A 52-Year-Old Man With Blurred Vision and Headache

Basma Abdulhadi, MD


February 05, 2018


Hypertension is a medical condition that affects approximately 1 billion people worldwide.[1] Hypertension accounted for more than 44 million emergency department visits in the United States in 2006; in 2009, the direct and indirect medical costs related to hypertension totaled $73 billion.[1] Moreover, an estimated 74% of patients are unaware that they have this condition, which explains why hypertension is often labeled the "silent killer."

Hypertension is a known risk factor for cardiovascular disease and is more common than cigarette smoking, dyslipidemia, and diabetes.[1,2] Globally, hypertension accounts for an estimated 47% of all ischemic heart disease events and approximately 54% of all strokes. Hypertension increases the risk for stroke, coronary artery disease, heart failure, atrial fibrillation, and vascular dementia.[3,4] The risk for coronary disease and stroke in patients older than 50 years progressively increases with increasing blood pressure; the risk was shown to double with every 20 mm Hg and 10 mm Hg in systolic and diastolic blood pressure, respectively, beginning at a blood pressure of 115/75 mm Hg.[4] Clinical trials have shown that decreasing systolic blood pressure by 10-12 mm Hg and diastolic blood pressure by 5-6 mm Hg results in decreased cardiovascular morbidity and mortality. Hypertension is considered a modifiable risk factor for cardiovascular disease, and attempts should be made to control blood pressure to reduce the significant morbidity and mortality associated with uncontrolled hypertension.[1,2]

Around two thirds of patients receiving hypertension treatment fail to achieve adequate blood pressure control; approximately 1%-2% of patients with hypertension develop hypertensive urgency or hypertensive emergency at one point during the course of their lives.[3,4] Hypertensive emergency is defined as severe hypertension with evidence of impending or progressive end-organ dysfunction; hypertensive urgency is defined as severe hypertension without acute end-organ dysfunction.[4] Systolic blood pressure in these settings is usually above 180 mm Hg and diastolic blood pressure more than 120 mm Hg.[2,5] The incidence of hypertensive emergencies or urgencies is higher in men, elderly persons, and African-American individuals. Medication noncompliance, the use of stimulant drugs (eg, cocaine, amphetamines), and withdrawal from medications (eg, clonidine, beta-blockers) can precipitate hypertensive urgencies and emergencies.

The clinical manifestation of hypertensive emergency depends on the target organs involved, but those that are mainly affected are the cardiovascular, neurologic, and renal systems; manifestations include acute coronary syndrome, acute encephalopathy, acute hemorrhagic or ischemic strokes, papilledema, pulmonary edema, aortic dissection, and acute renal failure.[4,5] Acute hypertensive encephalopathy is usually reversible with appropriate management. Acute aortic dissection has a high immediate morbidity and mortality and necessitates more aggressive blood pressure reduction. It usually presents with severe, tearing chest pain that radiates to the back.[5,6]


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