ABC | Volume 114, Nº4, April 2020

Statement Luso-Brazilian Position Statement on Hypertensive Emergencies – 2020 Arq Bras Cardiol. 2020; 114(4)736-751 Content 1. Definition, Epidemiology, and Classification of Hypertensive Emergencies .........................................................................................738 2. Pathophysiological Aspects of Hypertensive Emergency .........739 2.1. Autoregulation of Cerebral Blood Flow ..............................................739 3. Clinical and Laboratory Assessment ............................................740 4. Treatment of Hypertensive Emergencies: General Principles, Main Medications and Dosages ........................................................740 5. Hypertensive Encephalopathy .......................................................741 5.1. Clinical Manifestations .....................................................................741 5.2. Diagnosis ..........................................................................................741 5.3. Treatment .........................................................................................741 6. Malignant or Accelerated Hypertension ......................................742 7. Stroke and Hypertensive Emergency ...........................................742 7.1. Ischemic Stroke ................................................................................743 7.2. Hemorrhagic Stroke ..........................................................................744 8. Acute Coronary Syndromes and Hypertensive Emergency ....744 9. Acute Left Ventricular Dysfunction in Hypertensive Emergency ............................................................................................744 10. Acute Aortic Syndromes ..............................................................745 10.1. Treatment .......................................................................................745 11. Hypertensive Emergencies During Pregnancy .........................745 11.1. Treatment .......................................................................................746 12. Adrenergic Emergencies ..............................................................746 13. Illicit Drugs and Hypertensive Emergency ................................746 14. Postoperative Hypertensive Emergency Following Vascular Surgery ..................................................................................................747 References ............................................................................................748 1. Definition, Epidemiology, and Classification of Hypertensive Emergencies Hypertensive emergencies (HEs) comprise a wider nosological condition known as hypertensive crisis (HC). HC represents clinical situations with acute blood pressure (BP) elevation, often with levels of systolic BP (SBP) ≥ 180 mmHg and diastolic BP (DBP) ≥ 120 mmHg, which may or may not result in target-organ damage (TOD) (heart, brain, kidneys, and arteries). 1-5 HCs may present in two distinct forms in relation to severity and prognosis: hypertensive urgency (HU) and HE. Cases of HE have a marked elevation in BP associated with TOD and immediate risk of death, a fact that requires a rapid and gradual reduction in BP levels within minutes to hours, with intensive monitoring and use of intravenous medications. 1-5 HEs can manifest as cardiovascular, cerebrovascular, or renal events or as a pregnancy-related event in the form of preeclampsia or eclampsia. Although the classic definition of both HC presentations describes this condition with values above 180/120 mmHg, the largest current consensus is established on the concept that what distinguishes HEs from HUs is, more than the BP value, the occurrence of damage or imminent risk of target-organ involvement. Thus, HUs are characterized by BP elevations without TOD or imminent risk of death, a fact that allows for a slower reduction in BP levels over a period of 24 to 48 hours. Currently, there is a wide discussion about the actual existence of the diagnosis of “hypertensive urgency.” 6 Many advocate that this classification needs to be updated (if not abandoned) and that, instead of the BP value, the main diagnostic importance lies in the observation of signs/ symptoms and acute TOD. Others believe that the correct term should be “BP elevation without evolving TOD.” 5,7 As discussed, even though the BP levels are often very high (≥ 180/120 mmHg), HEs are defined by TOD and not by BP levels. Therefore, the numerical pattern that defines HC is conceptual and serves as a therapeutic parameter, but should not be used as an absolute criterion. If the definition of HC is more universally accepted today, the knowledge about the epidemiology and prevalence of this condition by the scientific community is still limited. The literature has only a few studies on the subject, all of which conducted in a small number of participants. Non-adherence to treatment is currently hypothesized to be one of the most prevalent factors in the etiology of HC, without distinction between HU and HE. The incidence of HC in the largest serial studies in the US was about 4.8%, with 0.8% attributed to HEs. 8,9 Other centers have shown that HCs account for a variable rate of 0.45 to 0.59% of all hospital emergency care and 1.7% of all clinical emergencies, with HU being more common than HE. 10-12 Ischemic stroke and acute pulmonary edema (APE) are the most common clinical conditions in HE. 10,11 Estimates indicate that about 1% of all hypertensive individuals will probably develop an episode of HC over their lifetimes. 1,2 The clinical conditions with TOD implicated in HEs are shown in Table 1. Table 2 shows the main conditions associated with HUs. 738