7th Brazilian Guideline of Arterial Hypertension: Chapter 14 - Hypertensive Crisis

1 The HUs are symptomatic clinical situations in which there is significant BP elevation (arbitrarily defined as DBP ≥ 120 mm Hg) without acute and progressive TOD. The HEs are symptomatic clinical situations in which there is significant BP elevation (arbitrarily defined as DBP ≥ 120 mm Hg) with acute and progressive TOD. 2,3 Patients complaining from headache, atypical chest pain, dyspnea, acute psychological stress, and panic syndrome associated with high BP levels characterize neither HU nor HE, but rather a pseudo hypertensive crisis. Treatment comprises the optimization of antihypertensive drugs and raising awareness about treatment adherence. Classification Chart 1 shows the classification of HE, and Chart 2 differentiates HU from HE regarding diagnosis, prognosis and management. Major epidemiological, pathophysiological and prognostic aspects Epidemiology Hypertensive crisis accounts for 0.45-0.59% of all hospital emergency treatments, while HE accounts for 25% of all cases of HC, ischemic stroke and APE, which are the most frequent HEs. Pathophysiology Increased intravascular volume and PVR, or reduced production of endogenous vasodilators seem to precipitate greater vascular reactivity, resulting in HC. 7 Self-regulation is compromised, particularly in the cerebral and renal vascular beds, resulting in local ischemia, which triggers a vicious circle of vasoconstriction, myointimal proliferation and target-organ ischemia. 8 Prognosis Survival up to 5 years is significantly higher in individuals with HU than with HE. Absence of nocturnal dipping associates with higher risk for TOD and consequent endothelial dysfunction, a situation involved in acute BP elevation. 10 Complementary clinical and laboratory investigation Clinical and laboratory investigation should properly assess BP and TOD. Initially, BP should be measured in both arms, preferably in a calm environment, and repeatedly until stabilization (minimum of 3 measurements). Data on the patient's usual BP should be rapidly collected, as well as information on situations that can raise it (anxiety, pain, salt), comorbidities, use of antihypertensive drugs (dosage and adherence) or drugs that can increase BP (anti-inflammatory drugs, corticoids, sympathomimetic drugs, alcohol). A systematic approach helps to check for the presence of acute and progressive TOD: arteriovenous crossings, arterial wall thickening and silver-or copper-wire aspect. The treatment of HU should begin after a period of clinical observation in a calm environment, which helps to rule out the cases of pseudocrisis (treated with only rest or use of painkillers or tranquilizers). Captopril, clonidine and Chart 1 – Classification of hypertensive emergencies HYPERTENSIVE EMERGENCIES Cerebrovascular-Hypertensive encephalopathy-Intracerebral hemorrhage-Subarachnoid hemorrhage-Ischemic stroke Cardiocirculatory-Acute aortic dissection-APE with …