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Hypertensive crisis: an update on clinical approach and management

Ipek, Emraha; Oktay, Ahmet Afşinb,c; Krim, Selim R.b,c

Current Opinion in Cardiology: July 2017 - Volume 32 - Issue 4 - p 397–406
doi: 10.1097/HCO.0000000000000398
HYPERTENSION: Edited by Hector O. Ventura and Carl J. Lavie

Purpose of review Here, we review current concepts on hypertensive crisis (HTN-C) with a focus on epidemiology, causes, pathophysiology and prognosis. We also offer a practical approach to the management of HTN-C.

Recent findings HTN-C is characterized by a severe and abrupt increase in blood pressure (BP) with impending or progressive acute end-organ damage (EOD). HTN-C can be divided into hypertensive emergency (HTN-E) and hypertensive urgency (HTN-U) based on the presence or absence of acute EOD, respectively. Recent retrospective studies have demonstrated that emergency department (ED) referrals from an outpatient clinic or rapid BP-lowering strategies in the ED do not lead to improved outcomes in patients with HTN-U.

Summary HTN-C can be a de-novo manifestation or a complication of essential or secondary HTN. The presence of acute EOD is a major poor prognostic indicator in HTN-C. The main objectives of the management of HTN-C are distinction of HTN-E from HTN-U and appropriate risk stratification, prevention or regression of acute EOD due to severely elevated BP, prevention of recurrence of HTN-C with an effective long-term management plan and avoidance of rapid lowering of BP except in some special circumstances. The majority of patients with asymptomatic HTN-U can be safely managed in the outpatient setting without exposing them to the risks of aggressive BP lowering. However, patients with HTN-E require hospitalization, prompt treatment and close monitoring.

aDepartment of Cardiology, Erzurum Training and Research Hospital, Erzurum, Turkey

bDepartment of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute

cOchsner Clinical School - The University of Queensland School of Medicine, New Orleans, Louisiana, USA

Correspondence to Selim R. Krim, MD, Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA. Tel: +1 504 842 3925; e-mail: selim.krim@ochsner.org

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