest in clarifying the natural history of the disease in this respect.

In conclusion, the present study indicates that hypertensive urgencies and emergencies
represent one fourth of all events in emergency medicine, that a quite differentclinical pattern
of presentation is present in hypertensive urgencies versus emergencies, and that cerebral
infarction and acute pulmonary edema are the most frequent types of end-organ damage in
hypertensive emergencies.

http://hyper.ahajournals.org/content/27/1/144.full

Acknowledgments

We are indebted to Claudio Vernetti for his skillful assistance in figure preparation and to
Mariangela Mosca for language revision.

Received April 27, 1995.

Revision received June 8, 1995.
Accepted September 11, 1995.
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Hypertension crisis in emergency departement http://sci-hub.bz/10.1016/j.ccl.2012.07.011