Hypertension, being one of the most common diseases worldwide, results in many complications. According to a recent study done in Malaysia, it is reported that approximately 50% of the adult population is diagnosed with hypertension, a medical term for high blood pressure. Hypertension is a multifactorial disease that can be caused by old age, unhealthy diet, stress, or it could be secondary to other concomitant medications; just to name a few. Unlike other diseases that show some kind of symptoms, hypertension is asymptomatic where you wouldn’t know you have it unless you take your blood pressure readings from time to time and is hence known as the “silent killer”. However, occasionally, hypertensive patients may experience early morning headaches, irregular heart beats, fatigue, chest pain or nausea and vomiting.
Today, we’ll be introducing 2 hypertensive crises; namely hypertensive urgency and hypertensive emergency that you may or may not have come across. Hypertensive crisis is defined as an elevated blood pressure that spikes up to 180/110 mmHg or even higher.
*The blood pressure reference range for a healthy adult is 120/80 mmHg.
How is hypertensive urgency different from hypertensive emergency?
The most distinct difference between hypertensive urgency and hypertensive emergency is that hypertensive urgency does not involve any organ damage or fatal complications whereas hypertensive emergency does. That said, treatment of hypertensive urgency is in oral form (ie: tablets, capsules) and is often treated in the outpatient setting while hypertensive emergency would warrant immediate medical care with fast-acting intravenous (IV) treatment to prevent further exacerbation of organ damage (ie: acute kidney failure, heart attack, heart failure, stroke).
Image credit: CPG Management of Hypertension 5th Ed (2018)
Who is at risk?
Hypertensive crisis is normally seen among hypertensive patients who consistently have uncontrolled, elevated blood pressure possibly due to medication non-adherence, poor eating habits, taking supplements that could increase blood pressure or they may be completely unaware that they have hypertension.
Sign and Symptoms of Hypertensive Crisis
Some patients may experience little to no symptoms while others may experience symptoms including:
i) confusion
ii) severe anxiety
iii) chest pain (angina)
iv) shortness of breath
v) visual changes
vi) nosebleed
vii) fits or seizures
Clinically, to identify whether patient is suffering from either hypertensive urgency or emergency, the attending physician may order specific tests such as:
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Routine blood pressure monitoring
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Eye exam to assess for any bleeding or swelling
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Blood and urine testing
Treatment options
Hypertensive Urgency:
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Captopril 12.5mg
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Nifedipine 10mg
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Labetalol 200mg
Hypertensive Emergency:
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IV Labetalol
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Nitroglycerine
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Isosorbide dinitrate
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Hydralazine
It is worth noting that lowering BP abruptly is not favourable as it may obstruct blood flow to other organs that may require high blood pressure and cause decreased blood flow (ischemic events). For instance, in hypertensive urgency, blood pressure ideally should not decrease more than 25% of its initial reading over 24 hours and not lower than 160/100 mmHg. Meanwhile in hypertensive emergency, the desired outcome would be nothing more than a 25% reduction of BP in the first hour.
All in All
As the classic saying goes, prevention is better than cure. Due to the silent nature of hypertension, hypertensive crisis may happen unannounced to anyone, at any time. Thus, it is of utmost importance for all hypertensive patients to take their prescribed antihypertensives as instructed and to avoid taking any herbal supplements or traditional medicines without verifying through your doctor. Regular monitoring of BP alongside with tracking your BP readings in a logbook should also be practised to allow revision in treatment plan if BP is found to be high consistently.
Written by Janelle Leong, Bpharm(Hons);
Medically reviewed by Nur Ariffin, MBBS UniSZA
References:
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High Blood Pressure and Hypertensive Crisis - WebMD
Available at https://www.webmd.com/hypertension-high-blood-pressure/guide/hypertensive-crisis Accessed on 3rd September 2022 -
What to know about Hypertensive Crises - Medical News Today. Available at https://www.medicalnewstoday.com/articles/hypertensive-crisis Accessed on 3rd September 2022
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Clinical Practice Guidelines Management for Hypertension (MOH) 5th Ed 2018. Available at https://www.moh.gov.my/moh/resources/penerbitan/CPG/MSH%20Hypertension%20CPG%202018%20V3.8%20FA.pdf Accessed on 3rd September 2022
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Hypertensive Crises: Urgencies & Emergencies - US Pharmacist. Available at https://www.uspharmacist.com/article/hypertensive-crises-urgencies-and-emergencies#:~:text=Hypertensive%20urgencies%20may%20be%20treated%20on%20an%20outpatient%20basis%2C%20by,antihypertensives%20in%20an%20inpatient%20setting. Accessed on 3rd September 2022
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The prevalence of hypertension among Malaysian adults and its associated risk factors: data from Malaysian Community Salt Study (MyCoSS) Available at https://pubmed.ncbi.nlm.nih.gov/34059165/ Accessed on 3rd September 2022
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WHO Hypertension Fact Sheet. Available at https://www.who.int/news-room/fact-sheets/detail/hypertension#:~:text=When%20symptoms%20do%20occur%2C%20they,chest%20pain%2C%20and%20muscle%20tremors Accessed on 4th September 2022
