Please note, same day specialist assessment is reserved for those with a BP over (either systolic or diastolic in excess of) 180/120 mmHg AND
• retinal haemorrhage or papilloedema (accelerated hypertension) or
• life-threatening symptoms such as new onset confusion, chest pain, signs of heart failure, or acute kidney injury or
• suspected pheochromocytoma (for example, labile or postural hypotension, headache, palpitations, pallor, abdominal pain or diaphoresis)*
*More on clinical presentation of pheochromocytoma
Symptoms and signs of pheochromocytoma include the following:
Anxiety, sense of doom
The classic history of a patient with a pheochromocytoma includes spells characterized by headaches, palpitations, and diaphoresis in association with severe hypertension. These 4 characteristics together are strongly suggestive of a pheochromocytoma. In the absence of these 3 symptoms and hypertension, the diagnosis may be excluded. (Blake 2020 Medscape.com)
Hypertensive emergency with target-organ damage is uncommon (1-2 per million per year)1. It is reasonable to manage severe hypertension in the community with oral antihypertensives as per national guidance when there are no signs or symptoms of acute target-organ damage. Reduction in BP should be gradual in these cases.
Accelerated or “Malignant” hypertension can be defined as a significantly high blood pressure with evidence of target organ damage.
A significantly high blood pressure will depend on a number of factors including age, ethnicity, comorbidities or an underlying diagnosis of essential hypertension. An accepted cut off in non-pregnant adults is a new SBP ≥180 or DBP ≥110 but this needs to be applied in context of each patient. For example, a rare case of accelerated hypertension has been recorded in a 22 year old with a BP of 150/95mmHg; in the Afro-Caribbean population the condition is more common, it presents with a higher BP and is associated with worse renal function and prognosis2.
Admission to ED/MAU should be considered for patients with clear signs or symptoms of acute target-organ damage.
Guidance on the management of accelerated hypertension can be found below.
The recommended topical mydriatic in this cohort of patients is Tropicamide because it has fewer systemic effects which might raise BP further. Information on the safe use of Tropicamide can be found on the Eye Casualty Tropicamide Patient Group Direction (PGD).
Nb Patients at risk of angle closure will often have already been identified by community optometrists and the Diabetic screening.
This guidance has been developed in conjunction with the RCHT Renal team and Eye Casualty
Hypertensive crisis profile. Prevalence and clinical presentation, Martin JF, Higashiama E, Garcia E, Luizon MR, Cipullo. Arq Bras Cardiol. 2004 Aug;83(2):131-6; 125-30. Epub 2004
SURVIVAL AND PROGNOSIS OF MALIGANT PHASE HYPERTENSION IN A MULTIETHNIC POPULATION: THE WEST BIRMINGHAM MALIGNANT HYPERTENSION REGISTER, Gregory YH Lip, Vyomest Bhatt, Shamik Agashi, Andrew Elliot, Michelle Beevers, D Gareth Beevers. Am J Hypertens. 2003 May; VOL. 16, NO. 5