#20: Hypertensive urgency and severe hypertension

The Curbsiders Internal Medicine Podcast

Summary:

On this episode we’ll teach you to dominate hypertensive urgency and severe hypertension (HTN) in the clinic, the ER, or on the hospital wards. The Curbsiders offer you this delicious serving of knowledge food so you can manage high blood pressure (BP) without making the same egregious errors that we made during our more formative years.

Of note, The Curbsiders are guestless for this episode. Guestless? Is that a word? Our guest for this episode was supposed to be Dr. Wallace Johnson, a Cardiologist, and expert on HTN from the University of Maryland. He did a fantastic job, but, unfortunately, technical difficulties caused us to lose any useable audio. Our sincerest gratitude and deepest apologies to Dr. Johnson. Nevertheless, we pressed on and used one of our own, the illustrious Dr. Paul Williams, as our expert guest.

Clinical Pearls:

1. Hypertensive crisis is divided into hypertensive emergency and hypertensive urgency.
2. • “Emergency” needs IV therapy NOW
   • “Urgency” needs increased oral therapy over next 24-72 hours
3. History, physical exam, and familiarity with the patient are key for triage (e.g. verify BP readings, assess compliance, etc.)
4. Severe HTN and hypertensive urgency can often be treated in the outpatient setting
5. IV agents are not indicated outside of true hypertensive emergency (i.e. objective end organ damage)
6. We recommend increasing dose or frequency of existing BP meds as 1st line (better long-term solution)
7. Intermittent dosing of oral labetalol, clonidine, and captopril can be considered as 2nd line (short-term solution)
8. Rule out uncontrolled pain, volume overload, alcohol withdrawal, illicit drug, and missed medications as cause of severe HTN
9. Evidence from observational studies suggests that headaches are NOT caused by HTN
10. Untreated severe HTN was historically fatal in months to years prior to development of antihypertensives

Goal: Listeners will become proficient in the appraisal of severe hypertension/ hypertensive urgency and employ safe and practical management strategies.

Learning objectives:

By the end of this podcast listeners will:

1. Confidently triage patients with severe hypertension and provide appropriate disposition in a variety of settings
2. Employ a safe and common sense approach to the treatment of severe hypertension in the clinic, the ER, or on the wards
3. Be familiar with pharmacologic management of severe hypertension in a variety of settings
4. Recognize the common causes of severe blood pressure elevation in the inpatient setting