On Call: Hypertension (HTN)
Definitions
Hypertension
- Elevated Blood Pressure: SBP ≥ 120 mmHg (DBP < 80 mmHg)
- Hypertension, Stage 1 (Mild): ≥ 130/80 mmHg
- Hypertension, Stage 2 (Moderate): ≥ 140/90 mmHg
- Hypertensive Crisis (Severe): ≥ 180/120 mmHg
Causes
- Essential Hypertension: Hypertension without Any Identifiable Cause
- Secondary Hypertension: Hypertension Due to an Identifiable Cause
Severe Hypertension
- Hypertensive Urgency: Severe Hypertension without Signs of End-Organ Damage
- Hypertensive Emergency: Severe Hypertension with Signs of End-Organ Damage
Complications of Hypertension
- Cardiac Sequelae:
- Heart Failure
- Acute Coronary Syndrome/Myocardial Infarction (MI)
- Left Ventricular Hypertrophy
- Neurologic Sequelae:
- Ischemic Stroke
- Intracerebral Hemorrhage
- Hypertensive Encephalopathy
- Vascular/Renal Sequelae:
- Aortic Dissection
- Acute Kidney Injury
- Chronic Kidney Disease
Evaluation
Vitals
- ABC’s – Airway, Breathing & Circulation
- Vital Signs
- Repeat Blood Pressure Reading to Ensure Accuracy
Signs of Hypertensive Emergency
- Chest Pain
- Back Pain
- Dyspnea
- Altered Mental Status
- Seizures
Evaluate Potential Causes of Secondary Hypertension
- Inadequate Pain Control
- Anxiety
- Bladder Distention
- Acute Volume Repletion
- Hypothermia
Inpatient Treatment
Inpatient Blood Pressure Goal
- General Inpatient Goals:
- SBP < 160 mmHg
- DBP < 100 mmHg
- Pitfalls:
- Inpatient Goals are Poorly Defined with Minimal Evidence to Support Treating Isolated, Episodic Asymptomatic Hypertension
- Some Patients May Require Stricter Blood Pressure Goals – Large Epidural Hematomas, Carotid Endarterectomy (CEA), etc.
- Outpatient Goals are Generally Lower
Initial Managements
- Aggressively Manage for Any Signs of Hypertensive Emergency – Symptomatic or Signs of End-Organ Damage
- Treat Any Possible Secondary Causes – Pain, etc.
- Restart Any Previously Held Home Antihypertensive Medications
General Approach
- Generally Start with PRN IV Medications
- Common Starting Medications: Hydralazine or Labetalol
- May Require Antihypertensive Drip (gtt) for Urgent and Precise Control
- Consider Adding a Long-Acting Oral Medication if Continuing to Require Frequent IV Dosing