Thread by @akhadilkarMD

As a Cardiology fellow, we get a lot of consults for hypertensive urgency/emergency.

Part 2: Etiology, Presentation, Diagnosis

-thread 🧵-

#arjuncardiology #MedTwitter #Cardiotwitter #IMG #MedEd

Etiology:
- 30-40% with hypertensive crisis have an identifiable underlying cause
- Should evaluate for secondary causes
- Common scenario: Inadequate treatment/medication non-compliance
- Risk factors: Male, low socioeconomic, tobacco use, oral OCP use

Underlying Contributing Pathology:
- Renal parenchymal disease
- Renovascular HTN
- Collagen vascular disease
- Scleroderma
- Vasculitis
- Pre-eclampsia
- Untreated OSA

Medications:
- Oral contraceptives
- Sympathomimetic agents (diet pills, amphetamines)
- Cold remedies (Pseudoephedrine)
- NSAIDS, TCA, MAO inhibitors

Withdrawal:
- Alcohol, Benzodiazepines, Clonidine

Illicit Substances:
- Cocaine, Tobacco

Presentation:
- Focus on end-organ damage!
- CV: Shortness of breath, chest pain
- Neurological: Headache, confusion, lethargy, AMS, nausea/vomiting
- Renal: Oliguria, changes in urine color (hematuria/proteinuria)
- Ocular: Blurred vision or changes in vision

Physical Exam Findings:
- Should measure BP in both upper and lower extremities (r/o dissection)

- Optic fundi: retinopathy, exudates, hemorrhages, or papilledema
- Neurological assessment: Mental status, confusion, seizure activity, motor deficits

Physical Exam Findings:
- CV/pulmonary: Presence of S3/S4, new murmur, and/or pulmonary edema. Should evaluate total volume status.
- Vascular: Palpation of pulses, auscultation of bruits (renal)

Diagnostic Evaluation:
- CBC/blood smear: Anemia & schistocytes should raise concern for hemolysis and microangiopathic hemolytic anemia
- Blood chemistry: Renal function & electrolyte levels (hypokalemia) can give clue to secondary causes such as primary hyperaldosteronism

Diagnostic Evaluation:
- UA: Proteinuria, hemolysis, and casts. Hematuria & moderate-to-severe proteinuria are surrogate markers for glomerular damage
- Finger-stick glucose test: Should exclude hypoglycemia as cause of AMS in setting of suspected hypertensive encephalopathy

Diagnostic Evaluation:
- EKG: Evaluate for chronicity of HTN (LVH), correlate w/ ischemia (troponin)
- CXR: Heart size, pulmonary edema, widened mediastinum
- Urine toxicology: Cocaine & other illicit substances
- Renin/aldosteronism & serum/urine metanephrines

Diagnostic Evaluation:
- Think about secondary causes of hypertension, including:
- Renovascular HTN
- Primary Hyperaldosteronism
- Coarctation of Aorta
- OSA
- Cushing's Syndrome

*Not to use for medical advice and always discuss with your fellow and attending*

As part of the work-up, focus on evaluating for end-organ damage, with focus on the brain, heart, kidneys, and eyes on both physical & labs. Stay tuned for Part 3A on Medical therapies next!