Severe hypertension & hypertensive emergency
Acute organ damage (oedema, ACS, dissection) now; LV hypertrophy, the aorta and secondary causes later.
Echo approach, step by step
In a hypertensive emergency, echo looks for acute organ damage: pulmonary oedema, ischaemia and aortic dissection [26]. In chronic hypertension, it measures LV mass and geometry, diastolic function and the aorta. The ESC suggests it when it will change management [23,26].
- LV mass and geometryLVMi, RWT → concentric remodelling or hypertrophy [1,23].
- Diastolic functionE/e′, LAVI, TR (HFpEF substrate) [2].
- Systolic functionLVEF, GLS [23].
- AortaRoot and ascending aorta; flap in the acute setting [9].
- CoarctationSuprasternal CW of the descending aorta: high velocity with a diastolic "tail" [25].
- Bicuspid aortic valveAssociated with coarctation [25].
- Takotsubo patternIn phaeochromocytoma crisis [133].
- LVMi, RWT, geometry
- Diastolic function
- LVEF, GLS
- Aorta
- Coarctation Doppler
- Aortic valve morphology
Causes & echo clues
| Finding | Meaning | Action |
|---|---|---|
| Pulmonary oedema with preserved EF | Hypertensive acute HF | Nitrates, afterload reduction [12,26] |
| New RWMA | ACS | ACS pathway [138] |
| Aortic flap | Dissection | CT angiography, surgery [9] |
| LVH | Target-organ damage | Intensify treatment; regression predicts better outcome [66,67] |
| Coarctation | Secondary hypertension | CT or CMR, ACHD team [25] |
| Takotsubo pattern | Catecholamine excess | Metanephrines [133] |
Clinical pathway to the diagnosis
- Confirm BPin both arms, with the correct cuff [26].
- Emergency or urgency?Look for acute organ damage: fundoscopy, ECG, troponin, creatinine, urinalysis, neurological examination [26].
- EmergencyControlled IV BP lowering with agent and target by organ (fastest in dissection) [9,26].
- Secondary causesIn young patients, resistant hypertension or sudden onset: aldosterone and renin, renal imaging, metanephrines, sleep apnoea, coarctation [26].
Clinical pearls & pitfalls
PitfallHypertension + chest pain + inter-arm BP difference → image the aorta before giving antithrombotics [9,203].
- LV mass regresses with treatment, and regression is associated with fewer events [66,67].
- Hypertensive heart disease or HCM? Hypertension produces concentric, modest (usually <15 mm) hypertrophy without SAM [13,23].
- AS gradient falls when BP is high. Re-measure when BP is controlled [5].
Red flags
- Chest or back pain → aortic dissection [9]
- Pulmonary oedema, ACS, encephalopathy, acute kidney injury, eclampsia → hypertensive emergency [26]
- Young patient, arm–leg BP gradient, radio-femoral delay → coarctation [25]
- Paroxysms with headache, sweating, palpitations → phaeochromocytoma