Hypertensive Emergencies: The Daily PANCE Blueprint

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Hypertensive Emergencies: The Daily PANCE Blueprint

A 77-year-old male with a history of substance abuse and hypertension presents to the ER with shortness of breath and altered mentation. Vitals reveal elevated blood pressure (208/122 mmHg) and hypoxemia (SpO2 87%). Labs reveal elevated serum creatinine (SCr 2.1). A chest radiograph demonstrates pulmonary edema. CT head is negative. Which of the following is the most appropriate way to lower this patient’s blood pressure?

A. Reduce the mean arterial pressure by 20% over the first hour and then lower BP to 160/110 mmHg over 2-6 hours
B. Reduce the mean arterial pressure by 30% over the first hour and then lower BP to 180/100 mmHg over 8 hours
C. Reduce the mean arterial pressure by 15% over the first hour and then lower BP to 140/60 mmHg over 12 hours
D. Rapidly reduce the mean arterial pressure by 50% over the first hour to SBP < 120 mmHg
E. None of the above

Answer and topic summary

The answer is A. Reduce the mean arterial pressure by 20% over the first hour and then lower BP to 160/110 mmHg over 2-6 hours

Hypertensive emergency is an acute elevation of blood pressure with evidence of end-organ damage. Usually, the blood pressure will be at least above a systolic BP > 180 mmHg and/or diastolic BP > 120 mmHg. Etiologies include abrupt withdrawal of anti-hypertensives, non-compliance, cocaine, pheochromocytoma, & eclampsia. Examples of end-organ damage include acute kidney injury, encephalopathy, pulmonary edema, and hemorrhagic stroke. Workup may include CMP, CBC, UA, urine drug screen, troponin, EKG, electrolytes, chest cardiograph, CT head, etc. Management is reducing the mean arterial pressure by 20% over the first hour and then lowering BP to 160/110 mmHg over the next two to six hours. First-line agents include nicardipine, labetalol, and nitroglycerin. Exceptions to the lowering rule include ischemic stroke, aortic dissection, and intracerebral hemorrhage.

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Smarty PANCE Content Blueprint Review:

Covered under ⇒ PANCE Blueprint Cardiology ⇒ Hypertension (PEARLS) ⇒ Hypertensive emergencies

Also covered as part of the Emergency Medicine EOR topic list