Hypertensive Crisis

Evolution of terminology and the target BP concept

Important terminological changes have recently taken place in emergency medical practice. The outdated term "uncomplicated hypertensive crisis" (a situation where blood pressure rises significantly, but there are no acute changes in target organs) is no longer recommended for use. Instead, a more precise concept has been introduced — "failure to achieve target BP levels".

Target BP is the level of blood pressure that a physician aims to achieve and maintain in a patient undergoing antihypertensive therapy. The main goal of this process is to minimize the risk of myocardial infarction, ischemic stroke, and target organ damage, provided that the patient tolerates the treatment well. According to current data, the optimal range is considered to be 120–129 / <80 mmHg.

Instrumental methods can be used to monitor treatment efficacy and assess the achievement of target values. For example, if the target BP is not reached, the patient is indicated for carotid-femoral pulse wave velocity measurement (performed at least once every three years).

Particular attention should be paid to uncontrolled "white-coat" hypertension. In this condition, office measurement records high blood pressure figures, whereas 24-hour ambulatory blood pressure monitoring (ABPM) shows normal values. Pathophysiologically, such patients have higher arterial stiffness, but their overall cardiovascular risk is equal to that of patients with truly controlled hypertension. If therapy is well tolerated, an increase in drug doses for optimal control is permitted.

Complication: acute left ventricular failure

One of the most severe complications of a sharp increase in blood pressure is acute left ventricular failure syndrome (pulmonary congestion). The emergency care tactics here critically depend on the current level of systolic BP.

When treating with diuretics, a physician may encounter furosemide resistance. This is often associated with hypoalbuminemia: the drug binds less effectively to albumin, and its efficacy drops. In such cases, the following approaches are used:

• Switching to torasemide, as its natriuretic and diuretic activity does not depend on blood albumin levels.
• Co-administration of furosemide and albumin solution.
• In persistent refractoriness: rotation of diuretics, addition of aldosterone antagonists or acetazolamide, combination of loop and thiazide diuretics, continuous furosemide infusion, or mechanical blood ultrafiltration (in this case, tablets are prescribed twice daily strictly on an empty stomach).

Important: Acute left ventricular failure may be directly related to acute myocardial infarction. The patient requires emergency hospitalization, serial ECG monitoring, and assessment of necrosis markers (troponins I and T, MB-CK) to determine the need for reperfusion therapy.

Hypertensive syndrome in children

In children, a sharp increase in blood pressure is most often secondary (symptomatic) in nature and frequently associated with kidney disease. A significant and rapid surge in blood pressure in a child is a life-threatening condition: it can provoke eclampsia or angiospastic encephalopathy accompanied by severe seizures.

Clinically, high blood pressure figures in children manifest as:

• Severe headache;
• Nausea and vomiting;
• Visual disturbances;
• Sharp behavioral changes (lethargy or, conversely, severe agitation).

Symptoms largely depend on the underlying disease. In acute glomerulonephritis (acute nephritic syndrome), hypertension forms a classic triad with edema and urinary syndrome (proteinuria, hematuria). The color of the urine changes: in an acidic environment, hemoglobin transforms, giving the urine a dark brown color, while in an alkaline environment, the urine resembles "meat slops".

In renovascular hypertension, the rise in blood pressure (predominantly diastolic) is persistent and treatment-resistant, while edema and urinary syndrome are absent. In reflux nephropathy, hypertension acts as a late symptom of secondary nephrosclerosis against the background of chronic renal ischemia.

The initiation of drug therapy in children is indicated upon the mere presence of symptomatic (renal) hypertension. In primary hypertension, drugs are prescribed if non-pharmacological methods have failed within 6–12 months (for stage 1 hypertension), in stable stage 2 hypertension, or in adolescents over 16 with high cardiovascular risk.

Role of related specialists

It is worth noting that the skills of managing life-threatening conditions associated with sharp blood pressure surges are mandatory not only for general practitioners or cardiologists. Physicians of related specialties, in particular dentists of any profile, are required to be able to provide emergency care for hypertensive crisis, myocardial infarction, heart failure, status epilepticus, and shock states. Performing a tracheotomy is also recognized as a mandatory practical skill in emergency situations.

Class and exam questions

What else to study on this topic

• Detailed clinical picture of hypertensive crisis in renal hypertension in children
• Emergency care algorithm for angiospastic encephalopathy with seizures
• Detailed description of target organ damage (left ventricular hypertrophy, retinopathy)
• The connection between acute left ventricular failure and acute myocardial infarction
• Mechanical treatment methods for refractory heart failure (blood ultrafiltration)

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.