Pathophysiology
This is the defining feature that separates a hypertensive emergency from hypertensive urgency.
Acute hypertension-mediated target-organ damage (e.g., neurologic deficits, pulmonary edema, MI/ischemia, AKI, aortic dissection, eclampsia).
About how many adults have high blood pressure in the U.S.?
Around 1 in 3.
When a patient’s blood pressure is ≥180/120, what’s the most important first step to figure out in the ER?
Check if there’s acute organ damage (to decide emergency vs urgency).
What imaging test do you order first if a hypertensive patient has sudden headache or neuro symptoms?
CT scan of the head (no contrast).
With age, arteries get stiffer. What kind of hypertension does this cause?
Isolated systolic hypertension.
Very high blood pressure can overwhelm this brain mechanism, leading to headache, confusion, or seizures.
Very high blood pressure can overwhelm this brain mechanism, leading to headache, confusion, or seizures.
Name one common cause for a hypertensive emergency related to medicines.
Not taking meds (nonadherence) or drug use like cocaine.
Which IV drug lowers blood pressure very fast but can cause cyanide toxicity?
Sodium nitroprusside.
What chest X-ray finding shows fluid in the lungs from high blood pressure?
Pulmonary edema.
This reflex that helps regulate BP is weaker in older adults, making them more prone to dizziness when standing.
Baroreflex.
Why can two patients with the same blood pressure have different risks for emergency? (Hint: Baselines)
It’s the rapid rise from their baseline that matters, not just the absolute number.
Give two examples of secondary causes of hypertension.
Renal artery stenosis and primary aldosteronism (others: pheochromocytoma, thyroid disease).
Which IV drug blocks both alpha and beta receptors and is safe in pregnancy?
Labetalol.
What EKG changes could mean a hypertensive emergency with heart involvement?
ST changes, arrhythmia, or LV strain.
Why are kidneys in older adults more likely to get injured in a hypertensive crisis?
They already have lower GFR and blood flow.
If the kidneys are injured in a hypertensive crisis, which lab test usually goes up?
Creatnine
Which lab test ratio screens for primary aldosteronism?
Aldosterone-to-renin ratio (ARR).
Which calcium channel blocker is good for long-term BP control but not for acute crisis?
Amlodipine.
What heart test helps look for heart failure or dissection?
Echocardiogram (TTE/TEE).
How much (Percentage) should you lower mean arterial pressure in the first hour or two of a hypertensive emergency?
About 20–25%.
Severe chest pain with unequal pulses in a hypertensive crisis makes you worry about what?
Aortic Disection
What imaging test can check kidney blood vessels for narrowing?
Renal Doppler ultrasound.
This nonselective beta-blocker is not usually first-line in emergencies and can cause problems in asthma.
Propranolol
On kidney Doppler, what high index suggests poor kidney blood flow?
High renal resistive index.
Where should patients with hypertensive emergency be managed, especially if older?
ICU with continuous monitoring.