Hypertensive crisis: symptoms and first aid, treatment at home

Hypertensive crisis (HC) is an extremely severe manifestation of arterial hypertension, which develops due to a violation of the mechanism of blood pressure regulation. The main manifestation of GC is a sharp sudden increase in blood pressure (BP), accompanied by a significant deterioration in renal and cerebral circulation. For this reason, the likelihood of severe cardiovascular complications increases (myocardial infarction, stroke, acute coronary failure, dissecting aortic aneurysm, subarachnoid hemorrhage, acute renal failure, pulmonary edema, acute left ventricular failure accompanied by pulmonary edema, etc.).

General information

Arterial hypertension is the most common chronic disease of the cardiovascular system, which is more common in older people (after 60 years it occurs in 60%). Arterial hypertension is registered more often in women than in men and is the cause of overall mortality. Proper treatment of hypertension helps to increase the life expectancy of patients. A decrease in systolic pressure of only 10 mm Hg. Art., and diastolic by 5 is accompanied by a decrease in the risk of strokes by 35%, and acute coronary pathology by 20%.
Despite the treatment, there are cases of uncontrolled disease, which is complicated by hypertensive crises. What is a hypertensive crisis? This is a significant increase in pressure from the usual level for a given patient, which is accompanied by disorders of the heart, brain and autonomic nervous system. The ICD-10 code for hypertensive crisis is I11.9. With an uncontrolled course, a repeated crisis develops within a year in 62% of patients, and in 11% the next crisis develops in the next two days. Each repeated crisis negatively affects the immediate and long-term prognosis. How dangerous is a hypertensive crisis? The most dangerous is a complicated crisis, the complications of which are myocardial infarction , pulmonary edema , and cerebrovascular accident. Moreover, cerebrovascular complications account for 81%. These complications cause disability and even death of patients. In this regard, it is important to relieve the crisis, eliminate cardiac and neurological symptoms and subsequently stabilize the patient’s condition.

Treatment

The goal of treatment for a hypertensive crisis is to gradually reduce blood pressure to an acceptable level. It must be remembered that this reduction must be carried out smoothly and slowly. It is generally accepted that blood pressure should be reduced no faster than 10 mmHg per hour. Art. With a sharper decrease in blood pressure, collapse may occur, accompanied by loss of consciousness and other consequences.

In the treatment of hypertensive crisis, various medications are used that are traditionally used for hypertension. Due to the fact that the disease is in the nature of attacks, it is treated by ambulance staff, but in general it can also be treated by general practitioners who happen to be close to the patient. Regardless of who provides care to the patient, it is important that the treatment is timely and correct. That is why even non-professionals, who know exactly which drug works best for the patient, can provide pre-medical assistance. However, this does not eliminate the need to call a doctor.

To alleviate the patient’s condition, he must be seated in a “half-sitting” position (in a chair), ensure peace and place a small pillow under his head. Then, before the ambulance arrives, the blood pressure and pulse rate should be recorded. The patient should not be left unattended. The arriving ambulance doctor will be able to give more detailed medical recommendations. The primary occurrence of a hypertensive crisis or the impossibility of stopping it are sufficient grounds for hospitalization in a cardiology hospital.

Classification

There are many classifications of hypertensive crises. According to one of them, a hypertensive crisis is divided into:

Complicated.
Uncomplicated.

In turn, uncomplicated crises are divided into forms:

Water-salt.
Neurovegetative.
Convulsive.

According to the type of hemodynamics there are:

Hyperkinetic crisis. With it, systolic pressure generally increases and cardiac output increases, and tachycardia . When compared with the classification of Ratner N.A. it corresponds to the first type of crisis (adrenal).
Hypokinetic. Characterized by a predominant increase in diastolic pressure, a decrease in cardiac output and a sharp increase in peripheral resistance, there is a tendency to bradycardia. Its manifestations correspond to a crisis of the second order.
Eukinetic crisis. Occupies an intermediate place between the first two. Characterized by normal cardiac output and increased peripheral resistance. With this type, systolic and diastolic pressure increases evenly.

According to the classification of Moiseev S.G., the following stands out:

Cerebral hypertensive crisis. Manifested by headache , vomiting , photophobia , various vestibular and visual disorders, focal symptoms characteristic of ischemic stroke .
Cardiac. It occurs in several variants: asthmatic ( pulmonary edema ), anginal ( myocardial infarction ) and arrhythmic (occurs with paroxysms of atrial fibrillation or paroxysmal tachycardia ).

According to one classification, the following forms of crises are distinguished:

Neurovegetative . It is characterized by a sudden onset, tachycardia , agitation, redness of the skin, sweating , excessive urination, and increased systolic pressure. That is, the crisis proceeds as a sympathoadrenal paroxysm . Crises of this type proceed favorably.
Water-salt . The deterioration of the condition occurs gradually, patients experience drowsiness , lethargy, deterioration of orientation in the environment, puffiness of the face and general swelling. It is severe and is often complicated by left ventricular failure . Pressure (systolic and diastolic) increases evenly, but diastolic pressure may predominate, then pulse pressure decreases.
Convulsive form . Occurs in acute glomerulonephritis and manifests as severe encephalopathy . It begins with severe throbbing headache , agitation, vomiting, and visual disturbances. After this, loss of consciousness occurs and convulsions develop. In some patients with acute glomerulonephritis, a convulsive crisis develops at low pressure.

An uncomplicated hypertensive crisis has another name: non-critical and urgent. It is not accompanied by damage to the heart, brain or kidneys. It occurs with minimal symptoms and a significant increase in pressure. Patients experience increased headaches , restlessness and anxiety, extrasystoles may appear . An uncomplicated crisis develops with emotional overstrain if the intake of antihypertensive drugs is disrupted. Patients need emergency care, which is provided at home, and it consists of a gradual decrease in pressure over several hours. Such patients do not require urgent hospitalization, since this crisis does not pose a threat to life.

A complicated crisis has another name - critical and life-threatening, since it is characterized by life-threatening damage to organs (heart, brain, kidneys). It requires urgent hospitalization, immediate (within an hour) pressure reduction and further intensive care. A complicated crisis is diagnosed when there are signs of organ damage even at low pressure and urgent measures are taken. In complicated crises, the following develop (in descending order):

cerebral infarction (ischemic stroke );
pulmonary edema;
hypertensive encephalopathy;
myocardial infarction;
eclampsia;
cerebral hemorrhage;
dissecting aneurysm ;
eclampsia in pregnant women;
papilledema;
retinal hemorrhages;
kidney damage.

A crisis is characterized by:

high blood pressure (individual for each patient);
sudden onset;
subjective feelings;
increase in systolic pressure more than 220 mm Hg. Art., and a diastolic reading of more than 120, which is asymptomatic, is also classified as a hypertensive crisis.

Hypertensive crisis: from traditional ideas to modern clinical recommendations

As is known, the main recommendations for the treatment of arterial hypertension (AH) are created by leading experts in the field of healthcare (2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension, Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation , and Treatment of High Blood Pressure). In addition, annual updates, on the one hand, and the development of national recommendations, on the other, provide the most realistic approach to the treatment and prevention of hypertension.

All of the above has made it possible to reduce morbidity and mortality from pathologies associated with hypertension. A meta-analysis of 14 large randomized clinical trials showed that a decrease in diastolic blood pressure (DBP) alone by 5–6 mmHg. Art. reduces the risk of stroke by 42% (Collins). In the Russian Federation, as well as throughout the world, programs for the optimal treatment of hypertension are also being developed and implemented. This gives certain results: the range of antihypertensive drugs used has changed, the educational level of the doctor and the patient has increased, and national recommendations have been adopted. A contrast against this background is the situation with hypertensive crisis (HC). HA is the most prognostically unfavorable manifestation of hypertension: 25–40% of patients who undergo complicated HA die over the next 3 years from renal failure (level of evidence A) or stroke (level B). This risk increases with age (level A), with essential hypertension (level A), with increased serum creatinine (level A), with serum urea above 10 mmol/l (level B), with longer duration of hypertension (level B), with the presence of 2nd and 4th degrees of hypertensive retinopathy (level C), 3.2% of patients develop renal failure requiring hemodialysis (level B). Because of this, HA is one of the manifestations of hypertension that determines mortality from its complications [2]. An analysis of domestic guidelines and recommendations, including those issued in 2004–2005, showed the following: there is no clear definition of GC, and what is available contradicts the WHO definition; the above classifications are mostly focused on pathophysiological processes and are not essential for determining treatment tactics; among the recommended range of drugs there are many with unproven effectiveness, obsolete or not registered in the Russian Federation, there is no definition of the purpose of treatment and prognosis.

It is well known that the first medical authority where patients with GC turn is emergency medical care (EMS). It should be taken into account that in total in Russia the daily number of EMS calls reaches 150,000, the share of emergency services in different regions ranges from 7 to 25%, amounting to ~ 15,000–30,000 calls. The situation is further complicated by the fact that in the Order of the Ministry of Health of the Russian Federation No. 100 dated March 26, 1999 “On improving the organization of emergency medical care for the population of the Russian Federation” in Appendix 13 “Approximate list of equipment for a visiting ambulance team” in the section “Antihypertensive drugs”, paragraph 2.14 Only one drug is indicated - clonidine (Clonidine, Gemiton) 0.01% - 1 ml, 2 amp. (!) In this article, in a certain sequence, basic information regarding GC will be presented, based on the recommendations of the NNPOSMP and the standards of medical care at the prehospital stage, approved by the Ministry of Health and Social Development on September 4, 2006.

GK is classified as an emergency condition accompanied by an increase in blood pressure (BP) (in English terminology - hypertensive emergencies). HA is characterized by a sudden increase in blood pressure to individually high values, accompanied by signs of deterioration of cerebral, coronary, and renal circulation, as well as severe autonomic symptoms. Even an increase in blood pressure < 180/120 mm Hg. Art., leading to the appearance or worsening of symptoms from target organs (unstable angina, acute left ventricular failure, dissection of aortic aneurysm, eclampsia, stroke, papilledema) should be interpreted as GC [3]. In all cases of target organ damage, GC is considered complicated and requires lowering blood pressure within the first minutes and hours using parenteral drugs. A sharp increase in blood pressure, possibly with vegetative symptoms, not accompanied by symptoms from target organs, is interpreted as uncomplicated hypertension. In this situation, immediate intervention is not required; blood pressure should be reduced over several hours (hypertensive urgencies) using oral medications. In most cases of uncomplicated HA, there is inadequate basic therapy for hypertension and/or insufficient cooperation between the patient and the doctor. Increased systolic blood pressure (SBP) ≥ 220 mm Hg. Art. and/or DBP ≥ 120 mm Hg. Art. requires a decrease in blood pressure over several hours even in the absence of symptoms.

Worsening of the course of hypertension, in contrast to GC, develops against the background of preserved self-regulation of regional blood flow and, as a rule, is a consequence of inadequate treatment. There is satisfactory tolerability of high blood pressure values, there are no acute signs of target organ damage, a burdened history of cardiovascular diseases, and there is no risk of developing life-threatening complications. Worrying headache, which often goes away spontaneously, blood pressure < 220/120 mm Hg. Art. In this situation, adjustment of antihypertensive therapy is required, possibly with the use of short-acting oral antihypertensive drugs (nifedipine, captopril).

Etiology and pathogenesis. The Civil Code develops against the background of:

hypertension (including as its first manifestation);
symptomatic hypertension.

Conditions in which a sharp increase in blood pressure is possible:

pheochromocytoma;
acute glomerulonephritis;
eclampsia in pregnancy;
diffuse connective tissue diseases involving the kidneys;
use of sympathomimetic drugs (in particular cocaine);
skull injury;
severe burns, etc.

The most common factors contributing to the development of GC:

stopping taking antihypertensive drugs;
psycho-emotional stress;
excess salt and fluid intake;
exercise stress;
alcohol abuse;
meteorological fluctuations.

In the pathogenesis of GC there are:

vascular mechanism - an increase in total peripheral resistance as a result of an increase in vasomotor (neurohumoral influences) and basal (with sodium retention) arteriolar tone;
cardiac mechanism - an increase in cardiac output, myocardial contractility and ejection fraction in response to an increase in heart rate (HR) and circulating blood volume.

Clinical picture. Complicated GC is characterized by:

sudden onset (from several minutes to several hours);
individually high blood pressure level > 180/120 mm Hg. Art.);
the appearance of signs of deterioration of regional blood circulation;
the presence of pronounced vegetative symptoms (Table).

The caller to the EMS department is asked to do the following before the EMS team arrives:

lay the patient down with the head end elevated;
in case of loss of consciousness, ensure a stable position on the side;
clarify whether the patient was taking scheduled antihypertensive drugs; if not, then recommend taking them at the usual dose;
measure pulse, blood pressure and write down the numbers;
find the patient’s previously taken ECG in order to show it to the EMS doctor;
do not leave the patient unattended.

During the examination by the EMS team, the following mandatory questions are asked for diagnostic purposes:

Have blood pressure rises been recorded before? For how many years have blood pressure rises been observed?
What are the most frequently recorded numbers during regular self-monitoring?
Does the patient receive regular antihypertensive therapy?
What is the usual subjective manifestation of increased blood pressure, what are the current clinical manifestations?
When did the symptoms appear and how long does the crisis last?
Have there been any attempts to stop hypertension on your own, how was it possible to lower blood pressure earlier?
What medications had the patient already taken before the EMS doctor arrived? This is necessary to know in order to take into account the possibility of interaction with the prescribed drug.
Has the patient recently suffered a stroke or subarachnoid hemorrhage?
Are there concomitant kidney and heart diseases?

The following diagnostic measures are carried out:

Assessment of the general condition and vital functions: consciousness (agitation, stupor, unconsciousness), breathing (presence of tachypnea).
Visual assessment:
- position of the patient (lying, sitting, orthoptic);
- skin color (pale, hyperemia, cyanosis) and humidity (increased, dry, cold sweat on the forehead);
- vessels of the neck (presence of vein swelling, visible pulsation);
- presence of peripheral edema.
Pulse examination (correct, incorrect), heart rate measurement (tachycardia, bradycardia).
Measurement of blood pressure in both arms (normal difference < 15 mm Hg).
Percussion: the presence of an increase in the boundaries of relative cardiac dullness to the left.
Palpation: assessment of the apex beat, its localization
Auscultation of the heart: assessment of sounds, presence of murmurs, accent and splitting of the second sound above the aorta.
Auscultation of the aorta (suspicion of aortic dissection or rupture of an aneurysm) and renal arteries (suspicion of their stenosis).
Auscultation of the lungs: the presence of moist rales of varying sizes on both sides.
Clarification of the presence of visual impairment, vomiting, convulsions, angina pectoris, shortness of breath; diuresis assessment.
Examination of neurological status: decreased level of consciousness (level A), visual field defects (level C), dysphagia (level A), impaired motor functions in the limbs (level B), impaired proprioception (level B), impaired statics and gait (level B ), urinary incontinence (level B).
Registration of ECG in 12 leads: assessment of rhythm, heart rate, conductivity, the presence of signs of left ventricular hypertrophy, ischemia and myocardial infarction.

Prehospital treatment involves the following:

The patient's position is lying with the head end elevated.
Monitor heart rate and blood pressure every 15 minutes.
Calming conversation.

In case of uncomplicated HA or asymptomatic increase in SBP ≥ 220 mm Hg. Art. and/or DBP ≥ 120 mm Hg. Art. necessary:

a gradual decrease in blood pressure by 15–25% of baseline or ≤ 160/110 mm Hg. Art. within 12–24 hours;
use of oral antihypertensive drugs (start with one drug). Evaluation of the effectiveness and correction of emergency therapy is carried out after the time required for the onset of the hypotensive effect of the drug to begin (15–30 minutes).

For GC in combination with tachycardia, the following are used:

propranolol (non-selective β-blocker) - 10–40 mg orally. The therapeutic effect develops after 30–45 minutes, duration - 6 hours. Main side effects: bradycardia, bronchospasm, AV block. Contraindications: grade II–III AV block, sinoatrial block, sick sinus syndrome (SSNS), bradycardia (heart rate <50 beats/min), bronchial asthma, spastic colitis. Use with caution in chronic obstructive pulmonary disease (COPD), hyperthyroidism, pheochromocytoma, liver failure, obliterating peripheral vascular disease, and pregnancy. The drug of choice for GC in young people with severe vegetative symptoms, against the background of alcohol abuse, and during thyrotoxic crisis;
clonidine (level B), a centrally acting drug - sublingually 0.075-0.150 mg, the therapeutic effect develops after 10-30 minutes, duration - 6-12 hours. Severe side effects: dry mouth (level A), increased fatigue (level A ), weakness (level A), drowsiness (level A), slowed speed of mental and motor reactions (level B), dizziness (level A), decreased gastric secretion (level A), constipation, orthostatic hypotension, bradycardia, AV block ( increased risk of development when interacting with β-blockers, cardiac glycosides), transient increase in blood glucose levels (level A), Na+ and water retention. In case of overdose, blood pressure may increase. Contraindications: depression, severe atherosclerosis of cerebral vessels, obliterating arterial diseases, severe sinus bradycardia, CVS, AV block II-III, simultaneous use of tricyclic antidepressants and ethanol, pregnancy. Currently, clonidine is being pushed out of widespread practice due to a sharp and short-term decrease in blood pressure followed by an increase phase (“hemitonic crises”). Drug of choice for clonidine withdrawal syndrome.

For GC without tachycardia, the following is prescribed:

captopril (level B), ACE inhibitor - 25 mg sublingually, the therapeutic effect develops in 15-60 minutes, duration - up to 12 hours. When you first take captopril, a sharp decrease in blood pressure is possible. Before prescribing the drug, it is necessary to clarify the pathology of the kidneys (the development of renal failure is possible with bilateral stenosis of the renal arteries, stenosis of the artery of a single kidney), and also to assess the presence of hypovolemia in the patient (the risk of an excessive decrease in blood pressure increases due to diarrhea, vomiting and when taking diuretics in high doses) . Side effects: hypotension (one hour after administration), dry cough, skin rash, proteinuria. Contraindications: hypersensitivity to ACE inhibitors, pregnancy. Caution should be prescribed for: aortic stenosis, cerebro- and cardiovascular diseases (including cerebrovascular insufficiency, coronary insufficiency), severe autoimmune connective tissue diseases (including systemic lupus erythematosus, scleroderma), suppression of bone marrow hematopoiesis, chronic renal failure, elderly (12.5 mg). In Russia, the drug is not approved for use in persons under 18 years of age. Drug of choice in patients with heart failure, post-infarction cardiosclerosis and diabetes mellitus;
nifedipine (level B), a short-acting calcium antagonist - 10 mg sublingually, the therapeutic effect develops in 5-20 minutes, its duration is 4-6 hours. When taken, facial hyperemia often develops. Side effects: dizziness, hypotension (dose-dependent, the patient should lie down for an hour after taking nifedipine), headache, tachycardia, weakness, nausea. Contraindications: acute myocardial infarction, tachycardia. Use with caution in cases of severe aortic or mitral stenosis, severe bradycardia or tachycardia, CVS, chronic heart failure, arterial hypotension, severe cerebrovascular accidents, liver failure, renal failure, in old age, under 18 years of age (the effectiveness and safety of use have not been studied) . It is used to relieve HA in pregnant women; it is equally effective compared to magnesium sulfate and labetolol (level A). Drug of choice in patients with renovascular hypertension, COPD, occlusive arterial diseases.

The use of furosemide (loop diuretic) is possible in congestive heart failure as an addition to other antihypertensive drugs.

It is necessary to avoid a sharp excessive decrease in blood pressure due to the risk of developing ischemia of the heart and brain. The goal of treatment is to achieve a DBP of less than 120 mmHg. Art. or reduce it by more than 20 mm Hg. Art. (level D).

For complicated GC, the following therapeutic measures are necessary:

sanitation of the respiratory tract;
provision of oxygen;
venous access;
treatment of developed complications and a differentiated approach to the selection of antihypertensive drugs;
antihypertensive therapy with parenteral drugs;
rapid decrease in blood pressure (by 15–20% of the initial value within an hour, then in 2–6 hours to 160/100 mm Hg (switching to oral medications is possible).

HA complicated by acute myocardial infarction or acute coronary syndrome. Against the background of high blood pressure, acute myocardial ischemia develops. Clinical signs: the patient complains of a sudden attack of pressing, burning, even tearing pain localized behind the sternum, throughout the entire anterior half of the chest; less often, pain is localized in the throat, lower jaw, in the left half of the chest or in the epigastrium. The pain does not depend on body position, movement and breathing; lasts more than 15–20 minutes, without the effect of nitroglycerin.

The ECG shows signs of acute ischemia (arcuate elevation of the ST segment merging with a positive T wave or turning into a negative T wave; possible arcuate ST depression with a convexity downwards), myocardial infarction (pathological Q wave and a decrease in the amplitude of the R wave or the disappearance of the R wave and the formation of QS ), acute bundle branch block.

Treatment is aimed at relieving pain, improving myocardial nutrition and lowering blood pressure. Appointed:

nitroglycerin (level B) sublingually in tablets (0.5 mg), aerosol or spray (0.4 mg or 1 dose, repeat every 5–10 minutes if necessary) or IV 0.1% - 10 ml of nitroglycerin diluted in NaCl solution 0.9% - 100 ml and administered intravenously at a rate of 5-10 mcg/min (2-4 drops/min) under constant monitoring of blood pressure and heart rate;
propranolol (level A), non-selective β-blocker - iv bolus, slowly inject 0.1% - 1 ml (1 mg), it is possible to repeat the same dose after 3-5 minutes until the heart rate reaches 60 beats/min, under control BP and ECG. The maximum total dose is 1 mg;
if high blood pressure values persist, enalaprilat 0.625–1.250 mg IV infusion over 5 minutes;
morphine (level B), narcotic analgesic, 1% - 1 ml, diluted with a solution of 0.9% sodium chloride to 20 ml (1 ml of the resulting solution contains 0.5 mg of the active substance) and administered intravenously in fractional doses of 4-10 ml ( or 2–5 mg) every 5–15 minutes until pain and shortness of breath are eliminated, or until side effects appear (hypotension, respiratory depression, vomiting);
acetylsalicylic acid (level A) (if the patient did not take it on his own before the arrival of the ambulance team) chew 160–325 mg in order to improve the prognosis.

It should be remembered that high blood pressure numbers are a contraindication to the use of anticoagulants (heparin).

Antihypertensive drugs not recommended: nifedipine, furosemide.

GK complicated by acute left ventricular failure. With the development of acute left ventricular failure due to myocardial overload, stagnation and increased pressure in the vessels of the pulmonary circulation develop, which leads to pulmonary edema. The patient assumes a forced position (orthopnea). Severe inspiratory shortness of breath and cyanosis of the skin are noted. Auscultation of the lungs reveals moist fine bubbling rales on both sides.

Treatment is aimed at relieving pulmonary edema and lowering blood pressure. Appointed:

enalaprilat (level B) - 0.625–1.25 mg IV bolus over 5 minutes;
furosemide (level B) intravenously (20–100 mg).

Antihypertensive drugs not recommended: β-blockers (propranolol), clonidine.

HA complicated by acute aortic dissection or ruptured aortic aneurysm. Suddenly, severe pain occurs in the chest (damage to the thoracic aorta) or in the abdomen and back with partial irradiation to the side and groin areas (damage to the abdominal region). There is pallor of the skin (hypovolemic shock), shortness of breath (frequent and shallow breathing). During auscultation, a systolic murmur may be heard above the apex of the heart, which is clearly audible on the back along the spinal column, and in 15% of cases - diastolic. The ECG often reveals signs of coronary insufficiency or focal changes in the myocardium.

You should strive to quickly reduce blood pressure to 100–120/80 mmHg. Art. (or by 25% of the initial value in 5–10 minutes, and subsequently up to the indicated figures).

To reduce myocardial contractility and quickly lower blood pressure, use:

propranolol - administered slowly IV at an initial dose of 1 mg (0.1% - 1 ml), repeat the same dose every 3-5 minutes (until the heart rate reaches 50-60 beats/min, pulse pressure decreases to 60 mm Hg ., the appearance of side effects or reaching a total dose of 0.15 mg/kg);
nitroglycerin - 0.1% intravenous drip - dilute 10 ml in 100 ml of 0.9% NaCl solution and administer at an initial rate of 1 ml/min (or 1-2 drops per minute). The rate of administration can be increased every 5 minutes by 2-3 drops, depending on the patient’s response.

The use of β-blockers should precede the administration of any drugs that can cause tachycardia, including nitrates.

If β-blockers are contraindicated, verapamil is prescribed intravenously as a bolus: 0.25% - 1-2 ml (2.5-5 mg) over 2-4 minutes, with possible repeated administration of 5-10 mg after 15-30 minutes. .

To relieve pain, use morphine 1% - 1 ml, dilute with a solution of 0.9% sodium chloride to 20 ml (1 ml of the resulting solution contains 0.5 mg of the active substance) and administer intravenously in fractional doses of 4-10 ml (or 2- 5 mg) every 5–15 minutes until pain and shortness of breath are eliminated or until side effects (hypotension, respiratory depression, vomiting) appear.

Antihypertensive drugs not recommended: nifedipine, furosemide.

GC complicated by hypertensive encephalopathy. Due to a violation of cerebrovascular self-regulation, vascular dilation and increased permeability occurs, which leads to cerebral edema. Early clinical signs: intense headache, dizziness, nausea, vomiting, blurred vision (papilledema, retinal hemorrhages). The neurological status includes an unstable emotional background, disinhibition, agitation, sometimes confusion, psychomotor stupor or disorientation. Later, focal neurological symptoms, seizures, and coma may develop. With a decrease in blood pressure, rapid recovery of brain function is observed. Differential diagnosis is carried out with subarachnoid bleeding and stroke, and therefore emergency hospitalization and consultation with a neurologist are indicated.

The decrease in blood pressure is rapid and careful. Enalaprilat is used (level B) - 0.625-1.25 mg or 5-10 ml (1.25 mg per ml) intravenously (over 5 minutes), the therapeutic effect develops after 15 minutes, duration of action is 6 hours. If necessary, re-administer the dose after 60 minutes. Hypotension is observed as a side effect (rare). The effect on cerebral blood flow is minimal. Contraindications: hypersensitivity to ACE inhibitors, pregnancy, porphyria, childhood. Use with caution in aortic and mitral stenosis, bilateral renal artery stenosis, stenosis of the artery of a single kidney, systemic connective tissue diseases, renal failure (proteinuria more than 1 g/day), old age (0.65 mg).

For convulsive syndrome, diazepam is prescribed (level B) - IV in an initial dose of 10-20 mg (0.5% - 2-4 ml), subsequently, if necessary, 20 mg IM or IV drip. The effect develops after a few minutes, the speed of its onset varies from patient to patient.

Antihypertensive drug not recommended: nifedipine.

GK complicated by acute cerebrovascular accident or subarachnoid bleeding. Against the background of high blood pressure values, acute cerebral ischemia (ischemic stroke) or vascular rupture (hemorrhagic stroke, subarachnoid bleeding) develops. Clinical signs, as a rule, develop acutely; differential diagnosis is carried out in the hospital.

With ischemic stroke, headache, dizziness, nausea, repeated vomiting, dysphagia, blurred vision, urinary incontinence, and disturbance of consciousness (confusion, stupor, stupor, coma) appear. Neurological status: persistent focal symptoms - imbalance, paresis, paralysis, paresthesia, dysarthria, dysphagia, visual field defects, etc.

Hemorrhagic stroke is characterized by apoplectiform development with loss of consciousness and rapid transition to a coma. Focal symptoms depend on the extent and location of the hematoma. As the brain stem is compressed, nystagmus, disorders of cardiovascular activity and breathing appear.

Subarachnoid hemorrhage develops after short-term precursors in the form of an acute headache, tinnitus, often with psychomotor agitation, and vomiting. Sometimes signs of damage to the cranial nerves are revealed, along with neck rigidity, bilateral Kernig's sign, photophobia, and epileptiform syndrome.

Therapy is aimed at maintaining the vital functions of the body. Blood pressure is lowered slowly. Enalaprilat is used - 0.625–1.25 mg intravenously in a bolus for 5 minutes.

The use of acetylsalicylic acid and clonidine is contraindicated!

GK complicated by preeclampsia or eclampsia. It should be remembered that calcium antagonists cause relaxation of smooth muscles throughout the body, which leads to a weakening of labor, and ACE inhibitors are potentially teratogenic drugs.

Treatment involves providing a protective (from external factors) regimen. To relieve seizures and lower blood pressure, magnesium sulfate (level A) is used - iv 400-1000 mg (10% - 40-100 ml or 20% - 20-50 ml), bolus, with the first 3 ml administered in a minute or drip in NaCl 0.9% - 200 ml.

For preeclampsia, nifedipine (level A) is also used - 10 mg sublingually.

Emergency hospitalization to a maternity hospital is required.

For GC complicated by acute glomerulonephritis , the following is prescribed:

nifedipine - 10–40 mg orally;
furosemide - 80–100 mg.

Emergency hospitalization for hemodialysis or blood ultrafiltration.

For GC, as a manifestation of pheochromocytoma, the following is used:

prazosin - 1 mg sublingually;
droperidol - 5-10 mg IV;
propranolol - 20–40 mg (after β-blockers).

Indications for hospitalization are:

uncomplicated HA that is not treated at the EMS stage (hospitalization in a therapeutic or cardiology department);
complicated GC (emergency hospitalization taking into account the developed complication (Fig. 1), transportation of the patient in the supine position).

Recommendations for non-hospitalized patients left at home are as follows:

after taking oral antihypertensive drugs, the patient should lie down for at least an hour;
consult a doctor for correction of planned antihypertensive therapy.

Common errors:

Parenteral administration of antihypertensive drugs for uncomplicated hypertension or worsening hypertension.
The desire to immediately reduce blood pressure to normal levels.
Intramuscular administration of magnesium sulfate.
Use of dibazole in the absence of cerebrovascular accidents.
The use of drugs that do not have antihypertensive properties (Analgin, Diphenhydramine, No-shpa, Papaverine, etc.).
The use of diuretics (furosemide) in GC complicated by ischemic stroke.

For questions regarding literature, please contact the editor.

A. L. Vertkin , Doctor of Medical Sciences, Professor M. I. Lukashov , Candidate of Medical Sciences O. B. Polosyants , Candidate of Medical Sciences N. I. Pentkovsky MGMSU, NNPOSMP, Moscow

Causes of hypertensive crisis

Considering the causes of this condition, we can name the most common:

psycho-emotional overload;
presence of pain syndrome;
meteorological influences;
obstructive apnea ;
improper continuous therapy for hypertension;
failure of the patient to comply with prescriptions;
alcohol abuse;
taking hormonal contraceptives ;
operations and injuries;
obstruction of the urinary tract;
taking narcotic drugs;
smoking.

In addition to hypertension, a hypertensive crisis develops with pheochromocytoma , kidney diseases ( acute glomerulonephritis , urolithiasis , diabetic nephropathy , connective kidney disease), eclampsia in pregnancy , and skull injuries .

Classification of hypertensive crisis

Depending on the speed of development of the attack, there are:

Type 1 crisis
- a sharp rise in systolic pressure and a decrease in the indicator with medical help (rapid course), throbbing headache, agitation, irritability, fever, sweating, tachycardia.
Type 2 attack
- a simultaneous increase in upper and lower blood pressure, slow development (from two days or more), decreased vision, hearing, drowsiness, lethargy, symptoms are difficult to eliminate even in a hospital setting. One of the causes of hemodynamic disturbances with subsequent complications.

The presence of complications after a hypertensive crisis allows us to determine whether the process is complicated or uncomplicated. In the first case, manifestations are observed either from the heart (cardiac crisis) and can result in myocardial infarction, or from the brain (cerebral), provoking a stroke.

The forms are:

Hypokinetic
(decreased cardiac output). Lasts up to several days. It is characterized by drowsiness, loss of strength, decreased vision, and compressive pain in the heart area.
Hyperkinetic
(opposite to the hypokinetic form - increased release). It is characterized by an acute onset, sharp pain in the temporal region, dizziness, decreased vision, agitation, and trembling in the body. Duration - from a couple of minutes to three hours.
Eukinetic
(with normal release dynamics, peripheral blood circulation increases).

Determining the form of the attack is necessary to select further therapy and prognosis.

Symptoms of hypertensive crisis

A sharp increase in pressure is typical for any type of crisis. In most cases, a crisis develops if the systolic pressure is above 180 mmHg. Art., and diastolic above 120 mm Hg. Art. In pregnant women, children and adolescents, the picture of crisis appears even with a moderate increase in pressure. The crisis can last several hours or several days. In most cases, this condition is characterized by a triad - headache , nausea , dizziness . During crises, signs of autonomic dysfunction come to the fore: restlessness , chills , fear , anxiety , sweating , fever , excessive urination . Neurological disorders are possible - dissociation of reflexes in the arms and legs.

Signs of a hypertensive crisis in women depend on which organ suffers more, and therefore a hypertensive crisis is divided into cardiac type and cerebral type. Hypertensive cerebral crisis is accompanied by severe headache (more in the occipital region), nausea, dizziness, blurred vision (double vision, “spots” in front of the eyes and even transient blindness). In some patients, cerebral crisis occurs with convulsions , turning into hemiparesis (paralysis), confusion (or loss of consciousness .

Symptoms such as palpitations, heart pain, interruptions and shortness of breath are characteristic of a cardiac hypertensive crisis . Features of hypertension in women include a form of menopausal syndrome, which causes a periodic (cyclic) hypertensive crisis in women on certain days of the month. Signs of this “crisis” form usually recur cyclically in the first 3-4 years of menopause . The symptoms of this form of menopause are similar to premenstrual syndrome - swelling, irritability, poor sleep, sudden surges in blood pressure, hot flashes, palpitations. The consequences do not differ from the consequences of hypertension - myocardial infarction , rhythm disturbances, cerebrovascular accidents.

Symptoms

When a doctor provides first aid for a hypertensive crisis, he cannot accurately determine the type of central hemodynamics, so a division based on clinical manifestations was developed to classify crises.

Hypertensive crisis type I (hyperkinetic). Its development occurs quickly, dizziness, acute headache, flickering (“spots”) before the eyes, nausea, and in some cases vomiting appear. The patient is excited, feels hot and trembles violently. Red spots may appear on the skin of the face, neck and chest. The skin is damp to the touch. Often the patient complains of increased heartbeat and feels heaviness in the chest. Among the symptoms of a hypertensive crisis, tachycardia is noted. Blood pressure is at a high level, predominantly systolic, above 200 mm Hg. Art.

Hypertensive crisis type II (hypokinetic). As a rule, it occurs in people with stage III hypertension, when treatment is not effective enough or their lifestyle is disrupted. Compared to a hyperkinetic crisis, the symptoms of a hypokinetic crisis develop more slowly, but quite intensely. Over the course of a few hours, a severe headache develops. Then, among the symptoms of a hypertensive crisis, the appearance of nausea, vomiting, lethargy, deterioration of vision and hearing is noted. The pulse is tense, but not rapid. Diastolic blood pressure rises sharply to 140–160 mm Hg. Art.

Complicated hypertopic crisis. Its course can be coronary, cerebral or asthmatic. Compared with an uncomplicated hypertensive crisis, complicated variants involve the development of acute coronary insufficiency (cardiac asthma, pulmonary edema), acute left ventricular failure, acute cerebrovascular accident (hypertensive encephalopathy, transient cerebrovascular accident, hemorrhagic or ischemic stroke) against the background of high blood pressure.

In children

In children, crises develop with secondary arterial hypertension against the background of glomerulonephritis , coarctation of the aorta , pheochromocytoma , intracranial hypertension , Itsenko-Cushing's disease , adrenal cortex dysfunction, meningitis , polyarteritis nodosa , traumatic brain injury .

During a crisis in children, systolic pressure rises above 150 mmHg. Art., and diastolic is more than 95. In most cases, children experience severe headache lasting several hours or days, nausea , sweating , vomiting . Symptoms such as dizziness , hand tremors , ringing, darkening in the eyes indicate damage to the central nervous system.

To stop the crisis it is important:

create a calm environment for the child;
give a sedative;
use antihypertensive drugs.

Antihypertensive drugs are used in children when repeated vomiting, cardiac dysfunction, disorientation and convulsions occur. Also, as in adults, groups of antihypertensive drugs are used: beta-blockers ( atenolol , esmolol , propranolol ), vasodilators ( sodium nitroprusside ), diuretics ( furosemide ), calcium channel blockers ( nifedipine ), α-blockers ( prazosin ). In case of a crisis that occurs with cardiac symptoms and damage to the central nervous system, the use of nifedipine ( Corinfar ) at a rate of 0.25 mg/kg is effective. The effect appears at the 6th minute and reaches its maximum after an hour.

In children, a crisis often occurs as a sympathoadrenal paroxysm (accompanied by autonomic symptoms). In case of sympathoadrenal crisis, tranquilizers ( Seduxen , Relanium , Diazepam ), an antipsychotic ( Sonapax ) or a combination of a tranquilizer and an antipsychotic ( Seduxen + Sonapax ), as well as Pirroxan ( an alpha-blocker ) and propronalol ( a beta-blocker ) are prescribed.

A rapid increase in diastolic pressure is accompanied by a risk of developing encephalopathy . In this case, it is important to eliminate increased peripheral resistance and brain symptoms (convulsions, agitation). In this situation, vasodilators ( nitroprusside ), beta blockers ( labetalol ), and sometimes ganglion blockers ( pentamine ) are prescribed. For cerebral edema, Lasix . For convulsive forms, emergency care includes intravenous administration of Diazepam and intravenous drip administration of magnesium sulfate .

During pregnancy

Hypertension during pregnancy is a cause of premature birth, eclampsia , fetal death, and is also associated with maternal deaths. Prevention of preeclampsia (hypertension in combination with proteinuria) is the addition of calcium salts to the diet, resting the pregnant woman lying on her left side, since in this position the pressure decreases and the uteroplacental blood flow increases. Pregnant women with preeclampsia are at risk of thromboembolic complications, and therefore mobility is recommended rather than staying in bed and wearing elastic stockings.

Pregnant women with blood pressure above 140/90 mm Hg. Art. are hospitalized to monitor the woman and fetus. Indications for urgent hospitalization are a state of hypertensive crisis , the addition of preeclampsia , impaired cerebral circulation and renal function, heart failure , and progression of changes in the fundus. If the pressure is above 160/110, the issue of emergency delivery is decided. Emergency delivery is undertaken when the pressure is above 180/110, which does not decrease even in the presence of eclamptic coma .

To reduce blood pressure, Nifedipine (5-10 mg sublingually or orally, if necessary, the drug is taken again after 30 minutes). Nitroglycerin intravenous drip and intravenous administration of labetolol . In severe cases, Pentamin (ganglionic blocker) is used intravenously, which is administered very carefully. It must be remembered that a sharp decrease in pressure leads to a deterioration in uteroplacental circulation and acute kidney damage. To prevent seizures, magnesium sulfate intravenously as a bolus, then slow infusions are continued until the magnesium level is 4.8-9.6 mg. Angiotensin II receptor blockers (ARBs) and ACE inhibitors, which inhibit fetal renal function and cause polyhydramnios in the 2nd and 3rd trimester, are contraindicated for pregnant women. After childbirth, while breastfeeding, it is allowed to take Nifedipine , Propranolol , Spironolactone , Verapamil , Diltiazem , Captopril , Hydrochlorothiazide and Enalapril .

Diet

Diet 10th table

Efficacy: therapeutic effect after 1 month
Timing: constantly
Cost of products: 1700-1850 rubles. in Week

Diet for hypertension

Efficacy: therapeutic effect after 21 days
Timing: constantly
Cost of products: 1600-1700 rubles. in Week

Proper nutrition for hypertension, along with drug treatment, can serve as a preventive measure for the development of crises. Patients are advised to eat a nutritious diet with limited salt, refractory fats and foods rich in cholesterol .

Salt can be consumed no more than 5 g per day.
Alcohol, strong tea and coffee, which stimulate the central nervous system, are limited/excluded.
Otherwise, pickles, spicy snacks, fatty foods, fatty meats, and rich broths are strictly limited.
If you are overweight, limit flour products, sugar, cereal products, honey, grapes, raisins, and jam.
Low fat dairy products.
Whole grain products.
Lean meat and poultry (boiled or baked).
Vegetable side dishes, vegetable salads, vinaigrettes, seaweed.

Great importance is attached to the content of potassium and magnesium in products. Consumption of potassium and magnesium has a beneficial effect on the course of hypertension, the condition of blood vessels and the heart. Potassium is rich in baked potatoes, bananas, currants, tomatoes, pumpkin, carrots, cabbage, zucchini, cucumbers, beets, melons, beans, oranges, figs, raisins, dried apricots, and nuts. Magnesium is found in seaweed, rice, buckwheat, bran, bananas, rolled oats and nuts. The diet must contain foods containing polyunsaturated fatty acids: fatty sea fish, fish oil, seeds, nuts and vegetable oils (linseed/rapeseed/olive).

Diagnosis of hypertensive crisis

After providing first aid for a hypertensive crisis, the heart rate is checked, a medical history is taken, tests are prescribed, hormones are determined, Holter monitoring is performed (a study of blood pressure fluctuations over the course of a day), an ECG, etc.

Concomitant diseases can complicate the diagnosis (additional examination by endocrinological, nephrological, and neurological specialists is possible).

Based on the results obtained, a patient management regimen is prescribed.

Prevention

Prevention of crises consists of controlling blood pressure and maintaining it at a certain level.

For this it is important:

eradicate bad habits;
fight excess weight;
eat rationally;
Do moderate physical activity 5 days a week (walking, swimming, cycling).

Prevention of crises, in addition to lifestyle correction measures mentioned above, also includes:

constant monitoring of blood pressure and taking antihypertensive drugs or the use of double and triple combinations of drugs;
adequate sleep and rest.
avoidance of stressful situations.

Consequences and complications

The following complications of a hypertensive crisis are possible:

cerebral infarction;
pulmonary edema;
hypertensive encephalopathy;
myocardial infarction;
eclampsia;
dissecting aortic aneurysm ;
aneurysm rupture;
acute renal failure;
retinal hemorrhages;
papilledema.

Severe complications lead to sudden death, for example with atrial fibrillation , myocardial infarction , strokes (ischemic or hemorrhagic), and the development of renal failure . The consequences of a hypertensive crisis include long-term dizziness and headaches, blurred vision, myocardial ischemia and the development of chronic heart failure . The consequences in women include impaired cognitive function and the development of dementia .

Diagnostics

Diagnosis of a hypertensive crisis usually includes urine tests, ECG, and calculation of creatinine and serum urea concentrations. Patients with neurological symptoms require a CT scan of the head to rule out edema, intracranial hemorrhage, or cerebral infarction. Patients who complain of chest pain and shortness of breath are usually ordered to have a chest x-ray. On ECG findings, if target organs are affected, there are signs indicating acute ischemia or hypertrophy of the left ventricle. Negative changes in the results of urine tests are typical in cases where the kidneys are involved in the process. The doctor makes a diagnosis based on excessively high blood pressure numbers, as well as target organ damage.

Forecast

The prognosis for an uncomplicated crisis with subsequent continuous maintenance treatment of hypertension is favorable. In a complicated hypertensive crisis, 25-35% of patients die within 4 years either from renal failure or from the consequences of a stroke . Unfavorable prognostic factors are the duration of arterial hypertension , old age, increased serum urea creatinine, hypertensive retinopathy .

Causes

The cause may be various factors. GK usually develops if the patient has arterial hypertension of any origin (hypertension or symptomatic manifestations of hypertension). In addition, HA can often occur with abrupt withdrawal of drugs that lower blood pressure (hypotensive medications). This condition is also called “withdrawal syndrome.”

External reasons include:

stress;
weather changes;
excessive consumption of table salt;
excessive physical activity;
excessive alcohol consumption;
hypokalemia.

List of sources

Andreev A.N., Belokrinitsky V.I., Dityatev V.P. Hypertensive crises. Ekaterinburg: State Educational Institution of Higher Professional Education UGMA, 2007; 204.
Gilyarevsky S.R., Kuzmina I.M. Modern approaches to the treatment of patients with acute, pronounced increases in blood pressure and hypertensive crises. Karyology. 2010; 19: 71–88.
Ruksin V.V. Emergency care for arterial hypertension. A short guide for doctors. M.: MEDpress-inform, 2009; 48.
Zadionchenko V.S., Gorbacheva E.V. // Hypertensive crises of breast cancer. – 2001. – No. 9. – P. 628-630.
Dolzhenko M. N. //Hypertensive crises: modern principles of therapy/Acute and emergency conditions in the practice of a doctor. 2007. pp. 19-21.

General information about hypertensive crisis

A sudden increase in blood pressure above generally accepted values in a short period of time should alert you.

This condition can develop in any person exposed to overexertion, emotional shock, and even as a consequence of an acute infectious disease.