Crisis Hipertensiva

Hypertensive Crises*
Paul E. Marik and Joseph Varon Chest 2007;131;1949-1962 DOI 10.1378/chest.06-2490

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CHEST is the official journal of the American College of Chest Physicians. It has been publishedmonthly since 1935. Copyright 2007 by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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CHEST

Postgraduate Education Corner
CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE

Hypertensive Crises*
Challenges and Management
Paul E. Marik, MD, FCCP; and Joseph Varon, MD, FCCP

Hypertension affects > 65 million people in the United States and is one of the leading causes of death. One to two percent of patients withhypertension have acute elevations of BP that require urgent medical treatment. Depending on the degree of BP elevation and presence of end-organ damage, severe hypertension can be defined as either a hypertensive emergency or a hypertensive urgency. A hypertensive emergency is associated with acute end-organ damage and requires immediate treatment with a titratable short-acting IV antihypertensiveagent. Severe hypertension without acute end-organ damage is referred to as a hypertensive urgency and is usually treated with oral antihypertensive agents. This article reviews definitions, current concepts, common misconceptions, and pitfalls in the diagnosis and management of patients with acutely elevated BP as well as special clinical situations in which BP must be controlled. (CHEST 2007;131:1949 –1962)
Key words: aortic dissection; -blockers; calcium-channel blockers; clevidipine; eclampsia; fenoldopam; hypertension; hypertensive crises; hypertensive encephalopathy; labetalol; nicardipine; nitroprusside; pre-eclampsia; pregnancy Abbreviations: ACE angiotensin-converting enzyme; APH acute postoperative hypertension; DBP diastolic BP; FDA Food and Drug Administration; JNC JointNational Committee; MAP mean arterial pressure; SBP systolic BP

H ypertension is one of the most common chronic medical conditions in the United States, affecting close to 30% of the population 20 years old.1 While chronic hypertension is an established risk factor for cardiovascular, cerebrovascular, and renal disease, acute elevations in BP can result in acute end-organ damage with significantmorbidity. Hypertensive emergencies and hypertensive urgencies (see definitions below) are commonly encountered by a wide variety of clinicians. Prompt recognition, evaluation, and appropriate treatment of these con*From the Department of Pulmonary and Critical Care (Dr. Marik), Thomas Jefferson University, Philadelphia, PA; and Department of Acute and Continuing Care (Dr. Varon), The University ofTexas Health Science Center at Houston, Houston, TX. The authors have no conflicts of interest to disclose. Manuscript received October 11, 2006; revision accepted January 23, 2007. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Paul E. Marik, MD, FCCP, 834 WalnutSt, Suite 650, Philadelphia, PA 19107; e-mail: paul.marik@ jefferson.edu DOI: 10.1378/chest.06-2490
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ditions are crucial to prevent permanent end-organ damage. This article reviews our current understanding of hypertensive crises, the common misconceptions and pitfalls in its diagnosis and management, as well as pharmacotherapy and special situations that clinicians may...