Teaching Pearls:

• Distinguish whether elevated blood pressure is secondary to other etiologies, including brain bleed, aortic dissection, drug use, etc
• Hypertensive emergency/urgency is a diagnosis of exclusion. Defined as very high blood pressure with active end organ damage. End-organ damage includes:
  • Acute encephalopathy
  • Pulmonary edema
  • Aortic dissection
• Cushing’s Reflex: Hypertension, Bradycardia, and Respiratory variation.
• In LVH, you can commonly see T wave inversions along lateral leads due to repolarization abnormalities.
• Hypokalemia, Metabolic Alkalosis, Hypertension –> consider hyperaldosteronism, bilateral renal artery stenosis, or Cushing’s syndrome. Check Renin and Aldosterone levels:
  • Elevated Renin/Elevated Aldosterone –> bilateral renal artery stenosis
  • Low Renin, Elevated Aldosterone –> Conn’s syndrome
  • Low Renin, Low Aldosterone –> Consider Cushing’s syndrome as corticosteroids can still bind to mineralocorticoid receptors.
• Treatment for Hypertensive emergency: Decrease of blood pressure 10-20% within the first hour. Then 5-15% for the next 23 hours. No more than 25% within the first 24 hours to prevent hypoperfusion.
• Two exceptions are acute CVA and aortic dissection.
  • Acute CVA – no need to treat unless BP>185/110 with consideration of tPA, or BP>220/120
  • Aortic Dissection – Important to treat aggressively to goal SBP 100-120. Use beta blockers.
•  Medications For Treatment
  • Nitroglycerin gtt, Nitroprusside (fast onset, short half life, risk factors for cyanide toxicity include AKI, increased infusion rate)
  • Beta Blockers – Labetalol or esmolol
  • Calcium Channel Blockers – Nicardipine