Summary
Definition
History and exam
Key diagnostic factors
- blood pressure (BP) >180/120 mmHg
Other diagnostic factors
- neurologic symptoms
- cardiac symptoms
- abnormal cardiopulmonary exam
- oliguria or polyuria
- abnormal fundoscopic exam
- abnormal neurologic exam
Risk factors
- inadequately treated hypertension
- chronic kidney disease
- renal artery stenosis
- renal transplant
- endocrine disorders with known hypertensive effects
- pregnancy
- older age
- black ethnicity
- male sex
- use of sympathomimetic drugs
- pharmacotherapy with known hypertensive effect
- obstructive sleep apnea
- vasculitis and connective tissue diseases
Diagnostic investigations
1st investigations to order
- blood chemistry
- CBC with smear
- urinalysis with microscopy
- ECG
- chest x-ray
Investigations to consider
- thyroid function tests
- cardiac enzymes
- brain natriuretic peptide (BNP)
- urine toxicology screen
- thoracic CT scan with contrast
- transesophageal echocardiography
- renal ultrasound with Doppler
- head CT without contrast
- head MRI
- plasma renin activity and aldosterone level
- spot urine or plasma metanephrine
- 24-hour urine free cortisol
- sleep study
Treatment algorithm
accelerated (malignant) hypertension or hypertensive encephalopathy or intracranial hemorrhage
acute ischemic stroke
myocardial ischemia/infarction
left ventricular failure and/or pulmonary edema
aortic dissection
acute kidney injury
hyperadrenergic state
severe hypertension in pregnancy (preeclampsia and eclampsia)
Contributors
Authors
M. Lee Sanders, PhD, MD
Clinical Associate Professor
Division of Nephrology
University of Iowa
Iowa City
IA
Disclosures
MLS is an author of a reference cited in this topic.
Manish Suneja, MD, FASN, FACP
Clinical Professor
Division of Nephrology
University of Iowa
Iowa City
IA
Disclosures
MS is an author of a reference cited in this topic.
Acknowledgements
Dr M. Lee Sanders and Dr Manish Suneja would like to gratefully acknowledge Dr Hector Ventura and Dr Madhavi T. Reddy, previous contributors to this topic.
Disclosures
HV declares that he has no competing interests. MTR is employed by Merck and owns stocks in Merck, and Johnson & Johnson.
Peer reviewers
Aparna Sundaram, DO, MBA, MPH
Physician Consultant
Preventive Medicine
Private Practice
Atlanta
GA
Disclosures
AS declares that she has no competing interests.
Ethan Cumbler, MD
Assistant Professor
Department of Internal Medicine
University of Colorado Health Sciences Center
Denver
CO
Disclosures
EC declares that he has no competing interests.
Michael Schachter, MB, BSc, FRCP
Department of Clinical Pharmacology
St Mary’s Hospital
Imperial College
London
UK
Disclosures
MS declares that he has no competing interests.
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