Curriculum · Cardiovascular and Hypertension
Severe asymptomatic hypertension versus hypertensive emergency
What it is
Severe hypertension is a blood pressure above 180 mm Hg systolic or above 110 mm Hg diastolic. The line between the two conditions is end-organ damage: severe hypertension with end-organ damage constitutes a hypertensive emergency, while SBP 180 mmHg or more and/or DBP 110 mmHg or more without HMOD is hypertension urgency, which is often associated with treatment discontinuation or non-adherence, and with anxiety, and which can also develop in medication-adherent patients following ingestion of large quantities of salt. Severe asymptomatic hypertension is the same blood pressure with no signs or symptoms of acute target organ injury.
How it is diagnosed
The first step in the management of severe hypertension is determining whether a hypertensive emergency is present, and a thorough history and physical examination are crucial. The examination should center on evaluating for papilledema, neurologic deficits, respiratory compromise, and chest pain; the signs and symptoms of acute target organ injury are neurologic deficits, altered mental status, chest pain, shortness of breath, and oliguria. Evaluation of HMOD rests on fundoscopy, which is a critical part of the diagnostic workup, and on a 12-lead ECG, which is essential in the evaluation process. Other investigations include urine routine, for proteinuria and haematuria, and serum creatinine, urea and potassium if clinically indicated. Diagnostic testing is not immediately indicated for asymptomatic patients. A basic metabolic panel or other testing should be considered if mild symptoms are present.