On Call: Hypertension (HTN)

Definitions

Hypertension

  • Elevated Blood Pressure: SBP ≥ 120 mmHg (DBP < 80 mmHg)
  • Hypertension, Stage 1 (Mild): ≥ 130/80 mmHg
  • Hypertension, Stage 2 (Moderate): ≥ 140/90 mmHg
  • Hypertensive Crisis (Severe): ≥ 180/120 mmHg

Causes

  • Essential Hypertension: Hypertension without Any Identifiable Cause
  • Secondary Hypertension: Hypertension Due to an Identifiable Cause

Severe Hypertension

  • Hypertensive Urgency: Severe Hypertension without Signs of End-Organ Damage
  • Hypertensive Emergency: Severe Hypertension with Signs of End-Organ Damage

Complications of Hypertension

  • Cardiac Sequelae:
    • Heart Failure
    • Acute Coronary Syndrome/Myocardial Infarction (MI)
    • Left Ventricular Hypertrophy
  • Neurologic Sequelae:
    • Ischemic Stroke
    • Intracerebral Hemorrhage
    • Hypertensive Encephalopathy
  • Vascular/Renal Sequelae:
    • Aortic Dissection
    • Acute Kidney Injury
    • Chronic Kidney Disease

Evaluation

Vitals

  • ABC’s – Airway, Breathing & Circulation
  • Vital Signs
  • Repeat Blood Pressure Reading to Ensure Accuracy

Signs of Hypertensive Emergency

  • Chest Pain
  • Back Pain
  • Dyspnea
  • Altered Mental Status
  • Seizures

Evaluate Potential Causes of Secondary Hypertension

  • Inadequate Pain Control
  • Anxiety
  • Bladder Distention
  • Acute Volume Repletion
  • Hypothermia

Inpatient Treatment

Inpatient Blood Pressure Goal

  • General Inpatient Goals:
    • SBP < 160 mmHg
    • DBP < 100 mmHg
  • Pitfalls:
    • Inpatient Goals are Poorly Defined with Minimal Evidence to Support Treating Isolated, Episodic Asymptomatic Hypertension
    • Some Patients May Require Stricter Blood Pressure Goals – Large Epidural Hematomas, Carotid Endarterectomy (CEA), etc.
    • Outpatient Goals are Generally Lower

Initial Managements

  • Aggressively Manage for Any Signs of Hypertensive Emergency – Symptomatic or Signs of End-Organ Damage
  • Treat Any Possible Secondary Causes – Pain, etc.
  • Restart Any Previously Held Home Antihypertensive Medications

General Approach

  • Generally Start with PRN IV Medications
    • Common Starting Medications: Hydralazine or Labetalol
  • May Require Antihypertensive Drip (gtt) for Urgent and Precise Control
  • Consider Adding a Long-Acting Oral Medication if Continuing to Require Frequent IV Dosing

Antihypertensive Medications

IV PRN (As Needed)

IV gtt (Drips)

PO (Oral)