Critical Care Medicine-Neurologic Disorders>>>>>Encephalopathy and Delirium
Question 2#

A 63-year-old man with a history of hypertension controlled with three agents and type 2 diabetes treated with metformin presents with new-onset confusion, nausea, and vomiting. His daughter states that he had self-discontinued his antihypertensive medications. He is normoglycemic but hypertensive with systolic blood pressure consistently above 200 mm Hg.

Brain imaging did not show evidence of acute hemorrhage or ischemic changes; chest imaging was unremarkable. Assuming that the patient’s symptoms are due to hypertension, the recommended goal for blood pressure reduction during the first hour is:

A. <140 mm Hg
B. <160 mm Hg
C. ≤15%
D. ≤25%
E. ≤40%

Correct Answer is D

Comment:

Correct Answer: D

This patient presents with a hypertensive emergency defined as acute target organ damage in the setting of significantly elevated blood pressure: systolic blood pressure >180 mm Hg and/or diastolic blood pressure >120 mm Hg. Confusion, nausea, and vomiting suggest hypertensive encephalopathy as the most likely diagnosis.

The current American College of Cardiology/American Heart Association (ACC/AHA) guidelines from 2017 for management of hypertension in adults recommend reducing blood pressure by a maximum of 25% over the first hour. The blood pressure goal for the following 2 to 6 hours is 160/100 to 110 mm Hg. Blood pressure should be normalized over the following 24 to 48 hours. Blood pressure goals for the first hour are different in patients with severe preeclampsia or pheochromocytoma crisis (<140 mm Hg) and aortic dissection (<120 mm Hg). Of note, for patients with markedly elevated blood pressure without evidence of new, progressive, or worsening target organ damage, the JACC/AHA guidelines recommend reinstitution or intensification of oral antihypertensive drug therapy and outpatient follow-up.

References:

  1. Whelton PK, Carey RM, AronowWS, 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:e127-e248.
  2. Johnson W, Nguyen ML, Patel R. Hypertension crisis in the emergency department. Cardiol Clin. 2012;30:533-543.
  3. Ipek E, Oktay AA, Krim SR. Hypertensive crisis: an update on clinical approach and management. Curr Opin Cardiol. 2017;32:397-406.