Hypertensive Crisis Signs and Symptoms

Last updated: 04 September 2024
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Introduction

Important note: The clinical differentiation between hypertensive emergencies and urgencies is dependent on the presence of target organ damage (TOD) rather than the level of blood pressure (BP)

  • For successful management of patients, it is necessary to differentiate hypertensive emergencies from hypertensive urgencies

Definition

Hypertensive Emergency

  • Severely elevated BP (systolic BP [SBP] ≥180 mmHg and/or diastolic BP [DBP] ≥110-120 mmHg) that is complicated by progressive or worsening TOD of the central nervous system (CNS), heart, kidneys, lungs, large arteries, retina or the gravid uterus
  • There is no definite BP threshold for the diagnosis of hypertensive emergency
  • Most TOD happen with DBP ≥130 mmHg

Hypertensive Urgency

  • Refers to patients with severely elevated BP (≥180 mmHg/110-120 mmHg) but with no evidence of acute end-organ damage, usually asymptomatic with a mild headache 
  • Frequently associated with non-compliance to or discontinuing or decreasing treatment as well as anxiety, acute pain, emotional stress or non-adherence to a low-sodium diet

Signs and Symptoms

  • Hypertensive encephalopathy may present with:
    • Neurologic symptoms like headache, dizziness, altered level of consciousness, seizures, agitation, and visual disturbances
      • Focal neurologic findings can occur, although rare, and should raise suspicion of acute ischemic stroke or cerebral hemorrhage
    • These patients usually have advanced retinopathy with arteriolar changes, hemorrhages and exudates, along with papilledema
  • Patients suspected of aortic dissection may present with severe chest pain, back pain, unequal pulses and widened mediastinum
  • Patients suffering from cardiac decompensation may have chest pain or pressure, dyspnea, cough, orthopnea or pulmonary edema
  • Renal failure may be suspected if oliguria and/or hematuria is present
  • Patients may also present with acute myocardial infarction (AMI) or angina
  • Patients with increased intracranial pressure (ICP) may present with nausea and vomiting
  • Preeclampsia or eclampsia may develop in pregnant patients with severe hypertension
  • Patients with hypertensive urgency may present with severe headache, shortness of breath, chest pain, edema, epistaxis, severe anxiety or faintness