HYPERTENSIVE EMERGENCY! SECONDARY CAUSES OF HYPERTENSION!

Dr. Oppegard presented a case of a young man who presented with hypertensive emergency with vision changes, headache, and vomiting. He was found to have a blood pressure of 230/150 and severe AKI (BUN 122, sCr 19)!.

We reviewed the initial work up for hypertensive emergency, BP target goals based on clinical picture, and what IV medications to use acutely. This article from The American Academy of Clinical Pharmacy's Critical Care Self-Assessment Program provides a nice review.

“Hypertensive Emergencies” by: Scott Benken, PharmD found in CCSAP 2018, Book 1

“Hypertensive Emergencies” by: Scott Benken, PharmD found in CCSAP 2018, Book 1

Conditions Requiring Different BP Goals in Hypertensive Emergency:

  • Aortic dissection: the goal SBP is less than 120 or as low as clinically tolerated.

  • Acute ischemic stroke: permissive hypertension due to potentially elevated ICP. Acute treatment is indicated if:

(1) use of thrombolytic therapy

(2) other target-organ damage (dissection, MI, etc)

(3)"severe" elevations in BP SBP >220 and/or DBP >120.

  • Acute hemorrhagic stroke: Complicated data but likely SBP <160 (per UTD).

From “Hypertensive Emergencies” by: Scott Benken, PharmD found in CCSAP 2018, Book 1)

Derived from UptoDate “Drugs used for the treatment of hypertensive emergencies” and “Hypertensive Emergencies” by: Scott Benken, PharmD found in CCSAP 2018, Book 1

Derived from UptoDate “Drugs used for the treatment of hypertensive emergencies” and “Hypertensive Emergencies” by: Scott Benken, PharmD found in CCSAP 2018, Book 1

Dr. Oppegard brought up an excellent teaching point!

All patients that present with hypertensive emergency should have a work up for secondary causes of hypertension.

See below for an excellent framework for thinking about secondary hypertension from the book Frameworks for Internal Medicine which was written by one of our OHSU attendings, Dr. Andre Mansoor.

It should also be noted that the work up for endocrinologic causes of secondary hypertension can be inaccurate in the setting of acute illness and increased sympathetic drive. For example, plasma metanphrines may be falsely positive in the hospital. Thus this work up is best suited for the outpatient setting.

From  Frameworks for Internal Medicine  By: Andre Mansoor (OHSU Faculty)

From Frameworks for Internal Medicine By: Andre Mansoor (OHSU Faculty)