Definition

Hypertension is the medical term for increased blood pressure above normal values. Blood pressure is measured using a sphygmomanometer. This device shows results based on two types of blood pressure: systolic and diastolic pressure.

Systolic pressure describes the pressure inside the blood vessels when the heart pumps blood throughout the body. While diastolic pressure refers to the pressure inside the blood vessels when the heart rests between each beat. Blood pressure measurements have units of millimeters of mercury (mmHg).

A sphygmomanometer displays the systolic pressure reading on top of the diastolic pressure reading. For example, if a person has normal blood pressure, the monitor will display a systolic pressure of <120 mmHg and a diastolic pressure of <80 mmHg (<120/80 mmHg).

Hypertension is divided into two stages, namely:

• Stage 1 hypertension, when the systolic pressure reads 130-139 mmHg or the diastolic pressure reaches 80-89 mmHg
• Stage 2 hypertension, which is a more severe form, when the systolic pressure is above 140 mmHg or the diastolic pressure is above 90 mmHg

Meanwhile, systolic pressure of 120-129 mmHg and diastolic pressure above 80 mmHg are called pre-hypertension.

According to the Centers for Disease Control and Prevention (CDC), 45% of adults in the United States suffer from hypertension. The CDC also estimates that only 1 in 4 adults has their hypertension under control.

Uncontrolled hypertension can lead to a sudden and severe increase in blood pressure. This increase is known as a hypertensive crisis. A hypertensive crisis occurs when blood pressure rises to an extreme systolic pressure of more than 180 mmHg and/or diastolic pressure of more than 120 mmHg.

If left untreated, a hypertensive crisis will damage blood vessels and organs. Blood vessels will become inflamed and leak, releasing fluid or blood. As a result, the heart cannot pump blood properly to the rest of the body.

There are two types of hypertensive crisis, namely:

• Urgent hypertension, or hypertensive crisis without associated symptoms. In this hypertensive crisis, generally, no organ damage has occurred. If not treated immediately, it is possible that it can worsen and cause organ damage
• Emergency hypertension, or hypertensive crisis with symptoms. In this hypertensive crisis, there is already organ damage. Emergency hypertension is associated with life-threatening complications

About 1-2% of people with hypertension will experience a hypertensive crisis. In 2018, nearly half a million deaths in the US were caused by hypertension.

Causes

According to The American Heart Association (AHA), several lifestyle and medical factors can increase the risk of hypertension, such as:

• Being overweight or obese
• Eating an unhealthy diet, including foods high in salt
• Seldom doing physical activity or exercise
• Smoking
• Having a history of heart and blood vessel disease
• Having certain health problems, such as diabetes or kidney disease

Meanwhile, the following factors are commonly associated with hypertensive crises, namely:

• Skipping or forgetting to take prescribed high blood pressure medications
• Taking medications that interact with each other and have the effect of increasing blood pressure
• Using illegal drugs, such as cocaine or amphetamines
• Having a life-threatening heart and blood vessel disease, such as a stroke or heart attack
• Having organ failure, such as heart or kidney failure

Risk factor

Risk factors for hypertensive crisis include:

• Women
• Obesity
• Advanced age, especially in emergency hypertension
• Non-compliance in taking high blood pressure medications
• Having heart, kidney, and stroke diseases
• Diabetes and hyperlipidemia (excess blood cholesterol), especially in emergency hypertension
• Alcohol consumption
• Use of illicit drugs

Symptoms

Risk factors for hypertensive crisis include:

• Women
• Obesity
• Advanced age, especially in emergency hypertension
• Non-compliance in taking high blood pressure medications
• Having heart, kidney, and stroke diseases
• Diabetes and hyperlipidemia (excess blood cholesterol), especially in emergency hypertension
• Alcohol consumption
• Use of illicit drugs

Diagnosis

The doctor will perform several blood pressure checks and ask about the patient's symptoms and medical history. The doctor will also ask about any medications or supplements the patient is taking and whether or not the patient has ever used illicit drugs.

If the doctor suspects a risk of organ damage due to a hypertensive crisis, the doctor will recommend further tests, such as:

• Blood tests
• Urine test
• Eye examination
• Echocardiography
• Ultrasound of the liver, kidneys, or both
• Chest X-ray to assess the heart and lungs
• CT or MRI scan of the brain

Management

The first-line treatment for hypertensive crisis is an antihypertensive medication injected into a vein. These drugs lower blood pressure faster than oral or drinkable medications.

Doctors usually lower blood pressure by no more than 25% in the first hour, as too rapid a drop in blood pressure can cause other problems.

Once the blood pressure is controlled, the doctor will switch to oral antihypertensive medications. The medications that doctors use to lower blood pressure are customized according to several patient conditions, including:

• Whether or not the patient is pregnant
• Whether the patient has a history of other diseases
• Whether or not the hypertensive crisis occurred due to the use of illicit drugs

Complications

Over time, untreated high blood pressure can lead to complications, such as:

• Heart disease, including heart attack and heart failure
• Stroke
• Visual impairment up to blindness
• Kidney failure
• Erectile dysfunction (impotence)
• Fluid buildup in the lungs
• Memory impairment

Meanwhile, a hypertensive crisis can lead to the following complications:

• Vascular damage leading to end-stage organ damage
• Heart attack
• Fluid buildup in the lungs
• Tearing of the aorta (the large blood vessel that circulates blood through the body) 
• Eclampsia or seizures in pregnant women
• Brain hemorrhage
• Death

Prevention

The most important thing to prevent a hypertensive crisis is to take your blood pressure medication as recommended by your doctor. A 2015 study found that people who frequently did not take their high blood pressure medication were more at risk of being hospitalized for heart problems.

Here are some lifestyle changes to lower blood pressure and reduce the risk of hypertensive crisis:

1. Healthy diet

A healthy diet is a diet rich in fruits, vegetables, and fiber that is low in fat and salt. Reducing salt consumption can accelerate blood pressure reduction. 

The National Heart, Lung, and Blood Institute suggests the DASH (Dietary Approaches to Stop Hypertension) diet for hypertensive patients to lower their blood pressure. This diet involves controlling calorie intake, which is heart-healthy.

2. Reduce alcohol consumption

Limiting alcohol intake will help lower blood pressure and improve overall health. The 2020-2025 Dietary Guidelines for Americans recommend men should consume no more than two drinks per day, while women should consume no more than one drink per day.

3. Regular physical activity or exercise

Regular movement or exercise can keep your heart and blood vessels healthy. Exercise also helps to lose excess weight, which will also help lower blood pressure. 

The CDC suggests 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity per week. However, these activities are customized to each patient's condition.

 4. Stop smoking

Smoking increases blood pressure and the risk of heart problems, such as heart attack and stroke. People who smoke need to consult a doctor regarding a smoking cessation program.

5. Get enough sleep

Getting enough sleep is very important for overall health, especially for heart and blood vessel health. This is because blood pressure naturally drops during sleep. Ideally, adults should get at least 7 hours of sleep every night.

Some of the following steps can help your sleep become regular and quality:

• Get plenty of physical activity during the day
• Wake up and go to bed at the same time every day
• Follow your bedtime routine consistently
• Make sure your environment is comfortable for sleeping, cool, dark, and free from noise or other distractions

When to see a doctor? 

Please consult a doctor if your current high blood pressure medication is not lowering your blood pressure. It may take up to two weeks for a new medication to have its full effect. If there is no change in blood pressure, it means that another medication is required, or it could result from other health issues that accompany high blood pressure.

If you suffer from high blood pressure, seek emergency medical attention immediately if you experience:

• Sudden visual impairment
• Headache
• Fatigue
• Nausea and vomiting
• Confusion
• Shortness of breath
• Chest pain
• Seizures
• Decreased consciousness or fainting