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

Basma Abdulhadi, MD


February 05, 2018

A thorough history and focused physical examination should be performed for every patient presenting with elevated blood pressure to identify the presence of end-organ dysfunction. The history should include the patient's blood pressure medications, dosages, and compliance. Also, the use of recreational drugs, especially stimulants, should be determined. Blood pressure should be measured in both arms with an appropriately sized blood pressure cuff. Ophthalmoscopy should also be performed to evaluate for papilledema and exudates.

A neurologic examination is important for assessing mental status and the presence of focal neurologic deficits. Cardiac and pulmonary examinations are also crucial to assess for the presence of acute pulmonary edema. Patients should undergo electrocardiography upon presentation to evaluate for acute ischemia, myocardial infarction, and left ventricular hypertrophy. Blood tests should include a basic metabolic profile to assess renal function, and measurement of cardiac biomarkers may be necessary if acute coronary syndrome is suspected. Chest radiography should be obtained to assess for pulmonary edema and cardiomegaly. If mental status is altered or focal neurologic signs are present on examination, head imaging is important to obtain, as in this case.

In this case, the presence of retinal hemorrhages and exudates upon examination and the presence of left ventricular hypertrophy on the ECG indicates that the patient has end-organ complications from uncontrolled hypertension; his altered mental status points to hypertensive encephalopathy, which is reversible with timely management.[6,7] Brain imaging was obtained and did not show signs of acute cerebrovascular events. The patient was admitted to the medical intensive care unit with a goal of reducing his blood pressure gradually in a monitored setting to prevent the complications from hypoperfusion (eg, tissue ischemia) that occur if blood pressure is more rapidly reduced.[7]

Initial therapy for hypertensive emergencies consists of admitting the patient to a monitored unit with an initial therapeutic goal of reducing mean arterial pressure by no more than 10% within the first hour. Blood pressure that decreases more excessively within the first hour puts the patient at risk for worsening renal, coronary, and cerebral perfusion, resulting in ischemia.[2] After the first hour, the blood pressure can be lowered by 10% per hour to a value around 160/100 mm Hg. The blood pressure should then be gradually dropped to the patient's baseline over the next 24-48 hours. Once blood pressure is under control and end-organ dysfunction has ceased, the intravenous antihypertensives can be gradually tapered, and the patient can be transitioned back to oral hypertensive therapy. An important exception is patients with aortic dissection, in whom blood pressure should be reduced to at least 120 mm Hg (systolic blood pressure) within 20 minutes.[2]

Hypertensive urgencies can usually be managed by oral antihypertensives, whereas hypertensive emergencies require parenteral medications. The choice of pharmacologic agent to control blood pressure should be individualized on the basis of the patient's comorbidities and the end-organ dysfunction that has resulted.[2,6,7] Intravenous calcium-channel blockers are preferred in the management of hypertensive emergencies in the absence of acute heart failure and cardiac ischemia; in patients with myocardial ischemia or acute pulmonary edema, intravenous nitroglycerin remains the drug of choice. Esmolol is used when beta-blocker withdrawal is thought to contribute to hypertensive emergency. Esmolol should be avoided in acute heart failure. In pregnant patients with uncontrolled hypertension, methyldopa and labetalol are considered safe and are the commonly used medications.[2,6,7]


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