Proposed diagnostic studies in patients with suspected hypertensive emergency

Proposed evaluation in patients with suspected hypertensive emergency

History taking

  • Symptoms (headache, confusion, somnolence, visual disturbance, seizures, focal neurological deficits).
  • Pre-existing hypertension, current treatment, withdrawal, compliance, previous control.
  • Over-the-counter medication use (eg, nonsteroidal anti-inflammatory drugs, sympathomimetics).
  • Recent corticosteroid exposure.
  • Recreational drug use (eg, cocaine).
  • Comorbidities (eg, kidney disease, renal artery stenosis).

Diagnostic examination

  • BP both arms.
  • Radiofemoral delay.
  • Signs of heart failure (gallop rhythm, raised jugular venour pulse, bibasal crepitations, peripheral oedema).
  • Detailed neurological exam.
  • Funduscopy (papilloedema, haemorrhages).
  • ECG (ischaemia, arrhythmias, left ventricular
  • hypertrophy).
  • Urinalysis (proteinuria, haematuria)

Further investigations as indicated

  • Troponin-T, creatine kinase (CK), CK-MB.
  • Peripheral blood smear (for assessment of schistocytes).
  • Chest X-ray (volume overload).
  • Transthoracic echocardiography (cardiac structure and function).
  • CT/MRI-brain (intracerebral haemorrhage).
  • CT-angiography of thorax and abdomen (acute aortic disease).
  • Renal ultrasound (postrenal obstruction, kidney size, asymmetry suggestive of renal artery stenosis).
  • Secondary hypertension workup (renal profile, 24 hours urine metanephrines/catecholamines or spot plasma metanephrines, plasma renin and aldosterone, 24 hours urinary cortisol, thyroid-stimulating hormone)

Reference:

Kelly, D., & Rothwell, P. (2019). Blood pressure and the brain: the neurology of hypertension. Practical Neurology, practneurol-2019-002269. doi: 10.1136/practneurol-2019-002269.

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