Hypertensive crisis

Prevalence

Causes of development

Kinds of crises

Symptoms

Diagnosis and how to measure pressure

Forecast

Prevention

Complications

Synonyms: hypertensive crisis, pressure surge. 

The ICD-10 code: the underlying disease is hypertension I.10-I.13 or secondary arterial hypertension I.15.

Hypertensive crisis – a sudden increase in blood pressure. The development of the crisis is accompanied by such symptoms as a sharp headache, tinnitus, visual impairment, sensation of heat, facial flushing. Diagnosis of a crisis is based on clinical symptoms and measurement of blood pressure. Treatment is only medication.

Hypertensive crisis – a sharp increase in blood pressure: systolic above 180 mm. Hg Art. and / or diastolic above 120 mm. Hg Art. But sometimes it develops with smaller values. The basis of the diagnosis in this case are more clinical symptoms.

Prevalence

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In Russia, about 40% of the population has high blood pressure. Among these people, about 1–5% suffer a hypertensive crisis every year. Most are mild, that is, without complications. However, in 25% of cases, patients suffer a crisis with the development of such complications as myocardial infarction, acute heart failure, pulmonary edema, hypertensive encephalopathy, stroke or cerebral infarction, aortic dissection, eclampsia (state of pregnant women with miscarriage) – complicated hypertensive crisis.

It is almost impossible to single out the age at which hypertonic crises occur more often. They occur in young people at the age of 30, and in the elderly at 80. More important here are comorbidities and conditions of the body, such as pregnancy, stress, as risk factors.

Causes of development

Hypertensive crisis develops mainly due to hypertension , or as it is also called, essential or primary hypertension. 

Less often, the cause is exacerbation of secondary arterial hypertension. It develops as a result of the following diseases:

  • Pathology of the kidneys and their vessels (pyelonephritis, glomerulonephritis, polycystic kidney disease, diabetic nephropathy, stenosis of the renal arteries, etc. );
  • A pheochromocytoma is an adrenal tumor that produces a large amount of adrenaline, which increases pressure.
  • Primary aldosteronism ( Conn syndrome ) is a congenital disease of the adrenal glands.
  • Syndrome and Itsenko-Cushing disease.
  • Coarctation (narrowing of the lumen) of the aorta.
  • Thyrotoxicosis (excessive production of thyroid hormones).
  • Dosage forms of arterial hypertension: continuous use of glucocorticoids (prednisone), nonsteroidal anti-inflammatory drugs ( indomethacin , naproxen , diclofenac).

Who is at risk

For cardiovascular pathology, in particular for the development of hypertensive crisis, common risk factors are characteristic:

  • male
  • age over 50 years;
  • hereditary burden;
  • smoking;
  • poor nutrition;
  • obesity;
  • low physical activity;
  • the presence of snoring and episodes of respiratory arrest in a dream.

There are general trigger factors for a sudden increase in blood pressure:

  • discontinuation of pressure reducing drugs;
  • stress;
  • surgery;
  • excessive salt and fluid intake;
  • taking hormonal contraceptives;
  • alcohol abuse.

Also distinguish reflex factors that contribute to a sharp increase in blood pressure levels:

  • pain;
  • anxiety;
  • acute urination disorders in prostate adenoma or urolithiasis;
  • sleep apnea syndrome (sleep apnea) in sleep.

The frequency of pressure shocks depends on several factors:

  • Firstly, this is adherence to therapy (regular intake of properly selected treatment regimens) and correction of lifestyle: weight loss, good nutrition with low fat, salt, increase in the diet of the share of herbal products, quitting smoking, alcohol, reducing the number of stressful situations. possibly a job change.
  • Secondly, from the timeliness of the initiated treatment of the underlying disease – hypertension or the causes of secondary hypertension (pathology of the kidneys, adrenal glands, Itsenko-Cushing’s disease, thyrotoxicosis, and others).
  • Thirdly, an important reason for the high frequency of hypertensive crises is genetics.

Kinds of crises

There is a huge number of classifications of hypertensive crisis. They are mainly associated with clinical manifestations.

First of all, doctors use the separation of the pathological process by the presence of complications:

1. Complicated hypertensive crisis is also called emergency, life-threatening . Patients develop acute damage to target organs (heart, brain, kidneys, eyes), sometimes resulting in fatal consequences – death. A person with this type of crisis is hospitalized in a hospital in an intensive care unit for emergency pressure reduction. Complicated hypertensive crisis also includes a sharp increase in blood pressure in preeclampsia , eclampsia in pregnant women, brain injury, drug intake.

2. Uncomplicated hypertensive crisis is characterized by the appearance of minimal symptoms on the background of increased pressure without the development of target organ damage. Emergency hospitalization is not required.

Also distinguish classification by AP Golikov:

  • hyperkinetic variant of the crisis, when predominantly systolic (upper) pressure rises, with pulse pressure (the difference between systolic and diastolic) increases, in patients with an increase in heartbeat;
  • hypokinetic type of crisis – an increase in diastolic (lower) blood pressure, a decrease in the difference between systolic and diastolic pressures, a tendency to bradycardia ( decrease heart rate);
  • Aukinetic crisis – a mixed version, characterized by increased and systolic and diastolic pressure. It can develop as both tachycardia and bradycardia.

The above options for hypertensive crisis correspond to a clinically different classification:

Adrenal crisis type I

Hypertensive crisis type 1 – adrenal. It develops quickly, suddenly, without harbingers. Characterized by headache, feeling hot, pulsating and trembling all over the body, redness of the skin, sweating. It flows quickly – from several minutes to several hours. Corresponds to the hyperkinetic variant of the development of the crisis.

Norepinephrine crisis type II

It is characterized by gradual development, severe course, long duration – from several hours to several days.

Patients complain of a sharp headache, impairment of hearing and vision, which go away on their own, sometimes transient (pass away on their own) motor impairment of the extremities, confusion, constricting, pressing pain in the region of the heart. Corresponds to the hypokinetic variant of the development of the crisis.

Complicated Crisis

It is characterized by acute coronary insufficiency, pulmonary edema, or acute cerebrovascular accident in the form of a stroke.

Symptoms

Hypertensive crisis, depending on its type, lasts from several minutes to hours (adrenal, type 1), to several days ( noradrenal , type 2).

Prodromal symptoms (harbingers of a crisis) with elevated pressure does not exist. Most often, patients immediately feel the symptoms already with increasing pressure. Therefore, to predict the development of the crisis is almost impossible.

Hypertensive crisis – a sharp increase in blood pressure: systolic above 180 mm. Hg Art. and / or diastolic above 120 mm. Hg Art. But sometimes it develops with smaller values. The basis of the diagnosis in this case are more clinical symptoms.

In the elderly, more often during hypertensive crisis, the upper, systolic blood pressure rises, while the lower, diastolic, can be either normal or increases, but to a lesser extent.

In 70-90% of patients with hypertensive crisis, the so-called triad of symptoms is detected:

  • headache, mainly in the back of the head;
  • dizziness;
  • nausea.

Somewhat less common are the following symptoms:

  • pain behind the sternum of oppressive, constricting nature;
  • dyspnea;
  • neurological symptoms (hearing, vision, limb movement, skin sensitivity, loss of consciousness, etc.);
  • psychomotor agitation;
  • nasal bleeding.

During a sharp increase in blood pressure, autonomic symptoms may also develop:

  • muscle tremors;
  • red spots on the skin;
  • increased sweating;
  • heartbeat;
  • by the end of the crisis increased urination;
  • sometimes loose stools.

Diagnosis and how to measure pressure

Diagnosis of hypertensive crisis is based on the measurement of blood pressure using a tonometer. There are automatic, semi-automatic and mechanical tonometers. The highest accuracy of measurement can only boast of mechanical. However, it is not always convenient to use.

It is worth noting that there are certain rules for measuring blood pressure:

  • Before measuring blood pressure, a person should catch his breath and calm down.
  • Sit as comfortably and comfortably as possible, do not cross your legs.
  • The hand is on the table at the level of the heart.
  • Cuff overlaps shoulder. Its bottom edge is 2 cm above the shoulder fold.


Photo: correct positioning of the cuff on the arm when measuring pressure

  • Measured pressure on both hands.
  • Where the pressure is maximal, pressure is measured 2 times on that arm.
  • Take the average value for the result.

Between measurements, intervals of 1–3 minutes should be taken.

When calling an ambulance crew to a patient, they also have to take an electrocardiogram, without fail, to exclude more serious heart problems. However, in hypertensive crisis complicated by acute coronary syndrome, electrocardiography reveals perfectly clear criteria for myocardial ischemia, which can later develop into a heart attack. Also, changes on the ECG may also occur with the development of acute cerebral circulatory disorders.

Research methods for complicated crisis:

  • Computed tomography or magnetic resonance imaging of the brain is recommended for the development of stroke, CT scan with contrasting of the aorta in the thoracic and abdominal part during its dissection.
  • Echocardiography – with acute coronary syndrome, acute heart failure.

First aid

At home, it is usually possible to help a person with high blood pressure. It is very important to reduce the pressure gradually.

Important! Acceptable reduction in blood pressure by 25% from baseline for 2 hours and not more. Otherwise, the risk of circulatory insufficiency of the brain and heart is high. 

Today there are only 3 drugs that cope with the task:

  • Captopril ( Capoten ) 25 mg per tablet. When a crisis is taken under the tongue usually start with half a pill. The drug will act in 15-20 minutes. With inefficiency after 30 minutes you can take another half a pill. And then wait for the arrival of ambulance.
  • Nifedipine ( Corinfar , Kordaflex ) 10 mg in one tablet. During the crisis, you can take 10 mg of the drug under the tongue. The action begins in 20 minutes. Repeated administration is undesirable. In case of inefficiency, we expect help.
  • Moxonidine ( Fiziote nz ) at a dosage of 0.2, 0.3 and 0.4 mg. With the development of hypertensive crisis, moxonidine is not a first-line drug. It is used in patients who are not helped by captopril and nifedipine or there are contraindications to their use. Moxonidine is taken in a dosage of 0.2 mg orally. The effect comes in 1-2 hours.

In addition to drugs, if there is no effect from them for an hour, hot foot baths with a water temperature of about 40 degrees or the imposition of mustard on the calf muscles can also help. However, you should not use both methods of lowering blood pressure.

In young people, the target level for reducing blood pressure is less than 140/90, and better still lower, up to 120/80. In the elderly, with a rise in both the upper and lower pressure, the target level is the same. If only systolic rises, then it should be lowered to a level less than 150 mm Hg . The diastolic pressure in this case should not be below 60-70 mm Hg .

After lowering blood pressure, a person may feel weak. The best option for recuperation will be a dream. You should not continue to work or engage in any physical activity, as this may provoke a second crisis. Usually, the next day the patient feels better, but if some symptoms persist, it is better to call the local therapist or an ambulance.

Hypertensive crisis can pass on their own. But it is not known whether he will pass so painlessly for a person. Each crisis is a stress for the organism, which in one way or another gradually changes the structure of the vessels. In any case, it is best to take the drug at elevated pressure and avoid possible consequences – myocardial infarction, stroke, aortic dissection, which can be fatal.

Medical assistance

Emergency medical care should be called in cases of:

  • if within an hour of treatment at home does not lead to a decrease in pressure;
  • chest pain, not passing after taking nitroglycerin;
  • sensation of heart rhythm disturbance, interruptions in his work;
  • visual impairment, hearing loss;
  • decreased sensitivity, numbness of the limbs, face;
  • violation of motor functions of the limbs.

Uncomplicated hypertensive crisis is treated at home by the patient or the emergency medical team. Blood pressure is reduced by no more than 25% from baseline over 2 hours using captopril , nifedipine or moxonidine . Hospitalization in a hospital is recommended only in case of development of a complicated hypertensive crisis or suspicion of a secondary nature of arterial hypertension.

The treatment of a complicated hypertensive crisis is carried out in conditions of resuscitation, the intensive care ward of the cardiological or therapeutic department. If a stroke is suspected, the patient is transferred to the ICU (intensive care unit) of the neurological department.

The pressure also decreases not too fast – no more than 25% of the initial one in 2 hours. For this purpose, use of intravenous drugs:

  • nitroglycerin or sodium nitroprusside;
  • ACE inhibitors ( enalaprilat );
  • beta blockers ( metoprolol , esmolol );
  • alpha blockers ( phentolamine );
  • diuretics (furosemide);
  • neuroleptics ( droperidol ).

After stabilization of the pressure level and returning it to normal values, antihypertensive therapy should be reviewed, it is possible to add or change any drugs. This all happens on an outpatient basis. since the selection of therapy is a long process, it takes from a week to several months.

In the intensive care unit or in the intensive care unit, patients with a hypertensive crisis lie until the state is stabilized and the acute symptoms are relieved. When the doctor according to the results of the examination decides that the life of the patient is not in danger, the person is transferred to the therapeutic, cardiological or neurological department, depending on the presence of complications.

It so happens that patients stay in the intensive care unit for several weeks and doctors cannot cope with high blood pressure. But these are mainly patients who have severe comorbidities: diabetes, renal failure, thyroid disease, and heart rhythm disturbances.

The rehabilitation process depends on the resulting complications. When stroke rehabilitation is very long, this includes not only the gradual restoration of lost and impaired functions, but also gymnastics and massage, aimed at preventing restrictions on the mobility of joints and normalizing muscle tone. With myocardial infarction – the gradual expansion of motor activity.

Complicated hypertensive crisis

Hypertensive crisis – a condition that flows in time and is complicated or not, it will be clear after a certain period of time, during which it is necessary to take measures to reduce blood pressure as soon as possible. This is the only way to prevent the development of a complicated hypertensive crisis, especially in hypertensive illness.

With some secondary arterial hypertension, crises are automatically considered complicated, and patients are immediately hospitalized as it is almost impossible to cope with the increased pressure at home. Such conditions include pheochromocytoma , eclampsia, preeclampsia of pregnant women, traumatic brain injury, drug taking.

To prevent the development of any complication with increasing blood pressure is very important regular medication. Moreover, this is usually a combination therapy of 2 or 3 drugs. With proper treatment and compliance with all the recommendations of the doctor for the correction of lifestyle, the frequency of crises is sharply reduced, especially complicated.

When a complicated hypertensive crisis develops:

Hypertensive encephalopathy

  • characterized by headache, confusion, nausea and vomiting, convulsions, the development of a coma.

Acute cerebrovascular accident:

  • hearing impairment, vision, motor ability, sensitivity of the skin.

Acute Heart Failure

  • choking, moist rales in the lungs, pink foam from the mouth.

Acute coronary syndrome – a clinical syndrome that includes:

  • severe burning pain behind the sternum, extending into the left shoulder, shoulder blade, lower jaw, as well as the corresponding changes in the electrocardiogram.

Stratifying aortic aneurysm.

  • With the defeat of the thoracic aorta – the most severe pain in the chest with the development of sometimes shock states with a sharp decrease in blood pressure, loss of consciousness.
  • During the dissection of the abdominal aortic aneurysm, patients complain of severe abdominal pains of various localization, which do not disappear after taking analgesic drugs, even narcotic drugs.
  • Also, signs of ischemia of the extremities (cooling, blanching, decreased pulse, decreased sensitivity), ischemia of the brain and spinal cord with the development of violations of the sensitivity of the skin, motor functions of the extremities, incontinence of the stool or urine are characteristic cardiac tamponade (asphyxiation, sharp chest pains, blue upper body, jugular veins on the neck, loss of consciousness).

Forecast

The prognosis of the disease depends on the correctness of the diagnosis. In the case of correct identification of the cause of increased blood pressure, the therapy will be chosen correctly and the prognosis in this case is the most favorable.

In this case, it is important for the patient to understand that the outcome of the disease also depends on his actions. If he does not comply with the recommendations of the doctor, especially with regard to the correction of lifestyle, the effectiveness of antihypertensive therapy is sharply reduced.

The prognosis worsens greatly with the development of a complicated hypertensive crisis. Approximately 3% of these patients develop renal failure, requiring hemodialysis. And 25-40% of those who have suffered a complicated crisis die within 3 years of a stroke or kidney failure.

Prevention

Arterial hypertension is a chronic disease that requires constant monitoring of blood pressure and regular medication. Planned visits to a therapist or cardiologist are required to evaluate the effectiveness of therapy.

It is obligatory to keep a personal diary of blood pressure, where his morning, evening measurement, as well as unscheduled with a sharp increase, is daily marked, in this case, symptoms should also be noted.

Prevention of hypertensive crisis also includes a diet low in salt, fatty foods, excess fluid. Also of great importance is given to quitting smoking, alcohol and the normalization of weight.

Medication should be regular. Preparations should not be changed too often, even within the same active ingredient.

Patients are encouraged to attend schools of patients with arterial hypertension, which are held in the medical institutions of the city. The presence of such schools can be obtained from your doctor.

Complications

With chronically elevated blood pressure, hypertensive retinopathy develops, which results in impaired vision by patients due to vascular lesions of the retina.

The organs that are most affected by high blood pressure are the kidneys. It is the main regulator of blood pressure in the body, and if their blood vessels are damaged, a vicious circle occurs, which worsens the course of arterial hypertension.

Complications develop with the appropriate variant of hypertensive crisis. Among them, the frequency of cerebral infarction (or ischemic stroke), pulmonary edema, hypertensive encephalopathy, acute heart failure, myocardial infarction or unstable angina, hemorrhagic stroke or subarachnoid hemorrhage, eclampsia in pregnant women, aortic dissection. 

In women, after menopause, hypertensive crises occur, as a rule, worse than in men. The reason lies in more fragile vessels, which are more easily damaged with a sharp increase in blood pressure. Because of this, strokes, as a complication of a hypertensive crisis, more often occur in women.

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