Hypertensive Crisis

A hypertensive crisis is a rapid and significant increase in blood pressure, with systolic values exceeding 180 mmHg and diastolic values above 120 mmHg. If left untreated, it can lead to acute organ damage affecting the brain, heart, kidneys, and vascular system, requiring urgent or emergency medical intervention.

A hypertensive urgency is characterized by a marked increase in blood pressure without acute organ damage. The patient may present with symptoms such as throbbing headache, visual disturbances, tachycardia, shortness of breath, and tinnitus. However, there are no immediate signs of organ failure. Blood pressure should be gradually reduced over 24-48 hours to avoid the risk of cerebral and renal hypoperfusion.

A hypertensive emergency, on the other hand, occurs when blood pressure reaches critical levels, exceeding 220/140 mmHg, and causes acute organ damage with potential complications such as ischemic or hemorrhagic stroke, myocardial infarction, pulmonary edema, aortic dissection, and acute renal failure. In such cases, rapid blood pressure reduction with intravenous medications is necessary.

A hypertensive crisis can be triggered by several factors, including poor adherence to antihypertensive therapy, leading to sudden increases in blood pressure. Acute medical conditions, such as renal failure or endocrine disorders (e.g., pheochromocytoma), may also cause severe hypertensive episodes. Factors such as extreme stress, the use of sympathomimetic substances (cocaine, amphetamines), or preeclampsia during pregnancy contribute to the onset of a crisis.

Clinical Manifestations

Symptoms vary depending on the severity of blood pressure elevation and the involvement of target organs. The patient may report an intense headache, often occipital, associated with visual disturbances and mental confusion. In more severe cases, symptoms such as chest pain, shortness of breath, and neurological deficits may appear, indicating ongoing brain damage.
Some patients may experience epistaxis (nosebleeds), which can indicate extremely high blood pressure.

Hypertensive crises can cause irreversible damage to target organs. At the brain level, high blood pressure can lead to ischemic or hemorrhagic stroke, causing permanent neurological deficits. The heart may suffer from myocardial infarction or acute heart failure, while the kidneys may experience ischemic damage progressing to acute renal failure. The retina may also be affected, leading to optic disc edema and retinal hemorrhages.

Treatment of Hypertensive Crisis

Management of hypertensive crises varies depending on whether or not organ damage is present:

• Hypertensive Urgency (not associated with acute organ damage):
  • Gradual blood pressure control with oral antihypertensive medications: Blood pressure should be reduced over 24-48 hours to avoid cerebral and renal hypoperfusion. ACE inhibitors (captopril, enalapril), calcium channel blockers (amlodipine, sustained-release nifedipine), and beta-blockers (labetalol, metoprolol) are used depending on the patient's clinical condition.
  • Optimization of long-term antihypertensive therapy: After initial crisis management, it is essential to adjust maintenance therapy to prevent recurrence by combining multiple drug classes and monitoring blood pressure regularly.
• Hypertensive Emergency (associated with acute organ damage): Requires immediate treatment with intravenous medications:
  • Vasodilators such as sodium nitroprusside, which rapidly lowers blood pressure.
  • Nitroglycerin, used in patients with associated myocardial ischemia.
  • Beta-blockers such as labetalol, particularly effective in hypertensive emergencies.
  • Phentolamine, indicated for hypertensive crises secondary to pheochromocytoma.

Prevention

To reduce the risk of hypertensive crises, it is essential to:
Strictly follow prescribed antihypertensive therapy and avoid sudden medication discontinuation.
Regularly monitor blood pressure and consult a physician in case of persistently high values.
Adopt a healthy lifestyle, including a low-sodium diet, regular physical activity, and weight control.
Avoid substances that can induce severe hypertension, such as alcohol and stimulant drugs.

Conclusion

A hypertensive crisis is a severe clinical condition that requires immediate attention. Early symptom recognition and appropriate treatment are crucial to prevent irreversible organ damage. Long-term blood pressure control and optimal risk factor management can significantly reduce the risk of recurrence and complications.

References
1. Whelton PK, et al. 2023 Guidelines for the Management of Hypertension. J Am Coll Cardiol. 2023;81(7):e93-e226.
2. Liu L, et al. Hypertensive Crisis: Pathophysiology, Clinical Presentation, and Management. Hypertension. 2022;79(5):e38-e50.
3. Mancia G, et al. European Society of Hypertension Guidelines for the Treatment of Hypertensive Emergencies. J Hypertens. 2021;39(9):1729-1744.
4. Williams B, et al. Hypertensive Emergencies and Urgencies: Clinical Practice Update. The Lancet. 2021;398(10310):1207-1219.
5. James PA, et al. Acute Management of Severe Hypertension. Ann Intern Med. 2020;172(3):181-194.
6. Khosla N, et al. Beta-Blockers and Vasodilators in Hypertensive Crisis: Mechanisms and Efficacy. Am J Med. 2019;132(6):715-723.