Elliott William J
Department of Preventive Medicine, RUSH Medical College, RUSH University, RUSH University Medical Center, Chicago, IL 60612, USA.
Prog Cardiovasc Dis. 2006 Mar-Apr;48(5):316-25. doi: 10.1016/j.pcad.2006.02.004.
A hypertensive emergency is a clinical diagnosis that is appropriate when marked hypertension is associated with acute target-organ damage; in this setting, lowering of blood pressure (BP) is typically begun within hours of diagnosis. For hypertensive urgency with no acute target-organ damage, BP lowering may occur over hours to days. A hypertensive emergency may present with cardiac, renal, neurologic, hemorrhagic, or obstetric manifestations, but prompt recognition of the condition and institution of rapidly acting parenteral therapy to lower BP (typically in an intensive care unit) are widely recommended. For aortic dissection, the systolic BP target is lower than 120 mm Hg, to be achieved during the first 20 minutes using a beta-blocker (typically esmolol) and a vasodilator to reduce both shear stress on the aortic tear and the BP, respectively. Otherwise, sodium nitroprusside is the agent with the lowest acquisition cost and longest record of successful use in hypertensive emergencies; however, it is metabolized to toxic thiocyanate and cyanide. Other attractive agents include fenoldopam mesylate, nicardipine, and labetalol; in pregnant women, magnesium and nifedipine are used commonly. Most authors suggest a reduction in mean arterial pressure of approximately 10% during the first hour and a further 10% to 15% during the next 2 to 4 hours; hypoperfusion can result if the BP is lowered too suddenly or too far (eg, into the range of <140/90 mm Hg). Oral antihypertensive therapy can usually be instituted after 6 to 12 hours of parenteral therapy, and the patient moved out of the intensive care unit, when consideration should be given to screening for secondary causes of hypertension. Long-term follow-up to ensure adequate control of hypertension is necessary to prevent further target-organ damage and recurrence of another hypertensive emergency.
高血压急症是一种临床诊断，当显著高血压与急性靶器官损害相关时适用；在此情况下，通常在诊断后数小时内开始降低血压（BP）。对于无急性靶器官损害的高血压亚急症，血压降低可在数小时至数天内实现。高血压急症可能表现为心脏、肾脏、神经、出血或产科症状，但广泛建议迅速识别病情并开始使用快速起效的肠外治疗降低血压（通常在重症监护病房）。对于主动脉夹层，收缩压目标低于120 mmHg，在最初20分钟内使用β受体阻滞剂（通常为艾司洛尔）和血管扩张剂分别降低主动脉撕裂处的剪切应力和血压来实现。否则，硝普钠是获取成本最低且在高血压急症中成功使用记录最长的药物；然而，它会代谢为有毒的硫氰酸盐和氰化物。其他有吸引力的药物包括甲磺酸非诺多泮、尼卡地平和拉贝洛尔；在孕妇中，常用镁剂和硝苯地平。大多数作者建议在第1小时内平均动脉压降低约10%，在接下来的2至4小时内再降低10%至15%；如果血压降低过快或过低（例如降至<140/90 mmHg范围），可能会导致灌注不足。肠外治疗6至12小时后通常可开始口服抗高血压治疗，患者可转出重症监护病房，此时应考虑筛查高血压的继发原因。进行长期随访以确保高血压得到充分控制对于预防进一步的靶器官损害和另一次高血压急症的复发是必要的。
