The Daily PANCE and PANRE Extended Edition: Question 34

A 46-year-old patient with chronic hypertension suddenly discontinues the use of his antihypertensive agent. This patient presents to your office with a blood pressure of 198/116 in the left arm. The patient denies chest pain and shortness of breath. You note no evidence of acute end-organ changes on physical examination. His laboratory studies and EKG are normal. What diagnosis will you place on this patient's chart?

1. hypertensive emergency
2. hypertensive urgency
3. malignant hypertension
4. idiopathic hypertension
5. hypertension of undetermined etiology

Answer: B

Hypertensive urgency

Traditionally, hypertensive crises have been divided into emergencies and urgencies. Hypertensive emergencies are severe elevations in blood pressure (BP) that are complicated by evidence of progressive target organ dysfunction and will require immediate BP reduction (not necessarily to normal ranges) to prevent or limit target organ damage. Examples include hypertensive encephalopathy, intracranial hemorrhage, unstable angina pectoris, or acute myocardial infarction, acute left ventricular failure with pulmonary edema, dissecting aneurysm, or eclampsia. While the level of BP at the time of presentation is usually very high (greater than 180/120 mm Hg), keep in mind that it is not the degree of BP elevation, but rather the clinical status of the patient that defines a hypertensive emergency. For example, a BP of 160/100 mm Hg in a 60-year-old patient who presents with acute pulmonary edema represents a true hypertensive emergency. Hypertensive urgencies are severe elevations of BP but without evidence of progressive target organ dysfunction and would be better defined as severe elevations in BP without acute, progressive target organ damage. Most of these patients are, in fact, nonadherent to drug therapy or are inadequately treated hypertensive patients and often present to the ED for other reasons. Patients with severe elevations of BP can be managed in the ED with oral agents and appropriate follow-up within 24 hours to several days depending upon the individual characteristics of the patient. It is the correct differentiation of these two forms of hypertensive crises, however, that presents the greatest challenge to the physician.