Diagnostic Approach: Hypertensive Urgency and Emergency Management

• Diagnosis requires meeting 3 criteria:
  • BP > 180/120 mm Hg (lower thresholds may apply in certain populations)
  • Acute end-organ dysfunction
  • Directly attributable to high BP

• Key initial diagnostic steps:
  • Assess vitals, including duplicate BP checks
  • Full history and physical exam
  • Identify symptoms or signs of end-organ involvement

• Evaluate for secondary causes:
  • History of prescription, OTC medication use, substance use
  • Dietary changes
  • Symptoms suggesting pheochromocytoma

• Assess for target organ dysfunction:
  • Neurological exam and imaging (stroke, encephalopathy)
  • Funduscopy (retinopathy, papilledema)
  • Troponin, ECG (MI, heart failure)
  • Creatinine, urinalysis (kidney injury)
  • CT chest (aortic dissection, pulmonary edema)

• Additional workup guided by organ involved:
  • Stroke evaluation (e.g. brain imaging, vascular studies)
  • ADHF evaluation (e.g. BNP, echocardiogram)
  • AKI evaluation (e.g. electrolytes, renal ultrasound)

• Make presumptive diagnosis based on BP, acute symptoms, and initial workup
• Confirm with response to antihypertensive therapy

In summary, the diagnosis of a hypertensive emergency relies on recognizing a severely elevated BP with signs and symptoms of acute end-organ dysfunction that can be attributed to the BP elevation. Pharmacists can assist by identifying secondary causes, guiding the diagnostic workup based on potential end-organ involvement, and assessing the response to treatment.