Clinical Presentation: Hypertensive Urgency and Emergency Management

• Signs and symptoms:
  • Headache, nausea, vomiting, confusion
  • Epistaxis, shortness of breath, chest pain
  • Neurological deficits (e.g. focal weakness, vision changes)
  • Dizziness, paresthesia

• Vital signs:
  • BP > 180/120 mm Hg
  • Tachycardia common
• Risk factors:
  • History of hypertension, especially if uncontrolled
  • Older age (>65 years)
  • Male sex
  • Low socioeconomic status
  • Black race
  • Medication nonadherence
  • Substance use (e.g. cocaine, amphetamines)
• Target organ involvement:
  • Brain (stroke, encephalopathy)
  • Heart (MI, HF)
  • Eyes (retinopathy, papilledema)
  • Kidneys (acute kidney injury)
  • Lungs (pulmonary edema)
  • Vasculature (aortic dissection)

The nonspecific signs and symptoms of hypertensive emergencies can lead to misdiagnoses such as migraine, panic attack, or stroke syndromes. However, the presence of severely elevated blood pressure should prompt consideration of a hypertensive emergency. Risk factors give clues to the likely etiology, but clinicians must investigate medication adherence, substance use, and dietary factors. Careful assessment for target organ involvement is critical, as signs and symptoms do not always correlate with the degree of end-organ damage present. Overall, maintaining a high index of suspicion in high-risk patients can help pharmacists recognize hypertensive emergencies early.