Clinical evaluation

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The initial evaluation of a patient with hypertension focuses on confirming an accurate blood pressure and, if it is severely elevated, categorizing the patient as emergent, urgent, or non-urgent. If evidence of acute organ impairment is confirmed, the patient is a true 'hypertensive emergency'; therapy should be initiated immediately without waiting for the results of further laboratory tests or other studies. Further information relating to history, physical findings, and laboratory values can be obtained after therapeutic interventions have been started ( Table 1). Evidence of specific acute endorgan dysfunction is sought. Acute cardiac impairment would be evidenced by ischemic changes on the ECG, anginal symptoms, or evidence of acute congestive heart failure with pulmonary edema. Evidence of related renal impairment includes new onset of hematuria, refractory oliguria, or acute elevation in blood urea nitrogen and creatinine. As most patients with severe hypertension are relatively hypovolemic, a normal urine output cannot be expected. Central nervous system involvement is evidenced by changes in the level of alertness, focal neurological findings, new severe headaches, new seizures, or papilledema. Any evidence of an acute aortic dissection, in the setting of even mild elevations in blood pressure, also constitutes a hypertensive emergency. Although somewhat controversial, severe perioperative elevations (e.g. diastolic pressure above 110 mmHg), even without acute organ impairment, are generally considered emergencies or, at least, urgencies.

Table 1 Evaluation of the patient with severe hypertension

Without delaying the initial therapy, some patients require additional specialized studies, for example CT head scan for neurological concerns, radiological studies if aortic aneurysm or dissection is suspected, and cardiac isoenzymes if myocardial ischemia is suspected.

Blood pressure should be measured repeatedly, both initially and after initiating treatment. Aggressive therapies should never be initiated based on a single blood pressure measurement. For ongoing monitoring, an intra-arterial catheter has the advantages of accuracy and continuous measurement although, being invasive, it does carry potential complications. Non-invasive automatic cuff blood pressure monitoring is an alternative option although accuracy is more variable; measurements should initially be confirmed by manual cuff readings. Repeat measurements should be very frequent when therapy is first started. Concurrent with measures to stabilize the hypertension, an evaluation for potential etiologies is initiated.

Hypertensive emergencies constitute a heterogeneous population of patients and so therapeutic endpoints should not be generalized. Target blood pressure and the time frame in which this should be achieved will vary, depending upon setting and etiology ( T§b.!e,.2.).

Table 2 Initial therapeutic options in hypertensive emergencies

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