Hypertensive Crisis Management

Definitions and Diagnosis

The presence or absence of acute target organ damage is the sole deciding factor in determining whether a patient has a hypertensive emergency or urgency, not the blood pressure number itself, according to the American Heart Association 1
Hypertensive emergency is defined as severe BP elevation (>180/120 mmHg) WITH evidence of new or progressive target organ damage, with a 1-year mortality rate of >79% if untreated 1
Hypertensive urgency is defined as severe BP elevation (>180/120 mmHg) WITHOUT acute target organ damage, with patients being clinically stable and having no evidence of acute end-organ dysfunction 1

For hypertensive emergencies, the American College of Cardiology recommends reducing mean arterial pressure by no more than 25% within the first hour, then reducing to 160/100-110 mmHg over the next 2-6 hours, and cautiously normalizing BP over the following 24-48 hours 1, 2, 3
For compelling conditions such as aortic dissection, severe preeclampsia/eclampsia, and pheochromocytoma, the goal is to reduce SBP to <140 mmHg within the first hour, and for aortic dissection specifically, reduce SBP to <120 mmHg if tolerated 1
Nicardipine is recommended as a first-line agent for hypertensive emergencies, with a dose of initial 5 mg/h IV, increasing every 5 min by 2.5 mg/h to a maximum of 15 mg/h, and an onset of 5-10 minutes 1, 2, 3
Labetalol is an alternative first-line option, with a dose of 0.3-1.0 mg/kg (max 20 mg) slow IV every 10 min, or 0.4-1.0 mg/kg/h infusion up to 3 mg/kg/h, and combined alpha-1 and beta-blocker properties 1

In patients with ischemic stroke, there is no clear evidence to support immediate antihypertensive treatment, except to enable thrombolytic therapy, according to the American Stroke Association 2, 3
In patients with aortic dissection, the most aggressive target is to reduce SBP to <100-120 mmHg if tolerated, as recommended by the American College of Cardiology 1, 2, 3
In patients with eclampsia, hydralazine is traditionally preferred, though labetalol and calcium antagonists are alternatives, according to the American College of Obstetricians and Gynecologists 1

La American College of Cardiology define la emergencia hipertensiva como presión arterial severamente elevada (>180/120 mmHg) con evidencia de daño nuevo o progresivo de órgano blanco 4, 5
La tasa de mortalidad a 1 año sin tratamiento en emergencia hipertensiva es >79% 5
La American College of Cardiology clasifica la urgencia hipertensiva como presión arterial severamente elevada en pacientes estables sin daño agudo de órgano blanco 5

Evaluar sistemáticamente los siguientes sistemas: cardíaco, neurológico, renal, oftalmológico, vascular 6
La American College of Cardiology recomienda evaluar edema pulmonar cardiogénico agudo, infarto agudo de miocardio, angina inestable, insuficiencia cardíaca en el sistema cardíaco 4, 5

La American College of Cardiology recomienda reducir la presión arterial sistólica a <140 mmHg en la primera hora en casos de disección aórtica, preeclampsia severa/eclampsia, crisis de feocromocitoma 4
La American College of Cardiology recomienda reducir la presión arterial media un 20-25% en la primera hora en casos sin condición específica 5

La American College of Cardiology recomienda nicardipina como agente de primera línea para reducir la presión arterial en emergencias hipertensivas 4, 7
La European Heart Journal recomienda labetalol como agente de primera línea para reducir la presión arterial en emergencias hipertensivas 7

La American College of Cardiology recomienda reinstituir o intensificar terapia antihipertensiva oral en casos de urgencia hipertensiva 5
La American College of Cardiology recomienda no referir al departamento de emergencias ni hospitalizar en casos de urgencia hipertensiva 5

La American College of Cardiology recomienda admitir emergencias hipertensivas a UCI con monitoreo hemodinámico estrecho 5, 7
La Praxis Medical Insights recomienda transicionar a terapia oral una vez estabilizado 6