Hypertension, affecting an estimated 29% of Americans older than 18 years of age, is one of the most common health problems that clinicians see today. Over the last decade in the United States, the prevalence of hypertension has escalated, paralleling the increase in the aging population and the numbers of obese and uninsured persons. This means that today’s acute care advanced practice nurses are likely to encounter more patients experiencing a hypertensive crisis.

A hypertensive crisis requires prompt identification and assessment, an accurate differential diagnosis, and swift and appropriate treatment to prevent permanent target organ damage. Hypertensive crisis, an umbrella term for acute, severe elevations in blood pressure (BP), encompasses 2 conditions on a continuum: hypertensive urgency and hypertensive emergency. Hypertensive urgency is severely elevated BP (diastolic BP > 120 mm Hg) with no obvious acute target-organ damage. By contrast, hypertensive emergency is the most serious but least common form of hypertensive crisis, representing only 5% of cases. Hypertensive emergency involves signs and symptoms of target-organ damage such as stroke, papilledema, heart failure, or aortic dissection. Neither form of hypertensive crisis typically develops without a long history of chronic disease, thus reflecting failure of accurate diagnosis and treatment by patients and/or the healthcare system.

What are the triggers to primary hypertensive crisis? Four common mechanisms have been identified:

* Dysfunction of the renin-angiotensin-aldosterone system
* High sodium-volume dependence
* Acute baroreflex failure
* Autodysregulation, such as malignant hypertension

Secondary causes of hypertensive crisis include left ventricular failure, acute coronary syndromes, acute aortic dissection, thyroid disorders, and chemical toxicities such as cocaine, weight-loss drugs, and steroids.

Hypertensive crisis is a growing clinical problem, and the cost to patients and society is high. In this article, Yeo and Burrell highlight the rising prevalence and financial burden of hypertension in the United States. Current recommendations for management of hypertensive crisis are discussed in detail.
Viewpoint

Epidemiologists have long recognized that because hypertension is often initially a silent disease, perhaps only a third of patients with hypertension have been diagnosed; only a third of these patients are under treatment; and only a third of these patients are keeping their blood pressure at goal levels. Although these statistics may vary over time, with an aging and obese population, it is clear that clinicians need to be more aggressive in their care of patients. Many undiagnosed patients are not unknown to the healthcare system, but the possibility of hypertension is not pursued and treated. Managing primary hypertension is critical to preventing the development of hypertensive crisis—which is physically and fiscally costly to the patient and to society.

In a country in which healthcare costs are out of control, the lack of affordability of healthcare accounts for many of these hypertensive patients being undiagnosed or untreated. Many hypertensive screening programs have been implemented by occupational health units. With the increase in individuals losing their jobs, or more companies refusing to offer health benefits, more individuals with undiagnosed hypertension will slip through the net until a hypertensive crisis occurs.

Healthcare reform must tackle the early diagnosis and treatment of more chronic problems such as hypertension. Using every patient encounter as an opportunity to recognize hypertension and educate patients about the imperative for treatment is essential if this cascade of severe problems is to stop.

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Yeo TP, Burrell SA
J Nurse Pract. 2010;6:338-346

Marilyn W. Edmunds, PhD, CRNP