A 62-year-old woman presents to your GP surgery complaining of dysuria. She has had previous UTIs and reports that her symptoms are similar to past episodes. You dipstick her urine and note the following results: Protein +++ Ketones + Blood ++ Leucocytes ++ Nitrites +ve You believe this to be a simple UTI and are about to prescribe some trimethoprim, when she mentions that she’s been having headaches for the past few weeks. She describes them as generalised, feeling like a pressure sensation all over her head. She takes no regular medication. She has not vomited, has no visual disturbances and has not had any change in her conscious level. She reports that the headaches are there almost constantly, even first thing in the morning when she wakes. Further examination reveals her blood pressure to be 220/120 mmHg. She is apyrexial, and has no rashes. Her heart rate is 92 bpm and regular and she has normal heart sounds. Her chest is clear to auscultation. You perform fundoscopy and note the presence of retinal haemorrhages bilaterally.

1. What is the diagnosis?

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This diagnosis in this case is that of hypertensive emergency. Hypertensive emergency can be defined as severe hypertension (blood pressure > 180/110mmHg) with acute damage to target organs. The organs affected include the heart, brain, kidneys and eyes. This is not to be confused with hypertensive urgency, which is when there is severe hypertension (blood pressure > 180/110mmHg) without acute damage to target organs.

2. How might the end target organs be affected?

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Affected target organs include eyes, heart, brain and kidneys. When the eyes are affected, the patient may experience visual disturbance and fundoscopy can reveal hypertensive retinopathy (the presence of haemorrhages and exudates) and papilloedema. Cardiac involvement can result in acute aortic dissection, acute coronary syndromes or acute pulmonary oedema. Acute renal failure can occur when the kidneys are affected. Cerebral damage can present as acute cerebral infarction, subarachnoid haemorrhage, intracerebral haemorrhage or eclampsia in a pregnant patient.

3. How should this patient be managed?

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This patient should be referred to the Emergency Department for further management.

NICE referral guidelines suggest that patients should be referred for specialist care on the same day with the following:

  • Accelerated hypertension (BP > 180/110 with signs of papilloedema +/or retinal haemorrhages)
  • Suspected phaeochromocytoma (labile or postural hypotension, headaches, palpitations, pallor)

The aim is to reduce blood pressure slowly. Over the first 2 hours, blood pressure should be reduced by 20-25%. If it is reduced too quickly, organ hypoperfusion can occur. This can result in a cerebrovascular accident, renal or coronary ischaemia. Continuous invasive blood pressure monitoring may be needed via an arterial line.

Nitroprusside is the most common intravenous drug used in this situation. Other alternatives include glyceryl trinitrite, esmolol or labetalol. If phaeochromocytoma is the cause, phentolamine should be used. Hydralazine is used in pregnancy.

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