DIAGNOSTIC AND THERAPEUTIC APPROACHES FOR MANAGING HYPERTENSIVE EMERGENCIES: THE PERSPECTIVE OF EMERGENCY PHYSICIANS

Objective: A hypertensive emergency is characterized by blood pressure (BP) over 180/110 mmHg accompanied by a mediated organ damage (HMOD). Malignant hypertension is a subset of hypertensive emergencies with distinct pathophysiology and management strategies. Severe hypertension is defined as BP over 180/110 mmHg without HMOD. Hypertensive emergencies account for less than 2% of emergency department admissions but require rapid management to prevent potentially life-threatening complications. The main challenge for emergency physicians is distinguishing patients at risk of complications from those whose elevated BP poses no immediate danger. Managing hypertensive emergencies is difficult due to varied clinical presentations and the lack of practical guidelines tailored for emergency settings, as existing recommendations are designed by specialists rather than frontline practitioners Design and method: This paper outlines practical diagnostic and therapeutic steps in the face of hypertensive emergencies, emphasizing the challenge for emergency physicians, based on the guidelines of European medical societies. Results: Routine recommendations for patient history-taking and physical examination are not always fully applicable in emergency settings, where swift intervention is paramount. We therefore propose adaptations for efficient triage. In cases of acute pulmonary edema, acute coronary syndrome, aortic dissection, and stroke, patients are generally managed in specialized care units, with BP targets tailored to the specific organ damage. We summarize these BP targets, along with treatment doses, administration methods, and contraindications, providing the information in a user-friendly format. Management challenges in emergency settings are particularly significant for patients without HMOD, where distinguishing between malignant hypertension and severe hypertension is not straightforward. For malignant hypertension, inpatient treatment typically involves intravenous rehydration, beta-blockers, calcium channel blockers, central antihypertensives, alpha-blockers, and titration of renin-angiotensin system blockers. For severe hypertension, dihydropyridine calcium channel blockers are suggested as the first-line treatment for untreated patients. Follow-up is crucial for these patients, as their cardiovascular and renal prognosis remains worse than that of other hypertensive patients. Conclusions: We have developed a decision-making algorithm tailored to the realities of emergency departments. This tool improves triage, directs patients to specialized care when necessary, to reduce the risk of short- and long-term complications.