Update: October 2018
Systemic hypertension is very common.
more than 1 billion people in the world (in America
– more than 65 million).
People with hypertension are at high risk.
early development of diseases of the cardiovascular system, kidney and
About 7 million die each year from complications of hypertension
person. About 30% of US residents over 18 are diagnosed
�”Hypertension” of varying severity, more often – chronic
High blood pressure – a condition that can
to be asymptomatic for a long period of time, and
vascular damage caused by the hypertensive condition, usually
develops over many years. However, in some cases
patient pressure may rise to critical values
suddenly and for no apparent reason.
Hypertensive crisis is a condition characterized by
significant increase in blood pressure to critical
indicators with diastolic blood pressure more than 120 mm Hg. Art.
Suddenly its up to high rates damages cells,
lining the walls of the arteries that causes the accumulation
platelet and fibrin in the damaged area. it начальный этап
the formation of a blood clot, which can later lead to blockage
blood vessel to the heart or lungs.
If this condition is ignored, the consequences
hypertensive crisis in the form of target organ damage may
- Stroke (see signs of stroke)
- Memory loss, impaired consciousness
- Heart attack
- Damage to the eyes and kidneys
- The development of renal failure (complete loss of renal
- Aortic rupture
- Pulmonary edema
- Eclampsia (in pregnant women)
With an increase in systolic pressure above 130 mm Hg. Art.
the probability of target organ damage approaches 100%.
The exceptions are children and pregnant women.
- According to statistics, approximately 3.2% of patients in the ward
emergency care and intensive care are delivered with a diagnosis
- Thanks to the improvement of approaches to the treatment of emergency
hypertensive conditions, 5-year patient survival,
suffered a hypertensive crisis, increased to 74%.
- Risk factors include older age, as well as dark
color of the skin. Besides, отмечается, что у мужчин данное состояние
develops twice as often as women.
- The most frequent complications of hypertensive crisis are
cerebrovascular disorders (39% – ischemic stroke, 17% –
hemorrhagic stroke) and pulmonary edema (25%).
Causes of hypertensive crisis
Hypertensive crisis – a condition that develops in patients with
high blood pressure, receiving inadequate treatment.
However, the percentage of development of this complication remains quite
low (in America – 1% for 60 million patients with chronic
hypertension, more often in African Americans).
Causes of hypertensive crisis включают:
- Waiver or delayed admission of antihypertensives
- Drug use (cocaine, amphetamine) abuse
- Head injury
- Some types of tumors
- Acute glomerulonephritis
Some surgical interventions in patients with chronic
hypertension can lead to the development of hypertensive crisis in
postoperative period. To increased risk (4-35%) are
cardiac surgery patients who underwent surgery for
large blood vessels, interventions in the head and neck,
as well as trauma patients.
Secondary risk factors include:
- Improperly organized monitoring of blood
pressure in patients
- Lack of a qualified general practitioner
- Autumn and winter season
There has also been an increase in the incidence of hypertensive
crisis in people with low income and social status and
minimum medical insurance.
How to recognize the development of hypertensive crisis?
This complication belongs to the category of emergency cases and
potentially life threatening to the patient. Sick can
celebrate the following characterizing hypertensive crisis
- Acute chest pain
- Severe headache accompanied by confusion
and blurred vision
- Nausea and vomiting
- Increased excitability, the feeling of “fear of death”
- Shortness of breath, shallow breathing
- Nosebleeds (causes)
- Loss of consciousness
Symptoms of hypertensive crisis in different patients may
manifest to varying degrees depending on the lesion
target organ, and in some cases the crisis is asymptomatic.
The most common “silent” hypertensive crisis is observed in blacks.
men younger than 25 years.
The development of specific symptoms indicates the beginning
damage to various organs. Signs of a crisis with complicated
Over time include:
- Chest pain (ischemia or myocardial infarction)
- Back pain (aortic rupture)
- Difficult breathing (pulmonary edema or congestive heart
- Consciousness convulsions (stroke, encephalopathy)
The most common symptoms are:
- Headache – 22%
- Nosebleed – 17%
- Weakness, fainting – 10%
- Psychomotor agitation – 10%
- Chest pain – 9%
- Respiratory failure – 9%
Rare symptoms include arrhythmias and
For an adequate assessment of blood pressure is necessary
measure on both hands and use correctly
matched cuff. The pulse is produced on
upper and lower limbs for comparative assessment of the state
In 83% of patients one organ is damaged, in 14% –
two target organs, approximately 3% develop multi-organ
If you control your blood pressure yourself
and after measurement they found that it was elevated to 180/110 mm Hg.
Art. or higher, repeat the measurement after a few minutes and if
figures remain the same, immediately call an ambulance,
since you probably have a hypertensive crisis.
If any symptoms of damage to any organ
background high blood pressure immediately call an ambulance
help or ask to be taken as soon as possible to
First aid to the patient
Even before the examination by a specialist and the appointment of a specific treatment
the patient and his relatives may take a number of measures to reduce the risk
development of severe complications and take the first steps to reduce
high blood pressure. Emergency help with
hypertensive crisis before the arrival of the ambulance includes the following
- Lay the patient on the bed in a reclining position. it
improves blood flow to the lungs and makes breathing easier;
- In the presence of chronic hypertension – take the prescribed
drug in standard dosage regardless of the time of admission
previous dose. Within half an hour it is permissible to reduce the pressure not
more than 30 mm Hg. Art., за 1 час – не долее, чем на 40-60 мм
- Take a sedative medication (validol, Corvalol,
First aid for hypertensive crisis is carried out
following tablet preparations:
- Каптоприл (капотен). Most appropriate
for starting therapy of crisis, they have a mild hypotensive effect.
In low doses do not cause serious side effects.
The standard dosage is 25 mg orally before meals. If after 15-30 minutes
the effect has not developed, it is allowed to reappoint
- Нифедипин (Адалат, Кордафен, Коринфар и др.).
High-speed drugs with short-term antihypertensive
effect. It should be used with caution as it is high.
the likelihood of a sharp uncontrolled pressure drop. With acute
pain in the heart taking nifedipine is prohibited, as this may worsen
состояние больного при инфаркте myocardium. With hypertensive crisis
rarely used. Dosage – from ½ to 2 tablets inside (1
tablet – 10 mg). Antihypertensive effect occurs within 5 minutes
после приема и продолжается 4-6 hours
- Clonidine (Клофелин). Currently almost
not used (due to the large number of side effects) and
is a reserve drug used when other
drugs. It is applied on ½ – 2 tablets inside (1 tablet – 0,15
mg). The development of the hypotensive effect – 15-60 minutes after
reception. Продолжительность действия – до 12 hours
When is emergency hospitalization necessary?
In the presence of risk factors, the patient is subject to mandatory
- suffered a stroke
- ischemia or myocardial infarction
Patients with hypertensive crisis leading to the development of organ
insufficiency are subject to immediate hospitalization in the department
intensive care to control and normalize pressure using
drugs для внутривенного введения. Besides, таким больным
Neurological status should be regularly assessed and
control the amount of fluid released.
In such patients, the pressure must be reduced to acceptable.
indicators for one hour. The goal is to reduce blood pressure by 20-25% in
within one hour, then within 2 hours to achieve
stabilization rates at 160/100 mm Hg. Art. Achievement
normal blood pressure should occur within 1-2 days.
Proper treatment of hypertensive crisis in conditions of separation
intensive care or day care is directed to
preventing damage to target organs and is intended to
restoration of blood pressure indicators to baseline
In the hospital in the absence of symptoms of organ
failure in patients diagnosed with Hypertensive crisis
лечение проводится с помощью пероральных drugs с регулярным
контролем давления через 12-24-48 hours Do not drastically reduce
pressure, as this can lead to ischemia and collapse.
The generally accepted recommendations suggest a fractional decrease in blood pressure to
160/100 mmHg Art. within a few hours (up to 24) using
небольших дозировок антигипертензивных drugs с коротким
period of validity. These drugs include:
- Captopril (use with caution due to rapid development
effect and risk of a sharp drop in blood pressure)
Avoid aggressive treatment of hypertension with
using intravenous infusions and high dosages of antihypertensives
remedies, as this can lead to cerebral ischemia,
myocardium, kidney or cause retinal detachment with development
At this stage, the treatment can be carried out on an outpatient basis.
provided that the patient will be advised on the reception of the prescribed
preparations and cases are described at which it is necessary to increase a dosage
take medication or start taking additional
Among the fast-acting antihypertensive drugs are preference
given to such means as:
Эналаприл и другие препараты из группы
ACE inhibitors are not recommended for use in the treatment of
complicated forms of hypertensive crisis. These recommendations
due to slow onset of action (1 hour) and large
the duration of the hypotensive effect (6 hours). Besides,
taking ACE inhibitors can aggravate the severity of
patient with renal failure.
Labetalol – неселективный а1-адреноблокатор,
providing a stable hypotensive effect for at least 5
hours A feature of its action is to maintain normal
cardiac output and expansion of peripheral vessels without
negative effects on cerebral, renal and coronary blood flow.
Significant improvement after labetalol
has been reported in patients with hypertensive encephalopathy, as well as
is the drug of choice in acute ischemic stroke and ischemia
Esmolol – альфа-блокатор с очень коротким
period of validity. It reduces myocardial contractility and frequency
heart rate. Used with caution in case of acute
myocardial infarction in combination with nitroglycerin.
Nicardipine (Нифедипин) – препарат из группы
calcium channel blockers providing a vasodilator
action on the vessels of the brain and heart. Advantage
use of this drug is to improve the coronary
blood flow, which allows to successfully apply it in patients with
diseases of the coronary vessels. His appointment is recommended.
patients with ischemic stroke, provided that indicators
blood pressure exceed the original.
Clevidipine – новый препарат короткого действия
from a group of calcium channel blockers that is selective
arterial vasodilator used in operating and
intensive care units. This is an alternative drug,
safe to treat moderate to severe hypertensive conditions
Fenoldopam – агонист А1-допаминовых рецепторов
with peripheral vasodilating and diuretic effect. it
fast acting, well tolerated and highly effective drug
for intravenous use in the treatment of severe hypertension.
Using nifedipine with a short-term effect today
declared unsafe due to a sharp uncontrolled decline
blood pressure, which can cause cerebral ischemia,
kidney and coronary vessels.
Нитроглицерин – вазодилатор, снижающий нагрузку
on the heart and normalizing his work. Usually used in
combination with other antihypertensive drugs.
Гидралазин – вазодилататор прямого действия с
периодом полувыведения около 10 hours Often used in
pregnant women, because it improves uterine blood flow (inhibitors
ACE have a teratogenic effect during pregnancy
In the future, patients undergoing hypertensive crisis,
it is necessary to continue treatment with antihypertensive drugs, as
usually in higher dosage. After a hypertensive crisis,
dosed on an outpatient basis or after discharge from
the hospital must visit the local GP or cardiologist
to determine further tactics of treatment and selection of the optimal
Concerning hypertensive crisis, there are several
verified statistics. 3 year survival rate
is about 40%.
The most common causes of death for patients are:
- Renal failure – 39.7%
- Stroke – 23.8%
- Myocardial infarction – 11.1%
- Heart failure – 10.3%
In many ways, high mortality rates are associated with a lack of
correct treatment and non-compliance with the prescribed regimen. Only 6%
cases before discharge the patients were carried out all the necessary
research, and in 10% of cases there was no
research in general.
In patients with a hypertensive crisis who did not receive treatment,
mortality within 1 year is 79%. When correct
treatment and compliance with the recommended 5-year regimen
survival of patients undergoing hypertensive crisis exceeds
Автор: Коробов Никита Александрович врач-анестезиолог