ABC | Volume 114, Nº4, April 2020

Statement Luso-Brazilian Position Statement on Hypertensive Emergencies – 2020 Arq Bras Cardiol. 2020; 114(4)736-751 hypertension with the pressure/flow (cerebral, coronary, and renal) autoregulation curve shifted to the right and do not present acute TOD, which is why a sudden decrease in BP may be associated with significant morbidity. 18-20 3. Clinical and Laboratory Assessment When managing a HE, the practitioner should discriminate between emergency and urgency, establishing a correct diagnosis of the various HE situations in order to select the most appropriate therapy for each TOD. This is very important since the correct diagnosis and treatment may prevent worsening of the clinical condition due to the critical situation. The approach to patients with HE requires clinical evaluation and complementary tests performed in clinical emergency centers with hospital support. BP should be measured in both arms (at least three measurements), preferably in a quiet environment. Individuals with acute BP elevations often present metabolic abnormalities characterized by hyperglycemia, dyslipidemia, lower potassium levels, and reduced renal function. 21 The sequence of steps in the management of patients with HC is as follows: 1-5,22,23 1. Seek factors that may have triggered the acute BP elevation. 2. Investigate symptoms or situations that simulate HC (headache, labyrinthitis, physical trauma, pain, emotional stress, and family or professional problems). 3. Observe history and duration of hypertension, use of antihypertensive drugs (doses and pharmacological adherence). 4. Investigate prior episodes similar to the current situation. 5. Investigate the use of medications that may interfere with BP control (anti-inflammatory drugs, steroids, analgesics, antidepressants, appetite suppressants). 6. Evaluate the use or abuse of alcohol and toxic substances (cocaine, crack, lysergic acid diethylamide [LSD]). 7. Investigate the use of suddenly discontinued adrenergic inhibitors (clonidine, methyldopa, and beta-blockers). 8. Observe the association with other morbidities and risk factors (diabetes, cardiac disease, renal disease, smoking, dyslipidemia). 9. Clinical history and physical examination should be performed according to the presence of TOD: • Central nervous system (observe the occurrence of headache, dizziness, visual and speech disorders, consciousness level, agitation or apathy, confusion, focal neurological deficits, neck stiffness, seizure, and coma). • Cardiovascular system (assess heart rate, symptoms of palpitations, and presence of carotid murmur; investigate the occurrence of thoracic, precordial, abdominal, and back pain and discomfort, in addition to signs and symptoms of left ventricular failure including gallop rhythm, dyspnea, jugular venous stasis, peripheral pulses, and oxygen saturation). • Renal and genitourinary system (assess changes in urinary volume, frequency, and characteristics, dehydration, lower limb edema, hematuria, and dysuria). Note: examination of the abdomen (for pulsatile abdominal masses and abdominal murmur) should not be overlooked. • Fundoscopy (observe the occurrence of vasospasm, arteriovenous nicking, arteriolar wall thickening and aspect of copper or silver-wiring, hard and soft exudates, hemorrhages, and papilledema). Complementary tests should be performed according to the involvement of target organs: • Central nervous system (computed tomography, magnetic resonance imaging, and lumbar puncture). • Cardiovascular system (electrocardiography, chest x-ray, echocardiography, markers of myocardial necrosis, angiotomography, magnetic resonance imaging). • Renal system (urinalysis, urea, creatinine, electrolytes, and blood gases). 4. Treatment of Hypertensive Emergencies: General Principles, Main Medications and Dosages Better diagnostic and therapeutic conditions have led to a great reduction in 1-year mortality, which improved from 80% in 1928 and 50% in 1955 to only 10% in 1989. 24,25 The aim of treating patients with clinical manifestations of HE is to reduce BP rapidly to prevent the progression of TOD. Patients should be admitted to an intensive care unit, undergo intravenous antihypertensive treatment, and be carefully monitored during parenteral therapy to prevent the occurrence of hypotension. The general recommendations for BP reduction suggested by the Seventh Report of the Joint National Committee (JNC) 26 for HEs are summarized as follows: • ↓ BP ≤ 25% within the first hour. • ↓ BP 160/100 to 110 mmHg in 2 to 6 hours. • BP 135/85 mmHg at 24 to 48 hours. However, HEs should be addressed considering the affected system or target organ. Thus, each type of HE (cardiovascular, cerebral, renal, and others) should be characterized prior to starting specific antihypertensive therapy (see “Clinical and Laboratory Evaluation”). Several pharmacological therapies are currently available for HE treatment. The ideal antihypertensive medication for parenteral use must present the following characteristics: ability to reverse the involved pathophysiological abnormalities, rapid onset of action, predictable dose- response curve, minimal dose adjustment, high selectivity, no increase in ICP, prompt reversibility, low risk of promoting hypotension, easy substitution for oral medications, and satisfactory cost-benefit ratio. Table 3 summarizes the pharmacokinetic and pharmacodynamic properties of the main antihypertensive medications used in HE. 2,22,26-28 In Brazil, the following medications are available for use in HEs: sodium nitroprusside, nitroglycerin, labetalol, esmolol, metoprolol, hydralazine, and enalaprilat. 740