#20: Hypertensive urgency and severe hypertension


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


The Curbsiders report no relevant financial disclosures, but hope to become successful enough to display an absurd list of disclosures in the future.

Time Stamps

0:00 Hook

0:26 Intro

1:38 Rapid fire questions

03:45 Triage of patient with severe HTN

05:05 Case example HTN in office

07:05 Does HTN cause a headache?

08:30 Workup of severe HTN in the office

10:20 Stuart discusses HTN and headaches

11:30 In office treatment of blood pressure

14:28 Recap

15:50 Stuart discuss HTN emergency at normal BP

17:00 Acute treatment of HTN in ER

18:10 Approach to the inpatient with HTN

20:50 Choice of agent for inpatient HTN

23:23 Italian study of HTN crisis in the ER

24:20 Outcomes in asymptomatic patients with severe HTN

26:15 Sleep apnea and HTN

27:10 Natural history of untreated severe HTN

29:10 Take home points

30:50 Outro

Links from the show:

  1. Blood Meridian by Cormack McCarthy
  2. Horton Hears a Who by Dr. Seuss
  3. ASCVD risk calculator http://tools.acc.org/ASCVD-Risk-Estimator/
  4. Epocrates. Download it here
  5. Dr. Johnson’s excellent review article on hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/23102030
  6. Another great review with tables on oral drug therapy and dosing for hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/18710665
  7. Fascinating article from 1928 on The Syndrome of Malignant Hypertension* http://archinte.jamanetwork.com/article.aspx?articleid=535650
  8. Observational study from Italy characterizing symptoms and outcomes in hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/8591878
  9. JNC 7 recommendations for hypertensive crisis: See page 54 of this PDF for details http://www.nhlbi.nih.gov/files/docs/guidelines/express.pdf
  10. Most recent review we could find on hypertensive crisis https://www.ncbi.nlm.nih.gov/pubmed/25575271
  11. Migraine and subsequent risk of stroke in the Physicians' Health Study. https://www.ncbi.nlm.nih.gov/pubmed/7848119
  12. Blood pressure as a risk factor for headache and migraine: a prospective population-based study. https://www.ncbi.nlm.nih.gov/pubmed/25155744
  13. Blood pressure and risk of headache: a prospective study of 22,685 adults in Norway. https://www.ncbi.nlm.nih.gov/pubmed/11909904

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