Login Register Cart 0
Generic placeholder image

Current Vascular Pharmacology

Editor-in-Chief

ISSN (Print): 1570-1611
ISSN (Online): 1875-6212

Back
Journal Home About Journal Editorial Board Journal Insight Current Issue Volumes/Issues
Subscribe
Review Article

Proposal of a Modified Classification of Hypertensive Crises: Urgency, Impending Emergency, and Emergency

Author(s): Goran Koracevic, Milovan Stojanovic*, Marija Zdravkovic, Dragan Lovic, Dragan Simic and Katarina Mladenovic

Volume 22, Issue 3, 2024

Published on: 14 December, 2023

Page: [180 - 186] Pages: 7

DOI: 10.2174/0115701611270174231204110557

Price: $65

Abstract

Systemic arterial hypertension (HTN) is the main cause of morbidity and mortality, and HTN crises contribute significantly to an unfavourable clinical course. For decades, HTN crises have been dichotomized into hypertensive emergency (HTN-E) and hypertensive urgency (HTN-U). The main difference between the two is the presence of acute hypertension-mediated organ damage (HMOD) – if HMOD is present, HTN crisis is HTN-E; if not, it is HTN-U. Patients with HTN-E are in a life-threatening situation. They are hospitalized and receive antihypertensive drugs intravenously (IV). On the other hand, patients with HTN-U are usually not hospitalized and receive their antihypertensives orally. We suggest a modification of the current risk stratification scheme for patients with HTN crises. The new category would be the intermediate risk group, more precisely the ‘impending HTN-E’ group, with a higher risk in comparison to HTN-U and a lower risk than HTN-E. ‘Impending HMOD’ means that HMOD has not occurred (yet), and the prognosis is, therefore, better than in patients with ongoing HMOD. There are three main reasons to classify patients as having impending HTN-E: excessively elevated BP, high-risk comorbidities, and ongoing bleeding/high bleeding risk. Their combinations are probable. This approach may enable us to prevent some HTNEs by avoiding acute HMOD using a timely blood pressure treatment. This treatment should be prompt but controlled.

« Previous Next »
Graphical Abstract

[1]
Karakayali M, Omar T, Artac I, Rencuzogullari İ, Karabag Y, Demir O. The relationship between the systemic immune‐inflammation index and reverse‐dipper circadian pattern in newly diagnosed hypertensive patients. J Clin Hypertens 2023; 25(8): 700-7.
[http://dx.doi.org/10.1111/jch.14688] [PMID: 37464585]
[2]
Karakayali M, Artac I, Omar T, et al. The association between frontal QRS-T angle and reverse dipper status in newly diagnosed hypertensive patients. Blood Press Monit 2023; 28(2): 96-102.
[http://dx.doi.org/10.1097/MBP.0000000000000637] [PMID: 36916470]
[3]
Altunova M, Püşüroğlu H, Karakayali M, et al. Relationship between fragmented QRS complex and long-term cardiovascular outcome in patients with essential hypertension. Anatol J Cardiol 2022; 26(6): 442-9.
[http://dx.doi.org/10.5152/AnatolJCardiol.2022.1322] [PMID: 35703480]
[4]
Pokharel Y, Karmacharya BM, Neupane D. Hypertension-A silent killer without global bounds. J Am Coll Cardiol 2022; 80(8): 818-20.
[http://dx.doi.org/10.1016/j.jacc.2022.05.043] [PMID: 35981825]
[5]
Lee EKP, Poon P, Yip BHK, et al. Global burden, regional differences, trends, and health consequences of medication nonadherence for hypertension during 2010 to 2020: A meta‐analysis involving 27 million patients. J Am Heart Assoc 2022; 11(17): e026582.
[http://dx.doi.org/10.1161/JAHA.122.026582] [PMID: 36056737]
[6]
Burnier M, Damianaki A. Hypertension as cardiovascular risk factor in chronic kidney disease. Circ Res 2023; 132(8): 1050-63.
[http://dx.doi.org/10.1161/CIRCRESAHA.122.321762] [PMID: 37053276]
[7]
Lauder L, Mahfoud F, Azizi M, et al. Hypertension management in patients with cardiovascular comorbidities. Eur Heart J 2023; 44(23): 2066-77.
[http://dx.doi.org/10.1093/eurheartj/ehac395] [PMID: 36342266]
[8]
De Bhailis ÁM, Kalra PA. Hypertension and the kidneys. Br J Hosp Med 2022; 83(5): 1-11.
[http://dx.doi.org/10.12968/hmed.2021.0440] [PMID: 35653320]
[9]
Campbell NRC, Whelton PK, Orias M, et al. 2022 World hypertension league, resolve to save lives and international society of hypertension dietary sodium (salt) global call to action. J Hum Hypertens 2022; 37(6): 428-37.
[http://dx.doi.org/10.1038/s41371-022-00690-0] [PMID: 35581323]
[10]
Egan BM, Kjeldsen SE, Grassi G, Esler M, Mancia G. The global burden of hypertension exceeds 1.4 billion people. J Hypertens 2019; 37(6): 1148-53.
[http://dx.doi.org/10.1097/HJH.0000000000002021] [PMID: 30624370]
[11]
Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39(33): 3021-104.
[http://dx.doi.org/10.1093/eurheartj/ehy339] [PMID: 30165516]
[12]
Zuo X, Liu L, Liu K, et al. Proximal aorta dilatation in hypertension. J Hypertens 2023; 41(10): 1511-20.
[http://dx.doi.org/10.1097/HJH.0000000000003518] [PMID: 37642588]
[13]
Li Z, Wang W, Sang F, Zhang Z, Li X. White matter changes underlie hypertension-related cognitive decline in older adults. Neuroimage Clin 2023; 38: 103389.
[http://dx.doi.org/10.1016/j.nicl.2023.103389] [PMID: 37004321]
[14]
Tomek A. The impact of uncontrolled hypertension on the CNS. Vnitr Lek 2023; 69(2): 105-8.
[http://dx.doi.org/10.36290/vnl.2023.017] [PMID: 37072268]
[15]
Pac M, Obrycki Ł, Koziej J, Skoczyński K, Starnawska-Bojsza A, Litwin M. Assessment of hypertension-mediated organ damage in children and adolescents with hypertension. Blood Press 2023; 32(1): 2212085.
[http://dx.doi.org/10.1080/08037051.2023.2212085] [PMID: 37259507]
[16]
Rizzoni D, Agabiti-Rosei C, De Ciuceis C. State of the art review: Vascular remodeling in hypertension. Am J Hypertens 2023; 36(1): 1-13.
[http://dx.doi.org/10.1093/ajh/hpac093] [PMID: 35961002]
[17]
Lu Q, Zhang Y, Geng T, et al. Association of lifestyle factors and antihypertensive medication use with risk of all-cause and cause-specific mortality among adults with hypertension in China. JAMA Netw Open 2022; 5(2): e2146118.
[http://dx.doi.org/10.1001/jamanetworkopen.2021.46118] [PMID: 35103793]
[18]
Guiga H, Decroux C, Michelet P, et al. Hospital and out‐of‐hospital mortality in 670 hypertensive emergencies and urgencies. J Clin Hypertens 2017; 19(11): 1137-42.
[http://dx.doi.org/10.1111/jch.13083] [PMID: 28866866]
[19]
Fragoulis C, Polyzos D, Dimitriadis K, et al. Sex-related cardiovascular prognosis in patients with hypertensive emergencies: a 12-month study. Hypertens Res 2023; 46(3): 756-61.
[http://dx.doi.org/10.1038/s41440-022-01129-2] [PMID: 36599889]
[20]
Kim BS, Kim HJ, Shin JH, et al. Sex differences in long-term mortality of patients with hypertensive crisis visiting the emergency department. J Womens Health 2022; 31(8): 1137-44.
[http://dx.doi.org/10.1089/jwh.2021.0430] [PMID: 34860590]
[21]
Reynard C, van den Berg P, Oliver G, et al. The prognostic value of emergency department measured hypertension: A systematic review and meta‐analysis. Acad Emerg Med 2022; 29(3): 344-53.
[http://dx.doi.org/10.1111/acem.14324] [PMID: 34553441]
[22]
Kulkarni S, Glover M, Kapil V, et al. Management of hypertensive crisis: British and irish hypertension society position document. J Hum Hypertens 2022; 37(10): 863-79.
[http://dx.doi.org/10.1038/s41371-022-00776-9] [PMID: 36418425]
[23]
Stewart MH. Hypertensive crisis: Diagnosis, presentation, and treatment. Curr Opin Cardiol 2023; 38(4): 311-7.
[http://dx.doi.org/10.1097/HCO.0000000000001049] [PMID: 37016936]
[24]
Desta DM, Wondafrash DZ, Tsadik AG, et al. Prevalence of hypertensive emergency and associated factors among hospitalized patients with hypertensive crisis: A retrospective cross-sectional study. Integr Blood Press Control 2020; 13: 95-102.
[http://dx.doi.org/10.2147/IBPC.S265183] [PMID: 32904390]
[25]
Weber MA, Schmieder RE, Kandzari DE, et al. Hypertension urgencies in the SPYRAL HTN-OFF MED pivotal trial. Clin Res Cardiol 2022; 111(11): 1269-75.
[http://dx.doi.org/10.1007/s00392-022-02064-5] [PMID: 35852582]
[26]
Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: The JNC 7 report. JAMA 2003; 289(19): 2560-72.
[http://dx.doi.org/10.1001/jama.289.19.2560] [PMID: 12748199]
[27]
van den Born BJH, Lip GYH, Brguljan-Hitij J, et al. ESC Council on hypertension position document on the management of hypertensive emergencies. Eur Heart J Cardiovasc Pharmacother 2019; 5(1): 37-46.
[http://dx.doi.org/10.1093/ehjcvp/pvy032] [PMID: 30165588]
[28]
Koracevic G, Stojanovic M, Lovic D, Radovanovic RV, Koracevic M. Rationale for the concept of impending hypertension-mediated organ damage. Curr Vasc Pharmacol 2022; 20(2): 127-33.
[http://dx.doi.org/10.2174/1570161120666220124105846] [PMID: 35068394]
[29]
Pierin AMG, Flórido CF, Santos J. Hypertensive crisis: clinical characteristics of patients with hypertensive urgency, emergency and pseudocrisis at a public emergency department. Einstein 2019; 17(4): eAO4685.
[http://dx.doi.org/10.31744/einstein_journal/2019AO4685] [PMID: 31482942]
[30]
Astarita A, Covella M, Vallelonga F, et al. Hypertensive emergencies and urgencies in emergency departments: A systematic review and meta-analysis. J Hypertens 2020; 38(7): 1203-10.
[http://dx.doi.org/10.1097/HJH.0000000000002372] [PMID: 32510905]
[31]
Benenson I, Waldron FA, Jadotte YT, Dreker MP, Holly C. Risk factors for hypertensive crisis in adult patients: A systematic review. JBI Evidence Synthe 2021; 19(6): 1292-327.
[http://dx.doi.org/10.11124/JBIES-20-00243] [PMID: 33555818]
[32]
Bojdani E, Chen A, Zhang T, Naqvi N, Tahera D. Hypertensive urgency and emergency in alcohol withdrawal: A literature review. Prim Care Companion CNS Disord 2019; 21(6): 19r02513.
[http://dx.doi.org/10.4088/PCC.19r02513]
[33]
Jolly H, Freel EM, Isles C. Management of hypertensive emergencies and urgencies: Narrative review. Postgrad Med J 2023; 99(1169): 119-26.
[http://dx.doi.org/10.1136/postgradmedj-2021-140899] [PMID: 37222066]
[34]
Ashraf M, Zlochiver V, Bolton A, Allaqaband SQ, Bajwa T, Jan MF. Thirty-day readmission rate among patients with hypertensive crisis: A nationwide analysis. Am J Hypertens 2022; 35(10): 852-7.
[http://dx.doi.org/10.1093/ajh/hpac088] [PMID: 35869656]
[35]
Talle MA, Doubell AF, Robbertse PPS, Lahri S, Herbst PG. The role of cardiac biomarkers in the diagnosis of hypertensive emergency. Diagnostics 2023; 13(9): 1605.
[http://dx.doi.org/10.3390/diagnostics13091605] [PMID: 37174996]
[36]
Koracevic G, Lovic D, Stojanovic M, Djordjevic D, Koracevic M. Hypertensive emergency is characterized by acute hypertension-mediated organ damage but also a life-threatening status. Hypertens Res 2020; 43(12): 1457-8.
[http://dx.doi.org/10.1038/s41440-020-0501-6] [PMID: 32601399]
[37]
Vilela-Martin JF, Yugar-Toledo JC, Rodrigues MC, et al. Luso-brazilian position statement on hypertensive emergencies - 2020. Arq Bras Cardiol 2020; 114(4): 736-51.
[http://dx.doi.org/10.36660/abc.20190731] [PMID: 32491016]
[38]
Brathwaite L, Reif M. Hypertensive emergencies. Cardiol Clin 2019; 37(3): 275-86.
[http://dx.doi.org/10.1016/j.ccl.2019.04.003] [PMID: 31279421]
[39]
Angeli F, Verdecchia P, Reboldi G. Pharmacotherapy for hypertensive urgency and emergency in COVID-19 patients. Expert Opin Pharmacother 2022; 23(2): 235-42.
[http://dx.doi.org/10.1080/14656566.2021.1990264] [PMID: 34634987]
[40]
Allgaier J, Emmich M, Rastegar V, Stefan MS, Lagu T. Hypertensive urgency or emergency? The use of intravenous medications in hospitalized hypertensive patients without organ dysfunction. Heart Lung 2020; 49(6): 824-8.
[http://dx.doi.org/10.1016/j.hrtlng.2020.09.014] [PMID: 33011460]
[41]
Krouss M, Tsega S, Alaiev D, et al. Reduction of intravenous antihypertensives through clinical decision support in a large safety net system. Jt Comm J Qual Patient Saf 2023; 49(6-7): 291-6.
[http://dx.doi.org/10.1016/j.jcjq.2023.03.001] [PMID: 37024423]
[42]
Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000; 356(9227): 411-7.
[http://dx.doi.org/10.1016/S0140-6736(00)02539-3] [PMID: 10972386]
[43]
Vidt DG. Hypertensive crises: Emergencies and urgencies. J Clin Hypertens 2004; 6(9): 520-5.
[http://dx.doi.org/10.1111/j.1524-6175.2004.03607.x] [PMID: 15365281]
[44]
Williams B, Poulter NR, Brown MJ, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 2004; 18(3): 139-85.
[http://dx.doi.org/10.1038/sj.jhh.1001683] [PMID: 14973512]
[45]
Cheng SL. Treating HTN crisis. How low? How fast? RN 2005; 68(6): 37-41.
[PMID: 15991815]
[46]
Varon J. Treatment of acute severe hypertension: Current and newer agents. Drugs 2008; 68(3): 283-97.
[http://dx.doi.org/10.2165/00003495-200868030-00003] [PMID: 18257607]
[47]
Desai RG, Muntazar M, Goldberg ME. Strategies for managing perioperative hypertension. Curr Hypertens Rep 2009; 11(3): 173-7.
[http://dx.doi.org/10.1007/s11906-009-0031-8] [PMID: 19442325]
[48]
Papadopoulos DP, Mourouzis I, Thomopoulos C, Makris T, Papademetriou V. Hypertension crisis. Blood Press 2010; 19(6): 328-36.
[http://dx.doi.org/10.3109/08037051.2010.488052] [PMID: 20504242]
[49]
Rodriguez MA, Kumar SK, De Caro M. Hypertensive crisis. Cardiol Rev 2010; 18(2): 102-7.
[http://dx.doi.org/10.1097/CRD.0b013e3181c307b7] [PMID: 20160537]
[50]
Awad AS, Goldberg ME. Role of clevidipine butyrate in the treatment of acute hypertension in the critical care setting: A review. Vasc Health Risk Manag 2010; 6: 457-64.
[PMID: 20730061]
[51]
Vilela-Martin JF, Vaz-de-Melo RO, Kuniyoshi CH, Abdo ANR, Yugar-Toledo JC. Hypertensive crisis: Clinical-epidemiological profile. Hypertens Res 2011; 34(3): 367-71.
[http://dx.doi.org/10.1038/hr.2010.245] [PMID: 21160483]
[52]
Vuylsteke A, Vincent JL, Payen de La Garanderie D, et al. Characteristics, practice patterns, and outcomes in patients with acute hypertension: European registry for Studying the Treatment of Acute hyperTension (Euro-STAT). Crit Care 2011; 15(6): R271.
[http://dx.doi.org/10.1186/cc10551] [PMID: 22087790]
[53]
Skoglund PH, Svensson P. Asking the patient or measuring blood pressure in the emergency department: Which one is best? Curr Hypertens Rep 2016; 18(7): 53.
[http://dx.doi.org/10.1007/s11906-016-0659-0] [PMID: 27209495]
[54]
Varounis C, Katsi V, Nihoyannopoulos P, Lekakis J, Tousoulis D. Cardiovascular hypertensive crisis: Recent evidence and review of the literature. Front Cardiovasc Med 2017; 3(3): 51.
[http://dx.doi.org/10.3389/fcvm.2016.00051] [PMID: 28119918]
[55]
Ipek E, Oktay AA, Krim SR. Hypertensive crisis. Curr Opin Cardiol 2017; 32(4): 397-406.
[http://dx.doi.org/10.1097/HCO.0000000000000398] [PMID: 28306673]
[56]
Salagre SB, Itolikar SM, Gedam K. A prospective, observational study to determine the prevalence and clinical profile of patients of hypertensive crisis in a tertiary care hospital. J Assoc Physicians India 2017; 65(6): 14-21.
[PMID: 28782308]
[57]
Kuniyoshi K. When to send a hypertensive patient to the ER. Optometry Times 2018; 10(9): 24-6.
[58]
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American college of cardiology/American heart association task force on clinical practice guidelines. J Am Coll Cardiol 2018; 71(19): 2275-9.
[http://dx.doi.org/10.1016/j.jacc.2017.11.005] [PMID: 29747841]
[59]
Timmermans SAMEG, Wérion A, Damoiseaux JGMC, Morelle J, Reutelingsperger CP, van Paassen P. Diagnostic and risk factors for complement defects in hypertensive emergency and thrombotic microangiopathy. Hypertension 2020; 75(2): 422-30.
[http://dx.doi.org/10.1161/HYPERTENSIONAHA.119.13714] [PMID: 31865800]
[60]
Afonso L, Bandaru H, Rathod A, et al. Prevalence, determinants, and clinical significance of cardiac troponin-I elevation in individuals admitted for a hypertensive emergency. J Clin Hypertens 2011; 13(8): 551-6.
[http://dx.doi.org/10.1111/j.1751-7176.2011.00476.x] [PMID: 21806764]
[61]
Qamar M, Ahmad N, Shaikh FA. Mismanagement of hypertensive emergency in a patient suffering from recurrent stroke. J Basic Clin Pharm 2012; 3: 2.
[62]
Lien SF, Bisognano JD. Perioperative hypertension: Defining at-risk patients and their management. Curr Hypertens Rep 2012; 14(5): 432-41.
[http://dx.doi.org/10.1007/s11906-012-0287-2] [PMID: 22864917]
[63]
Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension. Eur Heart J 2013; 34(28): 2159-219.
[http://dx.doi.org/10.1093/eurheartj/eht151] [PMID: 23771844]
[64]
Mallidi J, Penumetsa S, Lotfi A. Management of hypertensive emergencies. J Hypertens 2013; 2(2): 1-6.
[65]
Nonaka K, Ubara Y, Sumida K, et al. Clinical and pathological evaluation of hypertensive emergency-related nephropathy. Intern Med 2013; 52(1): 45-53.
[http://dx.doi.org/10.2169/internalmedicine.52.7398] [PMID: 23291673]
[66]
El Maraghi S, Yahia H, Heikal A, Ashraf M. B-type natriuretic peptide in hypertensive crises: Diagnostic use in hypertensive urgencies and emergencies. Egyptian J Crit Care Med 2013; 1(2): 61-7.
[http://dx.doi.org/10.1016/j.ejccm.2013.01.002]
[67]
Mancia G, Fagard R. Hypertensive urgencies and emergencies. J Hypertens 2014; 32(9): 1911.
[http://dx.doi.org/10.1097/HJH.0000000000000302] [PMID: 25098792]
[68]
Aronson S. Perioperative hypertensive emergencies. Curr Hypertens Rep 2014; 16(7): 448.
[http://dx.doi.org/10.1007/s11906-014-0448-6] [PMID: 24852830]
[69]
Manning L, Robinson TG, Anderson CS. Control of blood pressure in hypertensive neurological emergencies. Curr Hypertens Rep 2014; 16(6): 436.
[http://dx.doi.org/10.1007/s11906-014-0436-x] [PMID: 24771058]
[70]
Pak KJ, Hu T, Fee C, Wang R, Smith M, Bazzano LA. Acute hypertension: A systematic review and appraisal of guidelines. Ochsner J 2014; 14(4): 655-63.
[PMID: 25598731]
[71]
Gavriilaki E, Gkaliagkousi E, Nikolaidou B, Douma S. Mean platelet volume in hypertensive urgencies and emergencies: Opening the Pandora’s Box. Platelets 2015; 26(3): 275-6.
[http://dx.doi.org/10.3109/09537104.2013.868426] [PMID: 24433202]
[72]
Gulen B, Eken C, Kucukdagli OT, et al. Adropin levels and target organ damage secondary to high blood pressure in the ED. Am J Emerg Med 2016; 34(11): 2061-4.
[http://dx.doi.org/10.1016/j.ajem.2016.04.014] [PMID: 27592461]
[73]
Koracevic G, Stojanovic M, Lovic D, Djordjevic D. Impending hypertensive emergency is frequently considered in guidelines, but neither defined nor explained. Blood Press 2020; 29(5): 336-7.
[http://dx.doi.org/10.1080/08037051.2020.1769467] [PMID: 32441140]
[74]
Lin XL, Sun HX, Li FQ, et al. Admission high‐sensitivity C‐reactive protein levels improve the Grace risk score prediction on in‐hospital outcomes in acute myocardial infarction patients. Clin Cardiol 2022; 45(3): 282-90.
[http://dx.doi.org/10.1002/clc.23749] [PMID: 35066901]
[75]
Losordo DW, Henry TD. New lging? Circ Res 2016; 119(7): 774-5.
[http://dx.doi.org/10.1161/CIRCRESAHA.116.309622] [PMID: 27635077]
[76]
Koracevic G, Stojanovic M, Lovic D, et al. Blood pressure cut-offs to diagnose impending hypertensive emergency depend on previous hypertension-mediated organ damages and comorbidities. Natl Med J India
[77]
Academy of Medicine of Malaysia The Clinical Practise Guidelines (CPGs); Management of Hypertension. (5th Edition.), 2018. Available from: http://www.acadmed.org.my/index.cfm?menuid=67
[78]
Maloberti A, Cassano G, Capsoni N, et al. Therapeutic approach to hypertension urgencies and emergencies in the emergency room. High Blood Press Cardiovasc Prev 2018; 25(2): 177-89.
[http://dx.doi.org/10.1007/s40292-018-0261-4] [PMID: 29777395]

Rights & Permissions Print Cite
© 2024 Bentham Science Publishers | Privacy Policy