History and exam

Key diagnostic factors

common

blood pressure (BP) >180/120 mmHg

BP is usually >180/120 mmHg in hypertensive emergencies; however, the key determinant is the presence of new or worsening end-organ damage.[1][60]​​​ During pregnancy, hypertension in a previously normotensive woman with proteinuria or evidence of systemic involvement (e.g., renal insufficiency, impaired liver function, neurological complications, haematological complications) is diagnostic of pre-eclampsia.[48][61]​​ Pre-eclampsia should be considered in patients with headache who are at least 20 0/7 weeks of gestation, or within 6 weeks postnatally, and who have blood pressure ≥140 mmHg systolic or ≥90 mmHg diastolic.[55]​ At least two measurements should be made, at least 4 hours apart.[48]

presence of risk factors

Risk factors include: inadequately treated hypertension, older age, black ethnicity, male sex, use of sympathomimetic drugs, and use of monoamine oxidase inhibitors.

Other diagnostic factors

common

neurological symptoms

Neurological abnormalities, such as vision changes, dizziness, headaches, dysarthria, seizures, change in mental status, dysphagia, loss of sensation or paraesthesia, and loss of movement, are symptoms often associated with hypertensive emergency.[40] Commonly described features of pre-eclampsia headache include severe bilateral frontal headache and blurry vision, which may progress to bilateral cortical blindness.[55][56]​​ The headache typically develops in temporal relation to the onset of pre-eclampsia, or substantially worsens or improves in parallel with worsening or improvement of pre-eclampsia.[55]

cardiac symptoms

Cardiac abnormalities (e.g., chest pain, shortness of breath, orthopnoea, paroxysmal nocturnal dyspnoea, palpitations, oedema) are frequently associated with hypertensive emergency.[40]

abnormal cardiopulmonary examination

The presence of new murmurs, friction rub, S3, jugular venous distension, rales, or lower extremity oedema may be found.

abnormal abdominal examination

Tenderness to palpation in the right upper quadrant is seen in severe pre-eclampsia and HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome.[61][62]​ Phaeochromocytoma may be associated with an abdominal mass. Renovascular hypertension should be suspected in patients with severe hypertension who have abdominal bruits and/or unexplained renal deterioration with angiotensin-converting enzyme inhibitor treatment, although the clinical presentation is variable.

oliguria or polyuria

Any changes in renal output can be indicative of renal damage.[24]

abnormal fundoscopic examination

The following signs are indicative of hypertensive retinopathy: arteriolar spasm, retinal oedema, retinal haemorrhages, retinal exudates, papilloedema, engorged retinal veins.[7]​[69]

abnormal neurological examination

Abnormal findings in cognition, cranial nerve function, motor strength, gross sensory function, and gait can frequently result from hypertensive crisis.

Risk factors

strong

inadequately treated hypertension

A history of inadequately treated hypertension is commonly seen.[18][21][22][23]​​

In the US, lack of medical insurance or access to a primary care doctor have been shown to predispose to hypertensive emergency.[22]

chronic kidney disease (CKD)

CKD is a strong risk factor for hypertension and progression to hypertensive emergencies in both adults and children.[13][18]​​[24][25][26][27]​​​

renal artery stenosis

Renal artery stenosis is strongly associated with secondary hypertension.[28]

renal transplant

Renal transplantation is commonly associated with hypertension, with graft failure most commonly responsible.[29] Transplant renal artery stenosis accounts for between 1% and 5% of hypertension after transplantation.[30] Anti-rejection medication (e.g., calcineurin inhibitors) may also play a role.[7]​[31][39]

endocrine disorders with known hypertensive effects

There are a number of endocrine disorders that are associated with hypertensive emergencies. These include: primary aldosteronism, phaeochromocytoma, thyroid disorder, Cushing's syndrome, acromegaly, hyperparathyroidism, carcinoid tumour, congenital adrenal hyperplasia, or renin-secreting tumour.[31][35][36]​​[37] The treatment of certain endocrine disorders may also precipitate a hypertensive emergency. For example, the use of beta-blocker medication before the administration of an alpha-adrenergic receptor blocker in a patient with a phaeochromocytoma may lead to a hypertensive crisis.[46]​​[47]

pregnancy

Pre-eclampsia, eclampsia, and HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome can all result in a hypertensive emergency.[31][48]

weak

older age

Older age predisposes to hypertensive emergency.[10][11][12][13]

black ethnicity

Black people are predisposed to hypertensive emergency, compared with white people.[11][12]

male sex

Men may be more likely than women to suffer a hypertensive emergency.[11][12]

use of sympathomimetic drugs

Use of sympathomimetic street drugs (e.g., cocaine, LSD, amphetamines, ecstasy) predisposes to hypertensive emergency.[7]​[18]

pharmacotherapy with known hypertensive effect

Many medications can induce or exacerbate hypertension, leading to a hypertensive emergency. These include non-steroidal anti-inflammatory drugs, oral contraceptives, sympathomimetics, illicit drugs, glucocorticoids, mineralocorticoids, calcineurin inhibitors, erythropoietin, herbal supplements, vascular endothelial growth factor inhibitors, and inadvertent drug or food interactions with monoamine oxidase inhibitors (MAOIs).[7]​[31][39] If foods high in tyramine are ingested by patients taking MAOIs, this can precipitate a hypertensive emergency (the so called ‘tyramine reaction’).

obstructive sleep apnoea

Obstructive sleep apnoea is associated with secondary hypertension which, if left untreated, may precipitate a hypertensive emergency.[32][33][34]​​

vasculitis and connective tissue diseases

Multiple vasculitides and connective tissue disorders are associated with hypertension and hypertensive emergencies. These include scleroderma, systemic lupus erythematosus, Takayasu arteritis, and giant cell arteritis.[31][49][50][51]

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