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Balahura AM, Moroi ȘI, Scafa-Udrişte A, Weiss E, Japie C, Bartoş D, Bădilă E. The Management of Hypertensive Emergencies-Is There a "Magical" Prescription for All? J Clin Med 2022; 11:3138. [PMID: 35683521 PMCID: PMC9181665 DOI: 10.3390/jcm11113138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 05/29/2022] [Accepted: 05/30/2022] [Indexed: 12/04/2022] Open
Abstract
Hypertensive emergencies (HE) represent high cardiovascular risk situations defined by a severe increase in blood pressure (BP) associated with acute, hypertension mediated organ damage (A-HMOD) to the heart, brain, retina, kidneys, and large arteries. Blood pressure values alone do not accurately predict the presence of HE; therefore, the search for A-HMOD should be the first step in the management of acute severe hypertension. A rapid therapeutic intervention is mandatory in order to limit and promote regression of end-organ damage, minimize the risk of complications, and improve patient outcomes. Drug therapy for HE, target BP, and the speed of BP decrease are all dictated by the type of A-HMOD, specific drug pharmacokinetics, adverse drug effects, and comorbidities. Therefore, a tailored approach is warranted. However, there is currently a lack of solid evidence for the appropriate treatment strategies for most HE. This article reviews current pharmacological strategies while providing a stepwise, evidence based approach for the management of HE.
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Affiliation(s)
- Ana-Maria Balahura
- Internal Medicine Department, Bucharest Clinical Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.W.); (C.J.); (D.B.)
| | - Ștefan-Ionuț Moroi
- Department of Cardiology, Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C. Iliescu”, 022328 Bucharest, Romania;
| | - Alexandru Scafa-Udrişte
- Cardiology Department, Bucharest Clinical Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania;
| | - Emma Weiss
- Internal Medicine Department, Bucharest Clinical Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.W.); (C.J.); (D.B.)
| | - Cristina Japie
- Internal Medicine Department, Bucharest Clinical Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.W.); (C.J.); (D.B.)
| | - Daniela Bartoş
- Internal Medicine Department, Bucharest Clinical Emergency Hospital, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania; (E.W.); (C.J.); (D.B.)
| | - Elisabeta Bădilă
- Department of Cardiology, Colentina Hospital, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania;
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Abstract
ABSTRACT While acute blood pressure elevations are commonly seen in the ED, not all require emergency treatment. True hypertensive emergencies are characterized by a rapid elevation in blood pressure to a level above 180/120 mmHg and are associated with acute target organ damage, which requires immediate hospitalization for close hemodynamic monitoring and IV pharmacotherapy. Recognizing the clinical signs and symptoms of hypertensive emergency, which may vary widely depending on the target organ involved, is critical. High blood pressure levels that produce no signs or symptoms of target organ damage may be treated without hospitalization through an increase in or reestablishment of previously prescribed oral antihypertensive medication. However, all patients presenting with blood pressure this high should undergo evaluation to confirm or rule out impending target organ damage, which differentiates hypertensive emergency from other hypertensive crises and is vital in facilitating appropriate emergency treatment. Drug therapy for hypertensive emergency is influenced by end-organ involvement, pharmacokinetics, potential adverse drug effects, and patient comorbidities. Frequent nursing intervention and close monitoring are crucial to recuperation. Here, the authors define the spectrum of uncontrolled hypertension; discuss the importance of distinguishing hypertensive emergencies from hypertensive urgencies; and describe the pathophysiology, clinical manifestations, and management of hypertensive emergencies.
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Affiliation(s)
- Essie P Mathews
- Kartavya Sharma is an assistant professor in the Departments of Neurology and Neurological Surgery at the University of Texas Southwestern Medical Center, Dallas, where Essie P. Mathews is an advanced practice RN in the Department of Neurology and Faith Newton is an adult-gerontology acute care NP in the Department of Neurology. Contact author: Kartavya Sharma, . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the authors is available at www.ajnonline.com
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Shantsila A, Lip GYH. Malignant Hypertension Revisited-Does This Still Exist? Am J Hypertens 2017; 30:543-549. [PMID: 28200072 DOI: 10.1093/ajh/hpx008] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 01/06/2017] [Indexed: 12/27/2022] Open
Abstract
Malignant or accelerated hypertension is the most severe form of hypertension, defined clinically by very high blood pressure (diastolic above 130 mm Hg) accompanied by bilateral retinal hemorrhages and/or exudates, with or without papilledema. The aim of this review is to discuss if malignant hypertension still poses a clinically relevant entity and to highlight the diagnostic challenges of this form of hypertension. The substantial improvement in prognosis in patients with malignant hypertension over the last decades is well documented, but there is no strong evidence to suggest a significant change in its incidence. In fact, with the growing population and improving life expectancy, malignant hypertension is likely to become even more prevalent worldwide, especially in the developing countries with less advanced health care services. Despite simple diagnostic criteria of malignant hypertension, the diagnoses may be difficult in many patients. Malignant hypertension patients often have the diagnosis established only when the target organ damage occur. Furthermore, retrospective diagnosis is problematic, as malignant hypertensive retinopathy gradually resolves over a relatively short period of time, while persistent target organ damage will, however, lead to the development of complications and much poorer prognosis than in nonmalignant hypertension patients. Certainly, malignant hypertension still poses a clinically relevant and challenging form of hypertension and its possibility should be always considered during the assessment of patients with poorly controlled hypertension.
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Affiliation(s)
- Alena Shantsila
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Huang H, Luo Y, Liang Y, Long X, Peng Y, Liu Z, Wen X, Jia M, Tian R, Bai C, Li C, He F, Lin Q, Wang X, Dong X. CD4(+)CD25(+) T Cells in primary malignant hypertension related kidney injury. Sci Rep 2016; 6:27659. [PMID: 27278520 PMCID: PMC4899787 DOI: 10.1038/srep27659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/18/2016] [Indexed: 01/10/2023] Open
Abstract
CD4+CD25+ T cells are critical for maintenance of immunologic self-tolerance. We measured the number of CD4+CD25+ cells in the patients with primary malignant hypertension related kidney injury, to explore the molecular pathogenesis of this disease. We selected 30 patients with primary malignant hypertension related kidney injury and 30 healthy volunteers. Information on clinical characteristics and laboratory tests was obtained from each subject. The number of CD4+CD25+ cells and glomerular injury were assessed by flow cytometry and histopathology, respectively. Both serum IL-2, IL-4, and IL-6 and endothelial cell markers were analyzed by ELISA. ADAMTS13 antibody was detected by Western blotting. CD4+CD25+ cells were significantly reduced in patients with primary malignant hypertension related kidney injury compared to controls (P < 0.05). The number of CD4+CD25+ cells was negatively related to blood urea nitrogen, serum uric acid, proteinuria, and supernatant IL-4; whereas positively associated with estimated glomerular filtration rate in patients. Gradually decreasing CD4+CD25+ cells were also found as increasing renal injury. Additionally, patients exhibited increasing supernatant IL-4, serum IL-2 and IL-6, endothelial cell markers, and anti-ADAMTS13 antibody compared with controls (all P < 0.05). CD4+CD25+ cells may play a key role in the pathogenesis of primary malignant hypertension related kidney injury.
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Affiliation(s)
- Hongdong Huang
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China.,Division of Nephrology, Hunan Normal University, Hunan Provincial People's Hospital of China, Changsha, Hunan Province, P.R. China
| | - Yang Luo
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China
| | - Yumei Liang
- Division of Nephrology, Hunan Normal University, Hunan Provincial People's Hospital of China, Changsha, Hunan Province, P.R. China
| | - Xidai Long
- Department of Liver Surgery, the Affiliated Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Youming Peng
- Hunan Key Laboratory of Nephrology and Hemoperfusion, Division of Nephrology, Second Xiangya Hospital of Central South University, Changsha, Hunan Province, P.R. China
| | - Zhihua Liu
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China
| | - Xiaojun Wen
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China
| | - Meng Jia
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China
| | - Ru Tian
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China
| | - Chengli Bai
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China
| | - Cui Li
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China
| | - Fuliang He
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China.,Section of Hematology/Oncology, Section of Gastroenterology, Stephenson Cancer Center, Department of Internal Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, USA
| | - Qiushi Lin
- Section of Hematology/Oncology, Section of Gastroenterology, Stephenson Cancer Center, Department of Internal Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, USA
| | - Xueyan Wang
- Center of Allergy, Beijing Shijitan Hospital, Capital Medical University, Beijing, P.R. China
| | - Xiaoqun Dong
- Department of Interventional Therapy, Beijing Shijitan Hospital, Capital Medical University, The 9th Affiliated Hospital of Peking University, Beijing, P.R. China.,Section of Hematology/Oncology, Section of Gastroenterology, Stephenson Cancer Center, Department of Internal Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, USA
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