Hipertensión Aguda NEJM - FDR
Hipertensión Aguda NEJM - FDR
Hipertensión Aguda NEJM - FDR
Clinical Practice
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence
supporting various strategies is then presented, followed by a review of formal guidelines, when they exist.
The article ends with the author’s clinical recommendations.
B
lood-pressure elevations above 180/110 to 120 mm Hg can result From the Department of Internal Medi-
in acute injury to the heart, brain, and the microvasculature.1-3 If acute cine, Section of Nephrology, Yale School
of Medicine, and the Hypertension Pro-
hypertension-mediated target-organ damage is present, the condition is gram, Yale New Haven Hospital Heart
labeled “hypertensive emergency” and demands immediate and aggressive treat- and Vascular Center, New Haven, CT. Ad-
ment to limit progressive injury (Fig. 1). There is less agreement on terminology dress reprint requests to Dr. Peixoto at
Boardman 114 (Nephrology), 330 Cedar St.,
and management in the absence of acute target-organ damage (which I will refer New Haven, CT 06520, or at aldo.peixoto@
to here as “hypertensive urgency”), although this condition is two to three times yale.edu.
more common than hypertensive emergency.4,5 Acute severe hypertension, at times N Engl J Med 2019;381:1843-52.
with acute target-organ damage,6 may also manifest perioperatively; the present DOI: 10.1056/NEJMcp1901117
review focuses on the occurrence of acute severe hypertension outside the peri- Copyright © 2019 Massachusetts Medical Society.
Acute severe hypertension accounts for an es- sent home from the office or emergency depart-
timated 4.6% of all visits to emergency depart- ment.13,15,16 A recent analysis of 58,535 ambula-
ments and is a frequent reason for hospitaliza- tory office encounters with patients who had a
tions in the United States.5 It is more common systolic blood pressure of 180 mm Hg or higher,
in persons who are older than 60 years of age, a diastolic blood pressure of 110 mm Hg or
black, or uninsured or underinsured or who live higher, or both (mean, 182.5/96.4 mm Hg) showed
in lower-income areas.5,7 Large claims-based data a similar incidence of cardiovascular events at
sets in the United States indicate that hospital 6 months (0.9%) among patients who were hos-
admissions for hypertensive emergencies have pitalized and among propensity-matched patients
steadily increased during the past 20 years,5,7-9 who were discharged after the encounter.15
but in-hospital mortality has improved over time
and currently ranges between 0.2% and 11%.8-10 S t r ategie s a nd E v idence
Even in the absence of acute target-organ
damage, episodes of severe hypertension have Figure 1 outlines a structured approach to the
long-term implications. In a study involving management of acute severe hypertension. The
2435 patients with a previous transient ischemic key elements include accurate measurement of
attack, an isolated systolic blood pressure above blood-pressure levels; careful evaluation for po-
180 mm Hg (without symptoms) was associated tential precipitants, symptoms, and evidence of
with an increase in stroke risk during 3 years target-organ damage; and treatment decisions
of follow-up by a factor of 5, as compared with based on the presence of symptoms or acute
no episodes of systolic blood pressure above target-organ damage.
140 mm Hg, regardless of usual blood pressures.11
Similarly, a prospective cohort study showed that Blood-Pressure Measurement
patients who had an admission with hypertensive Blood pressure must be measured in both arms
urgency had a 50% higher risk of fatal or non- and the thigh using appropriate technique and
fatal cardiovascular events than controls, despite validated devices17 (Table S1 in the Supplemen-
similar blood-pressure levels during follow-up.12 tary Appendix, available with the full text of this
In contrast to these long-term implications, article at NEJM.org). Most hospitals use auto-
hypertensive urgencies do not appear to be as- mated devices that rely on oscillometric mea-
sociated with adverse short-term outcomes.13-16 surements. Two large registry studies comparing
Although rates of admission to the hospital are oscillometric and intraarterial measurements in
relatively high (up to 11% during the 30 days critical care18 or surgical19 patients showed that
after initial presentation10,15), studies have not oscillometric devices consistently underestimate Monitores
☒
Digitales
shown increased risks of adverse outcomes in blood-pressure levels by as much as 50/30 mm Hg
the days to several months after patients were when recorded intraarterial levels are above
•
Sindrome de Encefalopatía
& posterior Reversible
Are there findings of acute target-organ damage?
Brain (stroke, intracerebral hemorrhage, PRES)
Retina (hemorrhages, exudates, ⊕
•
Insuficiencia Cardiaca Aguda
papilledema) Descompensada
Heart (acute coronary syndromes, ADHF)
Large vessels (aortic dissection)
Kidneys (acute kidney injury)
Microvasculature (MAHA) Micro Angiopálica
☐ Anemia Hemolítica
No Yes
No Yes
Urgency Urgency
Adjust long-acting medications Give “rapid” oral agent
Follow up in 1–7 days Adjust long-acting medications
Discharge when symptoms have improved
and blood pressure is <180/110 mm Hg
Follow up in 1–7 days
raphy (for ischemic changes), and troponin measurement in most patients. Acute coronary syndromes include un-
stable angina and myocardial infarction. With respect to large vessels (aorta), ask about chest or back pain. Obtain
blood-pressure measurements in both arms and thigh, looking for asymmetry. If suspicion is aroused, obtain CT of
the chest and abdomen with contrast or transesophageal echocardiography. With respect to the kidneys, measure
the serum creatinine level to rule out acute kidney injury. Urinalysis may show proteinuria or hematuria as a sign of
microvascular injury. With respect to the microvasculature, obtain a complete blood count, looking for anemia and
thrombocytopenia suggestive of microangiopathy. ADHF denotes acute decompensated heart failure, IV intravenous,
MAHA microangiopathic hemolytic anemia, and PRES posterior reversible encephalopathy syndrome. Adapted from
Whelton et al.1
180/100 mm Hg. Auscultatory measurements even when meticulous technique is applied. Be-
that use aneroid or mercury devices also have cause of the potential underestimation of the
substantial discordance from intraarterial mea- severity of hypertension, the use of oscillometric
surements in high blood-pressure ranges,20,21 (and auscultatory) devices should be discouraged
(% of baseline)
100 Chronic
data suggest that treatment of severe hyperten- hypertension
sion for several months may improve autoregula-
tion to a modest extent,34 whereas patients with 50 Risk of Injury from Excessive
Treatment
mild-to-moderate hypertension (<180/110 mm Hg) Cerebral ischemia
recover autoregulatory responses within weeks
after the initiation of effective therapy.36 0
0 50 100 150 200
Choice of Treatment Mean Arterial Pressure (mm Hg)
There are relatively few trials comparing dif-
ferent agents for hypertensive emergency and Figure 2. Autoregulation of Cerebral Blood Flow and Implications
for the Treatment of Hypertensive Emergencies.
hypertensive urgency.37-39 Treatment is largely
Cerebral blood flow is relatively stable across a wide blood-pressure range
determined by an understanding of the patho- through changes in cerebrovascular resistance. On the high end of the curve,
physiological features, the presence and type of increased cerebrovascular resistance prevents pressure-induced increases
target-organ injury, the availability and costs of in blood flow. Once the upper limit of autoregulation is crossed, small
medications, and physician experience with given changes in blood pressure produce substantial increases in blood flow that
agents.10,40 There is considerable variability in result in vasogenic cerebral edema and its complications. On the low end
of the curve, decreased cerebrovascular resistance allows flow to be main-
practice regarding the choice of medications.10,40 tained despite progressively lower blood pressure. Once the autoregulatory
limit is reached, small decreases in blood pressure produce substantial im-
Hypertensive Emergencies pairment in cerebral perfusion. In clinical experiments, the lower limit of
All patients should be admitted to an intensive autoregulation occurs at blood-pressure levels approximately 25% lower
care unit and treated with intravenous antihyper- than baseline. Symptoms of cerebral hypoperfusion develop when cerebral
blood flow falls by more than approximately 30%. There is wide individual
tensive drugs on the basis of the clinical sce- variability in autoregulatory limits and thresholds at both ends of the curve.
nario (Tables 1 and 2 and Table S2). In the The autoregulatory curve is shifted to the right in uncontrolled hypertension.
United States, labetalol, nitroglycerin, nicardipine, Treatment of hypertension for weeks to months may improve or correct the
hydralazine, and nitroprusside are the most com- autoregulatory abnormalities, especially in patients without long-standing
monly used agents.10 Of these medications, hy- severe hypertension.
dralazine has unpredictable effects, often leads
to excessive blood-pressure lowering,41 and should
generally be avoided as a first option.1,3 Studies reduction (resulting in systolic blood pressure
comparing labetalol and nicardipine have shown below 100 to 120 mm Hg) may occur in up to
faster achievement of blood-pressure control and 10% of patients10,40 and is associated with an
less variability in blood pressure (allowing blood increased risk of death.44,45 If excessive blood-
pressure to stay closer to target) with nicardipine pressure reduction occurs, prompt discontinua-
but no significant differences in adverse events tion of intravenous drugs and, in some cases,
or mortality.39,42,43 In one trial comparing clevi- temporary use of vasopressors, intravenous fluids,
dipine with nicardipine, clevidipine resulted in or both is indicated. Resumption or initiation of
less variability than nicardipine.38 long-acting antihypertensive drugs should take
In the absence of studies comparing different place alongside intravenous therapy to provide a
rates of blood-pressure reduction, management is smoother transition, shorten the need for intra-
guided by autoregulatory principles; guidelines venous drugs and intensive care, and minimize
recommend that blood pressure be decreased by the risk of rebound hypertension, which is also
no more than 20 to 25% during the first hour associated with increased mortality.44 The appro-
and then to 160/100 to 110 mm Hg during the priate timing for starting or restarting oral
ensuing 2 to 6 hours.1 Excessive blood-pressure drugs is uncertain; because the risk of hypoten-
Acute Target-Organ Damage Timing for Acute BP Reduction† Preferred Intravenous Drugs‡
Diffuse microvascular injury Decrease BP by 20–25% during first hr and to 160/100 mm Hg by 2–6 hr Labetalol, nicardipine, nitroprusside
Copyright © 2019 Massachusetts Medical Society. All rights reserved.
(“malignant hypertension”)§
Hypertensive encephalopathy Decrease BP by 20–25% during first hr and to 160/100 mm Hg by 2–6 hr Labetalol, nicardipine, nitroprusside; avoid hydralazine
Acute intracerebral hemorrhage If systolic BP is 150–220 mm Hg, decrease systolic BP to 140–150 mm Hg Labetalol, nicardipine, clevidipine, nitroprusside; avoid hydral-
The
within 1 hr, particularly in patients without known hypertension and those azine
n engl j med 381;19
n e w e ng l a n d j o u r na l
The New England Journal of Medicine
Acute coronary syndromes Decrease systolic BP to <140 mm Hg within 1 hr; keep diastolic BP >60 mm Hg Nitroglycerin, labetalol, esmolol, metoprolol; avoid hydralazine
of
m e dic i n e
Acute heart failure Decrease systolic BP to <140 mm Hg within 1 hr Nitroglycerin, nitroprusside; loop diuretics needed in most cases;
enalaprilat or hydralazine may be useful; avoid beta-blockers
Aortic dissection Decrease both systolic BP to <120 mm Hg and heart rate to <60 beats/min Esmolol (or labetalol) plus one of nicardipine, clevidipine, nitro-
within 20 min prusside, or nitroglycerin; both a beta-blocker (unless brady-
cardia is already present) and a vasodilator should be used
Labetalol Combined nonselective 10–20 mg IV bolus followed by Rapid onset (5 min) but prolonged duration of Contraindicated in patients with heart failure,
n engl j med 381;19
beta-blocker and alpha-1 drip; may repeat at same action (3–6 hr, sometimes longer at higher bradycardia or heart block, asthma or severe
blocker (IV beta-to-alpha dose or double dose after doses) airway reactivity; caution in cocaine overdose
blocking ratio, approx. 7:1) 10 min before starting drip;
0.5–10 mg/min IV drip;
The New England Journal of Medicine
Clinical Pr actice
for intermittent boluses,
10–80 mg IV every 10 min
(maximum cumulative
nejm.org
* This table is restricted to agents available in the United States. Detailed information is provided in Table S2 in the Supplementary Appendix. IV denotes intravenous.
The n e w e ng l a n d j o u r na l of m e dic i n e
sion is greatest in the first 6 hours of intrave- in cardiovascular events.50 Medications can be
nous therapy, a reasonable approach is to start administered every 30 minutes until the target
oral agents 6 to 12 hours after starting intrave- blood pressure is achieved. A systematic review
nous therapy.44 Long-acting drugs are chosen on of comparative trials and cohort studies suggest-
the basis of standard guidelines for chronic hy- ed similar acute blood-pressure reductions with
pertension management.1,2 After initial stabiliza- different agents.51 Clinical experience and de-
tion, experience indicates that most patients can scriptions of the acute effects of clonidine and
tolerate normalization of blood pressure within labetalol suggest that they may be associated
48 to 72 hours, although some require longer with less abrupt blood-pressure changes than
periods owing to dizziness, fatigue, or mental other agents.52-54 Patients are generally discharged
slowness. once symptoms have improved, which often co-
The recommended pace and intensity of blood- incides with a decrease in blood pressure to a
pressure reduction vary depending on the pres- level below 160 to 180/100 to 110 mm Hg.
ence of certain conditions, particularly aortic
dissection, eclampsia, pheochromocytoma crisis, A r e a s of Uncer ta in t y
and intracerebral hemorrhage, all of which de-
mand more aggressive approaches to limit ongo- Large randomized trials are lacking to identify
ing injury.1,3,46 Ischemic stroke1,3,47 requires more the most effective treatment for hypertensive
conservative management to avoid peri-infarction urgencies and emergencies generally and for spe-
hypoperfusion and worse stroke outcomes. Con- cific underlying conditions. For previously un-
sensus recommendations are based on very treated patients who present to the emergency
limited data and in some cases are not uniform department, there is controversy regarding
across guidelines.1,3,48,49 whether antihypertensive medication should be
prescribed at discharge.55 The American College
Hypertensive Urgencies of Emergency Physicians currently recommends
Most patients without acute target-organ damage initiation of therapy in the emergency depart-
can be cared for as outpatients.13-16 Treatment with ment only for selected patients who are likely to
guideline-concordant long-acting medications1,2 have poor follow-up and recommends referral
should be started, reinstated, or adjusted, and without initiation of treatment in the rest. Al-
follow-up should be scheduled within 1 to 7 days. though there is reasonable concern about inap-
In a study involving more than 500 patients propriate treatment of normotensive patients,
presenting to an emergency department with withholding treatment may represent a missed
severe hypertension, blood pressure fell to less opportunity to minimize risk.
than 180/110 mm Hg after 30 minutes of quiet
rest (before medication administration) in ap- Guidel ine s
proximately one third of the patients.13 If quiet
rest or control of anxiety or other precipitating Recommendations for the management of acute
factors is insufficient, an oral antihypertensive severe hypertension are included in major U.S.
agent may be given. Intravenous medications are and European hypertension guidelines.1-3 There
discouraged in this context. are variations in terminology and specific blood-
For patients with symptoms that are presumed pressure thresholds, but all the guidelines ac-
to relate to hypertension but are not indicative of knowledge the critical role of acute target-organ
target-organ damage (e.g., headache, atypical damage and adopt blood-pressure thresholds of
chest pain, or epistaxis), it is reasonable to choose 180/110 to 120 mm Hg to define urgencies and
an oral agent with a faster onset of action, such emergencies (Table S3). There is general agree-
as clonidine (0.1 to 0.3 mg), labetalol (200 to ment on the pace of blood-pressure reduction
400 mg), captopril (25 to 50 mg), prazosin (5 to and the need for the use of intravenous drugs in
10 mg), or nitroglycerin 2% topical ointment an intensive care environment for the manage-
(1 to 2 in.). Nifedipine (given orally or sublin- ment of hypertensive emergencies. The approach
gually) should be avoided owing to unpredict- proposed in this article is generally consistent
able blood-pressure reduction, possibly resulting with these guidelines.
References
1. Whelton PK, Carey RM, Aronow WS, et al. Effect of Joint National Committee 14. Levy PD, Mahn JJ, Miller J, et al. Blood
et al. 2017 ACC/AHA/AAPA/ABC/ACPM/ VII report on hospitalizations for hyper- pressure treatment and outcomes in hy-
AGS/APhA/ASH/ASPC/NMA/PCNA guide- tensive emergencies in the United States. pertensive patients without acute target
line for the prevention, detection, evalua- Am J Cardiol 2011;108:1277-82. organ damage: a retrospective cohort. Am
tion, and management of high blood pres- 8. Shah M, Patil S, Patel B, et al. Trends J Emerg Med 2015;33:1219-24.
sure in adults: a report of the American in hospitalization for hypertensive emer- 15. Patel KK, Young L, Howell EH, et al.
College of Cardiology/American Heart gency, and relationship of end-organ Characteristics and outcomes of patients
Association Task Force on Clinical Prac- damage with in-hospital mortality. Am J presenting with hypertensive urgency in
tice Guidelines. Hypertension 2018;71(6): Hypertens 2017;30:700-6. the office setting. JAMA Intern Med 2016;
e13-e115. 9. Polgreen LA, Suneja M, Tang F, Carter 176:981-8.
2. Williams B, Mancia G, Spiering W, BL, Polgreen PM. Increasing trend in ad- 16. Effects of treatment on morbidity in
et al. 2018 Practice Guidelines for the man- missions for malignant hypertension and hypertension: results in patients with dia-
agement of arterial hypertension of the hypertensive encephalopathy in the Unit- stolic blood pressures averaging 115
European Society of Hypertension and the ed States. Hypertension 2015;65:1002-7. through 129 mm Hg. JAMA 1967;202:
European Society of Cardiology: ESH/ESC 10. Katz JN, Gore JM, Amin A, et al. Prac- 1028-34.
Task Force for the Management of Arterial tice patterns, outcomes, and end-organ 17. Muntner P, Shimbo D, Carey RM, et al.
Hypertension. J Hypertens 2018;36:2284- dysfunction for patients with acute severe Measurement of blood pressure in humans:
309. hypertension: the Studying the Treatment a scientific statement from the American
3. van den Born BH, Lip GYH, Brguljan- of Acute hyperTension (STAT) registry. Heart Association. Hypertension 2019;
Hitij J, et al. ESC Council on Hypertension Am Heart J 2009;158(4):599-606.e1. 73(5):e35-e66.
position document on the management 11. Rothwell PM, Howard SC, Dolan E, 18. Lehman LW, Saeed M, Talmor D,
of hypertensive emergencies. Eur Heart J et al. Prognostic significance of visit-to- Mark R, Malhotra A. Methods of blood
Cardiovasc Pharmacother 2019;5:37-46. visit variability, maximum systolic blood pressure measurement in the ICU. Crit
4. Pinna G, Pascale C, Fornengo P, et al. pressure, and episodic hypertension. Lan- Care Med 2013;41:34-40.
Hospital admissions for hypertensive cri- cet 2010;375:895-905. 19. Wax DB, Lin HM, Leibowitz AB. Inva-
sis in the emergency departments: a large 12. Vlcek M, Bur A, Woisetschläger C, sive and concomitant noninvasive intra-
multicenter Italian study. PLoS One 2014; Herkner H, Laggner AN, Hirschl MM. As- operative blood pressure monitoring: ob-
9(4):e93542. sociation between hypertensive urgencies served differences in measurements and
5. Janke AT, McNaughton CD, Brody AM, and subsequent cardiovascular events in associated therapeutic interventions. Anes-
Welch RD, Levy PD. Trends in the inci- patients with hypertension. J Hypertens thesiology 2011;115:973-8.
dence of hypertensive emergencies in US 2008;26:657-62. 20. Ribezzo S, Spina E, Di Bartolomeo S,
emergency departments from 2006 to 2013. 13. Grassi D, O’Flaherty M, Pellizzari M, Sanson G. Noninvasive techniques for
J Am Heart Assoc 2016;5(12):e004511. et al. Hypertensive urgencies in the emer- blood pressure measurement are not a re-
6. Aronson S. Perioperative hypertensive gency department: evaluating blood pres- liable alternative to direct measurement:
emergencies. Curr Hypertens Rep 2014; sure response to rest and to antihyperten- a randomized crossover trial in ICU. Sci
16:448. sive drugs with different profiles. J Clin World J 2014;2014:353628.
7. Deshmukh A, Kumar G, Kumar N, Hypertens (Greenwich) 2008;10:662-7. 21. Kallioinen N, Hill A, Horswill MS,
Ward HE, Watson MO. Sources of inac- 34. Strandgaard S. Autoregulation of cere- 46. Hemphill JC III, Greenberg SM, An-
curacy in the measurement of adult pa- bral blood flow in hypertensive patients: derson CS, et al. Guidelines for the man-
tients’ resting blood pressure in clinical the modifying influence of prolonged agement of spontaneous intracerebral
settings: a systematic review. J Hypertens antihypertensive treatment on the toler- hemorrhage: a guideline for healthcare
2017;35:421-41. ance to acute, drug-induced hypotension. professionals from the American Heart
22. Zampaglione B, Pascale C, Marchisio Circulation 1976;53:720-7. Association/American Stroke Association.
M, Cavallo-Perin P. Hypertensive urgen- 35. Strandgaard S, Olesen J, Skinhoj E, Stroke 2015;46:2032-60.
cies and emergencies: prevalence and Lassen NA. Autoregulation of brain cir- 47. Powers WJ, Rabinstein AA, Ackerson
clinical presentation. Hypertension 1996; culation in severe arterial hypertension. T, et al. 2018 Guidelines for the early
27:144-7. Br Med J 1973;1:507-10. management of patients with acute ische-
23. Saguner AM, Dür S, Perrig M, et al. 36. Zhang R, Witkowski S, Fu Q, Claas- mic stroke: a guideline for healthcare pro-
Risk factors promoting hypertensive crises: sen JA, Levine BD. Cerebral hemodynam- fessionals from the American Heart As-
evidence from a longitudinal study. Am J ics after short- and long-term reduction in sociation/American Stroke Association.
Hypertens 2010;23:775-80. blood pressure in mild and moderate hy- Stroke 2018;49(3):e46-e110.
24. Conn VS, Ruppar TM, Chase JA, En- pertension. Hypertension 2007;49:1149- 48. Ponikowski P, Voors AA, Anker SD,
riquez M, Cooper PS. Interventions to im- 55. et al. 2016 ESC Guidelines for the diagno-
prove medication adherence in hyperten- 37. Perez MI, Musini VM. Pharmacologi- sis and treatment of acute and chronic
sive patients: systematic review and cal interventions for hypertensive emer- heart failure: the Task Force for the diag-
meta-analysis. Curr Hypertens Rep 2015; gencies: a Cochrane systematic review. nosis and treatment of acute and chronic
17:94. J Hum Hypertens 2008;22:596-607. heart failure of the European Society of
25. Victor RG, Lynch K, Li N, et al. A clus- 38. Aronson S, Dyke CM, Stierer KA, et al. Cardiology (ESC): developed with the spe-
ter-randomized trial of blood-pressure The ECLIPSE trials: comparative studies cial contribution of the Heart Failure As-
reduction in black barbershops. N Engl J of clevidipine to nitroglycerin, sodium sociation (HFA) of the ESC. Eur Heart J
Med 2018;378:1291-301. nitroprusside, and nicardipine for acute 2016;37:2129-200.
26. Wu JR, Cummings DM, Li Q, et al. hypertension treatment in cardiac surgery 49. Rosendorff C, Lackland DT, Allison
The effect of a practice-based multicom- patients. Anesth Analg 2008;107:1110-21. M, et al. Treatment of hypertension in pa-
ponent intervention that includes health 39. Peacock WF, Varon J, Baumann BM, tients with coronary artery disease: a sci-
coaching on medication adherence and et al. CLUE: a randomized comparative entific statement from the American Heart
blood pressure control in rural primary effectiveness trial of IV nicardipine versus Association, American College of Cardi-
care. J Clin Hypertens (Greenwich) 2018; labetalol use in the emergency depart- ology, and American Society of Hyperten-
20:757-64. ment. Crit Care 2011;15:R157. sion. Hypertension 2015;65:1372-407.
27. Santschi V, Chiolero A, Colosimo AL, 40. Vuylsteke A, Vincent JL, de La Garand- 50. Grossman E, Messerli FH, Grodzicki T,
et al. Improving blood pressure control erie DP, et al. Characteristics, practice pat- Kowey P. Should a moratorium be placed
through pharmacist interventions: a meta- terns, and outcomes in patients with acute on sublingual nifedipine capsules given
analysis of randomized controlled trials. hypertension: European registry for Study- for hypertensive emergencies and pseudo-
J Am Heart Assoc 2014;3(2):e000718. ing the Treatment of Acute hyperTension emergencies? JAMA 1996;276:1328-31.
28. Carey RM, Calhoun DA, Bakris GL, (Euro-STAT). Crit Care 2011;15:R271. 51. Campos CL, Herring CT, Ali AN, et al.
et al. Resistant hypertension: detection, 41. Campbell P, Baker WL, Bendel SD, Pharmacologic treatment of hypertensive
evaluation, and management: a scientific White WB. Intravenous hydralazine for urgency in the outpatient setting: a sys-
statement from the American Heart Asso- blood pressure management in the hospi- tematic review. J Gen Intern Med 2018;33:
ciation. Hypertension 2018;72(5):e53-e90. talized patient: its use is often unjusti- 539-50.
29. Nishijima DK, Paladino L, Sinert R. fied. J Am Soc Hypertens 2011;5:473-7. 52. Atkin SH, Jaker MA, Beaty P, Quadrel
Routine testing in patients with asymp- 42. Liu-DeRyke X, Levy PD, Parker D Jr, MA, Cuffie C, Soto-Greene ML. Oral labet-
tomatic elevated blood pressure in the Coplin W, Rhoney DH. A prospective eval- alol versus oral clonidine in the emergen-
ED. Am J Emerg Med 2010;28:235-42. uation of labetalol versus nicardipine for cy treatment of severe hypertension. Am J
30. Levy P, Ye H, Compton S, et al. Sub- blood pressure management in patients Med Sci 1992;303:9-15.
clinical hypertensive heart disease in black with acute stroke. Neurocrit Care 2013; 53. Greene CS, Gretler DD, Cervenka K,
patients with elevated blood pressure in 19:41-7. McCoy CE, Brown FD, Murphy MB. Cere-
an inner-city emergency department. Ann 43. Peacock WF IV, Hilleman DE, Levy bral blood flow during the acute therapy
Emerg Med 2012;60(4):467-74.e1. PD, Rhoney DH, Varon J. A systematic re- of severe hypertension with oral cloni-
31. Martin JF, Higashiama E, Garcia E, view of nicardipine vs labetalol for the dine. Am J Emerg Med 1990;8:293-6.
Luizon MR, Cipullo JP. Hypertensive crisis management of hypertensive crises. Am J 54. Jaker M, Atkin S, Soto M, Schmid G,
profile: prevalence and clinical presenta- Emerg Med 2012;30:981-93. Brosch F. Oral nifedipine vs oral clonidine
tion. Arq Bras Cardiol 2004;83:131-6. 44. Mayer SA, Kurtz P, Wyman A, et al. in the treatment of urgent hypertension.
32. Karras DJ, Kruus LK, Cienki JJ, et al. Clinical practices, complications, and mor- Arch Intern Med 1989;149:260-5.
Evaluation and treatment of patients with tality in neurological patients with acute 55. Wolf SJ, Lo B, Shih RD, Smith MD,
severely elevated blood pressure in aca- severe hypertension: the Studying the Fesmire FM. Clinical policy: critical issues
demic emergency departments: a multi- Treatment of Acute hyperTension registry. in the evaluation and management of
center study. Ann Emerg Med 2006;47: Crit Care Med 2011;39:2330-6. adult patients in the emergency depart-
230-6. 45. Peacock F, Amin A, Granger CB, et al. ment with asymptomatic elevated blood
33. Reed G, Devous M. Cerebral blood Hypertensive heart failure: patient char- pressure. Ann Emerg Med 2013;62:59-
flow autoregulation and hypertension. acteristics, treatment, and outcomes. Am 68.
Am J Med Sci 1985;289:37-44. J Emerg Med 2011;29:855-62. Copyright © 2019 Massachusetts Medical Society.