HYPERTENSIVE CRISIS

Hello friends. Hope we are doing good. Hypertension, as we know, is a chronic condition characterized by persistently elevated blood pressure. Even though there is no cure for hypertension, for now, there are drugs used to manage the condition for life and it enables those who have hypertension to live their normal life without complications.

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The effective management of hypertension is always a combination of lifestyle modifications and drug therapies which puts the blood pressure under control. However, when this elevated blood pressure is not properly controlled, it can rise to such an extremely high level that it will start damaging the vital organs in the body. This is referred to as a hypertensive crisis.

A person is said to have hypertension when the blood pressure is 140/90 mmHg and above. At this point, the person may not even be aware and there may be no symptoms. For those who have symptoms, it may just be a headache and lightheadedness. If this is not controlled, the blood pressure can rise as high as 220/140 mmHg. At this point, the patient will start experiencing many symptoms due to damage to the vital organs.

Hypertensive crisis can be grouped into Hypertensive urgency and Hypertensive emergency. In Hypertensive urgency, the blood pressure is very high, but there is no ongoing organ damage. But in Hypertensive emergency there is very high blood pressure with associated organ damage. In this discussion, we will focus more on a Hypertensive emergency which is a life-threatening medical emergency that needs intensive care.

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TARGET ORGANS DAMAGED BY HYPERTENSION
When the blood pressure is highly elevated, certain organs in the body are always the target for damage. We will discuss them one after another.

The first is the brain. A highly elevated blood pressure leads to a condition called Hypertensive encephalopathy. This is damage to the brain caused by a high level of blood pressure. It manifests as an altered level of consciousness, headache, blurring of vision, nausea, and vomiting, convulsions may also occur. Hypertension can also cause the bleeding of the blood vessels in the brain which lead to stroke or bleeding into the sub arachnoid space.

The second target organ damaged by hypertension is the eye. This causes bleeding of the blood vessels that supply the retina of the eye (retinal hemorrhages), papilloedema, and exudates.

Another very important organ damaged by hypertension is the heart. Persistently high level of blood pressure causes heart failure. When the left lower chamber of the heart (left ventricle) is affected, a condition called left ventricular failure, it leads to the accumulation of fluid in the lungs (Pulmonary edema).

Hypertension also affects the heart by reducing the blood supply to the heart which leads to Myocardial Ischemia and Infarction. This condition manifests as chest pain, heart attack, or even cardiac arrest and sudden death.

The kidneys are also important organs damaged by high blood pressure and this result in kidney failure. The manifestation here is that the patient develops a very low urine output and in some cases, there will be no urine at all.

This highly elevated blood pressure also affects pregnant women in a condition known as Eclampsia. They develop leg swelling and convulsions, and in some cases, if the baby is not up to term, the available option will be to terminate the pregnancy to save the mother.

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MANAGEMENT OF HYPERTENSIVE CRISIS
When patients come with a hypertensive crisis, it is always a critical condition and something must be done immediately to bring down the blood pressure.

Those who have a hypertensive emergency, are usually admitted to the Intensive Care Unit where their blood pressure is monitored closely. Intravenous antihypertensive drugs are given alongside oral drugs. But for hypertensive urgency, oral rapid-acting antihypertensive drugs are used instead of Intravenous drugs.

The initial goal of blood pressure reduction in these patients is to achieve not more than a 25% reduction in the first 1-2 hours. This is because the vital organs in the body are already conditioned to highly pressure blood supply. Crashing the blood pressure suddenly will lead to a shortage of blood supply to those organs. So, the blood pressure reduction here is gradual and not to achieve normal blood pressure at first.

The blood pressure is monitored regularly and the target in the next 2 - 6 hours will be to bring the blood pressure down to 160/100 or 110 mmHg, and this is maintained for the next 24 hours. Then the patient is converted to oral medications and a normal blood pressure management protocol is instituted to now normalize the blood pressure to below 140/90 mmHg.

This stepwise reduction in blood pressure described here is very important in managing hypertensive crises as suddenly crashing the blood pressure from 220 to 120 will be very fatal to the patient.

RISK FACTORS AND PREVENTION
The most important part of this management is patient education. You must explain to the patient what led to the crisis and how to prevent it, especially non-drug compliance.

One of the common problems that result in this hypertensive crisis is non-drug compliance or abruptly stopping a drug. When patients skip their drugs or don't take the right drug or the right dosage, they are at risk of this crisis. Though it's not easy because these medications are for life, at a point some may get tired. But family and caregivers should always encourage them to keep to their drug schedule to avoid complications. I have seen many instances of people who develop these complications from non-drug compliance.

Lifestyle is also another factor to consider here. In the management of hypertension, there are some lifestyle adjustments that the patient needs to make. Like quitting smoking, excessive alcohol, high fat diet, high salt diet, etc. They are to eat healthy foods, fruits, and vegetables, maintain a healthy weight and exercise regularly. Those who don't follow these lifestyle modifications are at increased risk of this crisis.

Excessive stress, lack of sleep, and use of other recreational drugs can also predispose one to hypertensive crisis. Therefore, those living with hypertension should avoid all these risk factors and causes of hypertensive crises.

In conclusion, hypertension is a long-term condition that when well managed, one can live a normal healthy life. However, one must faithfully follow his diet and lifestyle modifications as well as the drug prescriptions. Non-compliance with these often results in life-threatening crises which usually have poor outcomes.

It is also important to note that hypertension can go on in the body without symptoms until the blood pressure gets extremely high and organ damage sets in. So everyone must check their blood pressure from time to time for early detection and prompt management, especially those at risk. Check your blood pressure today!

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Thanks for reading.

For references and further information on Hypertensive crises, please check the resources below:

American Heart Association

MSD Manuals

British journal of Medical Practitioners

WebMD

Medical News Today